Mr. T, a 21-year-old male, presented with a 4-day history of cough with white phlegm and a 10-month history of frequent coughing. Imaging showed an inhomogeneous solid mass in the right lung that appeared to encase the superior vena cava and compress the right lung. Biopsies and tests were negative for malignancy but showed xanthogranulomatous inflammation. A diagnosis of a possible right lung tumor versus mediastinal tumor was made, and oncology consultation was planned along with further biopsies to determine the nature of the mass.

1. CASE REPORT
Wednesday, 10th August 2022

2. PATIENT
IDENTITY
 Name : Mr. T
 Age : 21 years old
 Adress : Ngalang
 Admission date : 8th August 2022
 Medical record : 01580614
 Room : Flamboyan 7

3. Chief Complaint
Cough

4. HISTORY OF PRESENT ILLNESS
4 days BA
Coughing up phlegm for 4 days BA, white phlegm, sometimes
difficult to expel, coughing up blood (-), history of hemoptysis (-).
Sore throat (+)
Shortness of breath (-) shortness of breath not affected by activity,
weather (-) dust (-) frequent wheezing (-) frequent use of breath
inhaler (-)
Fever (-) summer fever (-) sweating without activity at night (-)
Decreased appetite, reduced eating and drinking.
Defecation and urination no complaint.
10 months BA
Cough started
frequently since 10
months BA

5. HISTORY OF PAST ILLNESS
 History of Tuberculosis : denied
 History of asthma or allergy : denied
 History of hypertension : denied
 History of Diabetes Melitus : denied
 History of heart disease : denied
 History of CVA : denied

6. HISTORY OF SOCIOECONOMIC
 History of Occupation : students
 History of Smoking : denied
 History of cooking with firewood : denied
 History of living near industrial area : denied
 History of contact with patient confirm COVID-19 : denied
 History of special hobby/habits : denied
 History of vaccination : 2x

7. History of Hospitalization and Examination
History of Hospitalization Information
25/2/2022 Outpatient in RS Paru Surakarta because of cough
11/04/2022 – 18/04/2022 Inpatient in RS Paru Surakarta
10/06/2022 – 22/06/2022 Inpatient in RSDM, patient was performed a chest x-ray,
MSCT scan thorax contrast, bronchoscopy and TTNA
05/07/2022 – 14/07/2022 Inpatient in RSDM, patient was performed a chest x-ray
TTNA blind

8. History of Hospitalization and Examination
History of Examination Information
25/2/22 TCM: MTB not detected
12/4/22 MSCT thorax contrast:
Inhomogeneous solid mass right paravertebrae to apical
hemithorax which appears to partially encase the
vena cava and compresses the right lung parenchyma
8.26 x 10.14 cm), tends to be a mediastinal mass,
lymphadenopathy in the left paratracheal, right
axillary right, left axilla and right supraclavicular (largest
2.81 x 1.72 cm left paratracheal)
10/6/22 pleural fluid cytology: no malignant cells found

9. History of Hospitalization and Examination
History of Examination Information
17/6/22 cell block TTNA: no malignant cells found
17/6/22 TTNA cytology: no malignant cells found
20/6/22 cytology of bronchial brushes and washings: no
cells were found
27/6/22 Sputum cytology: no malignant cells found
19/07/22 Lung Biopsy Core Tissue: the core biopsy preparations
showed Xanthogranulomatous inflammation, no tumor
was found in the core biopsy preparations we received.

10. PHYSICAL
EXAMINATION
General condition: moderately ill
Level of consciousness : E4V5M6,
fully alert
Vital Sign
 Blood pressure : 118/75 mmHg
 Heart Rate : 98 x/minute
 Respiration rate : 22x/minute
 Temp : 36.5 oC
 SpO2 : 98 % with O2 room
 qSOFA : 0
 SOFA score : 0
 VAS : 0
 SIRS : 0
 NEWS : 0
 MEWS : 0
 Height : 161cm
 Weight : 56 kg
 BMI : 20.8 kg/m2
 Nutritional status : normorweight

11. PHYSICAL
EXAMINATION
Head : Round and symmetrical shape, normocephalic size
Hair : Black color, alopecia (-), hair easily pulled out (-)
Eyes : Man's eye (-/-), pale conjunctiva (+/+), icteric
sclera (-/-), ptosis (-/-), exophthalmos (-/-), light reflex (+/+),
hemorrhage (-/-)
Mouth: cyanosis (-), purse lip breathing, halitosis (-)
Neck : Tracheal deviation (-), lymph node enlargement (-
), JVP increase (-), thyroid not enlarged

12. PHYSICAL EXAMINATION
Thorax: Normal shape, asymmetrical (+), retraction (+), venectation
(-)
Heart :
Inspection: ictus cordis not visible
Palpation: ictus cordis not palpable
Percussion :
Upper right border: second intercostal space, right parasternal line.
Lower right border: 5th intercostal space, right parasternal line.
Upper left border: 2nd intercostal space, left parasternal line.
Lower left border: 6th intercostal space, left midclavicular line.
Auscultation: single sound I and II, additional sound (-) systolic
murmur

13. PHYSICAL EXAMINATION
Abdomen
Inspection: Flat wall surface
Palpation: Soepel, normal skin turgor and elasticity, hepatomegaly (-
), splenomegaly (-), tenderness (-)
Percussion : Tympani, shifting dullness (-)
Auscultation: Bowel sounds (+) 10x/minute
Upper Extremities: Edema (-/-), pitting edema (-/-), warm acral,
CRT <2, Cyanosis (-), Clubbing Finger (-), normal muscle strength
Lower Extremities: Edema (+/+), pitting edema (+/+), warm acral,
CRT <2, Cyanosis (-), Clubbing Finger (-), normal muscle strength

14. ANTERIOR PULMO
EXAMINATION
Anterior Right Left
Inspection Inflated chest symmetrical static/dynamic
Palpation Tactile fremitus symmetrical
Percussion
Border of right lung-heart
Border of left lung-heart
Border of lung-liver
Resonant
Difficult to evaluate
Difficult to evaluate
Resonant
Vth ICS of left mid clavicle
line
Auscultation
Basic sound
Additional sounds
- Crackles
- Wheezing
- Bronchophony
- Egophony
- Whisper pectoriloquy
Vesicular (+)
(-)
(-)
(-)
(+)
(-)
Vesicular (+)
(-)
(-)
(-)
(-)
(-)

15. POSTERIOR PULMO
EXAMINATION
Posterior Right Left
Inspection Inflated chest symmetrical static/dynamic
Palpation Tactile fremitus right < left
Percussion Resonant Resonant
Auscultation
Basic sound
Additional sounds
- Crackles
- Wheezing
- Bronchophony
- Egophony
- Whisper pectoriloquy
Vesicular (+)
(-)
(-)
(-)
(+)
(-)
Vesicular (+)
(-)
(-)
(-)
(-)
(-)

16. Laboratorium
(8/08/2022)
Hb 12.2
Hematocrit 41
AL 44
AT 477
AE 4.67
Eos 0.18
Baso 0.39
Neu 92.65
Limf 4.55
Mono 2.23
SGOT 23
SGPT 31
Ur 11
Cr 0.6
Antigen negative

17. CHEST X-RAY
05/072022
RSDM

18. CHEST X-RAY
21/072022
RSDM

19. CHEST X-RAY
08/08/2022
RSDM

20. MSCT scan (14/06/2022)

21. MSCT scan (14/06/2022)

22. MSCT scan (14/06/2022)

23. MSCT scan (14/06/2022)
Inhomogeneous solid mass right paravertebrae to apical right hemithorax which appears to
partially encase the superior vena cava and compresses the right lung parenchyma (13.23 x
8.26 x 10.14 cm), tends to be a mediastinal mass, multiple lymphadenopathy in the left
paratracheal, right paratracheal, axillary right, left axilla and right supraclavicular (largest size
2.81 x 1.72 cm left paratracheal)

24. PROBLEM LIST
Chronic respiratory
symptoms
• Cough since 10 months BA
• Loss of appetite
• Cough since 4 days BA
• Sore throat

25. PROBLEM LIST
Lung tumor
• Chronic respiratory symptoms
• Physical examination
• RO thorax, MSCT scan, biopsy, TTNA

26. RESUME-PROBLEM PATHWAY
Chronic respiratory
symptoms
Acute respiratory
tract infection
Systemic symptoms
Lung tumor
immunocompromised

27. DIAGNOSIS
 Right lung tumor type (?) dd mediastinal tumor PS 70-80 with problem of
leukocytosis

28. THERAPY
• O2 2 lpm Nasal Cannula
• 1500 kcal HCHP diet
• Inf sohobion drip/24 hr
• NAC 3x200mg

29. PLANNING
• Consul for oncology
• proTTNA CT guiding (waiting the schedule)

30. GeneXpert (08/07/2022)
• MTB not detected

31. Cell block TTNA (17/06/2022)
• no malignant cells found

32. Lung BiopsyCoreTissue (19/07/2022)
• the core biopsy preparations showed Xanthogranulomatous inflammation,
no tumor nest was found in the core biopsy preparations we received

33. Lung BiopsyCoreTissue (19/07/2022)
• the core biopsy preparations showed Xanthogranulomatous inflammation,
no tumor nest was found in the core biopsy preparations we received

34. Thank you