Overview.
Inflammatory granulomatous disease of the lungs known as pulmonary nodular disease is mostly asymptomatic, with a few cases of shortness of breath, dry cough, and chest pain. The cause is unknown, and may be related to infections and heredity. Asymptomatic or mild symptoms do not require treatment, and medications may be an option for severe symptoms.
Definition
Pulmonary nodular disease is the most common site of nodular disease, a systemic granulomatous disease of unknown cause characterized by non-caseating necrotizing epithelioid cell granulomas. Nodular disease can involve almost every organ of the body, but the lungs and intrathoracic lymph nodes are most commonly involved, followed by the skin and eyes.
Pulmonary nodular disease is not neoplastic.
Staging
The current clinical staging of nodular disease is the Scadding staging based on chest radiographs, which was introduced in the 1960s:
Stage 0: indicates no abnormal chest X-ray;
Stage I: bilateral hilar lymph node enlargement;
Stage II: bilateral hilar lymph node enlargement with intrapulmonary infiltrative shadows;
Stage III: intrapulmonary infiltrate shadow only;
Stage IV: pulmonary fibrosis.
Morbidity
Overall situation: China is a region with a low incidence of pulmonary nodular disease, and epidemiologic information on nodular disease is still lacking.
High incidence population: lung nodular disease is mainly found in young and middle-aged people, and the incidence rate of women is slightly higher than that of men.
Region and time of incidence: It is more frequent in cold regions and less frequent in the tropics. More cases of nodular disease are usually diagnosed in winter and early spring.
Causes
The cause of pulmonary nodular disease is unknown. Recent studies have found that the disease may be related to infection by pathogenic microorganisms (bacteria or viruses), an immune response to exposure to dust or chemicals, genetic factors or autoimmunity.
Symptoms
Main Symptoms
Pulmonary nodular disease is asymptomatic and unnoticeable when mild, and is usually detected during a physical examination.
About 20% of patients will develop a chronic disease leading to pulmonary fibrosis, which affects the respiratory function of the lungs and presents respiratory symptoms:
Shortness of breath, which worsens with activity.
Persistent dry cough.
Chest pain.
Wheezing or chest tightness.
Other Symptoms.
Systemic symptoms may also occur in pulmonary nodular disease:
Weakness.
Fever.
Eye inflammation, pain, blurred vision, and sensitivity to light.
Night sweats.
Pain in the joints and bones.
Skin rashes, lumps, color changes on face and extremities.
Weight loss.
Seek medical attention
Department of Medicine
Respiratory Medicine
Prompt medical consultation is recommended when there is an abnormality in the chest X-ray during physical examination or when there is shortness of breath, dry cough, or chest tightness.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, and common problems.
Tips for Medical Consultation
Chest X-ray or chest CT is often needed, so avoid wearing clothing made of metal, and inform the doctor if you are pregnant or planning to become pregnant.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms and special symptoms.
Is there a cough? Is there phlegm?
Is there chest tightness, shortness of breath or chest pain?
Is there a fever? What is the highest degree?
Are there painless, movable swellings in the armpits, neck, etc.?
Are there painful subcutaneous nodules on the face, back, etc.?
Is there any loss of vision, dry eyes, or eye pain?
How long have the symptoms been present?
Medical History Checklist
Has anyone in the family had nodular disease?
Checklist
Test results for the last 6 months to bring to the doctor’s office
Laboratory tests: blood count, erythrocyte sedimentation rate (ESR), liver and kidney function, cardiac enzyme profile, tuberculin test
Imaging tests: Chest X-ray, Chest CT scan
Others: lung function test, bronchoscopy
Medication list
Medication used in the last 3 months, if there is a box or package, you can bring it with you to the doctor’s office
Glucocorticoid: prednisone, methylprednisolone
Immunosuppressants: methotrexate, azathioprine
Diagnosis
Diagnosis is based on
Medical history
Family members may have a relevant medical history.
Clinical manifestations
Approximately 50% of patients are asymptomatic and are discovered on examination of the chest X-ray or physical examination.
Patients may present with cough, chest pain, dyspnea, fever, weight loss, weakness, night sweats, and airway hyperresponsiveness with rales on examination.
Laboratory tests
Routine blood tests, liver and renal function, and cardiac enzyme tests.
Leukopenia, anemia, and elevated blood sedimentation may be present in the progressive stage of nodular disease. Hypercalcemia with increased concentrations of angiotensin-converting enzyme is often suggestive of nodular disease.
Imaging
Chest X-ray and CT scan. They can show lung abnormalities, monitor disease progression, and assess treatment efficacy.
Abnormal chest X-ray findings are often the first sign of pulmonary nodular disease and often show bilateral hilar and mediastinal lymph node enlargement.
CT will show small nodules along the bronchovascular bundles, which may fuse to form a ball, and other abnormalities such as ground-glass lesions, cords, and flaky shadows. The lesions are usually found in the upper part of the lungs.
Lung function tests
It can show whether there is restrictive ventilation dysfunction and help doctors to determine the degree of lung function impairment, the need for treatment and the prognosis.
Bronchoscopic Biopsy and Bronchoalveolar Lavage
The doctor will use a thin, long flexible tube that is placed into the patient’s lungs through the throat, with a light at the end of the tube to help the doctor diagnose and evaluate the disease.
Bronchoscopy also allows for biopsies and lung lavage, where some tissue or cells are removed and examined under a microscope, which can identify inflammation and infection and help rule out certain causes.
The high diagnostic yield and low risk of sampling and further examining the biopsy tissue through this method makes it an important tool for diagnosing tuberculosis.
Tuberculin test
A negative or weak reaction to the tuberculin skin test is characteristic of nodular disease and can be used to differentially diagnose pulmonary nodular disease and tuberculosis.
Diagnostic criteria
There are no objective diagnostic criteria for tuberculosis and it is an exclusionary diagnosis, i.e., other possible diagnoses need to be ruled out before a diagnosis of tuberculosis is made.
The diagnosis of nodular disease is usually made by the clinician based on the clinical presentation, imaging features, pathological biopsy results (non-caseous necrotizing epithelioid cell granuloma) of the affected area, combined with the medical history, serologic examination, bronchoscopy, etc., and the exclusion of granulomatous diseases caused by other reasons.
Differential diagnosis
Lung cancer
Similarity: both have symptoms of cough and sputum, and bilateral hilar and mediastinal lymph node enlargement can be seen on imaging.
Differences: Lung cancer can be seen as lumpy or nodular shadow on chest X-ray, which cannot be completely dissipated after antibiotic treatment. Bronchoscopy, bronchoalveolar lavage and biopsy are helpful for differential diagnosis.
Tuberculosis
Similarities: both have symptoms of cough, fever and night sweats.
Differences: tuberculosis has a positive tuberculin test result, as opposed to pulmonary nodular disease.
Lymphoma
Similarities: generalized weakness, fever, cough.
Differences: Lymphoma can be differentially diagnosed from pulmonary nodal disease by imaging as well as pathologic biopsy.
Metastatic tumor
Similarity: Bilateral hilar and mediastinal lymph node enlargement can be seen on imaging.
Differences: Metastatic tumor patients’ lymph node enlargement mostly occurs in one side of the lung, and the patients are in poor physical condition and the disease progresses more rapidly. Differential diagnosis can be made by biopsy.
Treatment
Principles and objectives of treatment
There is no specific treatment for pulmonary nodular disease. If there are no symptoms or the symptoms are very mild, it can be observed without treatment.
The need for treatment and the specific method of treatment need to be determined according to the severity of the disease and the extent of involvement.
Treatment
Medication
Glucocorticoids
Glucocorticosteroids are the drug of choice for treatment and can be given orally as prednisone and methylprednisolone.
The use of glucocorticosteroids should be monitored for adverse effects, such as electrolyte disorders, gastrointestinal ulcers or bleeding, Cushing’s syndrome, etc. Seek medical help promptly.
Other drugs
Methotrexate and azathioprine are used as second-line drugs for the treatment of pulmonary nodular disease, mainly for cases where glucocorticoid drugs are ineffective or there is intolerance of adverse effects.
Both methotrexate and azathioprine may lead to leukopenia, liver and kidney function damage, and methotrexate may also lead to interstitial lung damage, so regular rechecks of blood tests and liver and kidney function are needed.
Other treatments
Patients with respiratory symptoms can reduce them by modifying their diet, drinking plenty of fluids, and performing pulmonary rehabilitation.
If severe pulmonary, cardiac, or hepatic invasion occurs in tuberculosis, comprehensive treatment measures need to be considered, and organ transplantation may be considered for those with end-stage or ineffective drug therapy.
Patients who do not require treatment need to be reviewed every 3 to 6 months to monitor changes in their condition.
Prognosis
Cure
Self-healing: Pulmonary nodular disease is currently incurable. 69% to 89% of patients with type I nodular disease experience spontaneous remission, while the spontaneous remission rate for stage II is 50% to 60%, and less frequently for stages III and IV.
Death: Chronic progressive nodular disease can invade the vital organs of the heart and brain and cause extensive pulmonary fibrosis leading to death, with a case fatality rate of less than 5%.
The vast majority of patients with nodular disease have a good prognosis after drug treatment.
Daily
Dietary management
White fungus, lungs of pigs, sheep and cattle can be eaten frequently. For spleen yang deficiency, add yam, seaweed, small beans and jujube; for kidney yang deficiency, add mushrooms, walnuts, walnut meat and mealybug powder; for yin and yang deficiency, add pear juice.
Light, easy-to-digest food and high-calorie drinks, such as milk and coconut juice, are recommended.
It is advisable to eat more fresh vegetables and fruits, such as watermelon, citrus and pear.
Drink plenty of water to keep the throat moist.
Avoid eating fatty, sweet, thick and spicy foods.
Avoid eating seafood, such as crab, shrimp, scallop and yellowtail.
Exercise management
Physical exercise can improve the patient’s mood and slow down fatigue. Exercise can strengthen the respiratory function of the lungs. It is recommended to exercise 2 to 4 times a week for 20 to 40 minutes each time.
Prevention
Since there is no clear cause of pulmonary nodular disease, disease prevention is currently based on avoiding harmful substances such as second-hand smoke and dust as much as possible.
Regular medical checkups are recommended for high-risk groups with a family history of the disease.