A 57-Year-Old Man With Persistent Miliary Pattern Pulmonary Nodules and New Lung Masses on Chest CT Scan

A 57-year-old man presented to the hospital with a 6-year history of slowly progressive persistent cough, shortness of breath, and wheezing. He had been prescribed budesonide and oxygen therapy 2 months prior for presumable asthma, but his symptoms had not subsided. He had been intermittently using 2 L oxygen via nasal canula with exertional activities until the day of hospitalization. He first experienced similar symptoms 5 years prior, and a workup at that time showed multiple tiny pulmonary nodules. His history was notable for a remote 27-pack-year smoking history, quitting 10 years prior, and he was diagnosed with asthma 2 years before his presentation. His occupational history included 17 years working in Israel with polished granite, quartz, and artificial marble. He denied exposure to asbestos, beryllium, radon, or chemicals, aluminum, semiconductors, dental materials, cosmetic powders, or talc. The patient denied environmental exposures such as black mold, hot tubs, or birds. Preceding our assessment, the patient had undergone a chest CT scan 6 years prior, revealing profound chronic alterations in the pulmonary architecture alongside mediastinal adenopathy. Three of his previous chest CT scans found numerous nodules of varying sizes throughout both lung fields, which had remained relatively stable over the years.