A Case for Diagnosis: A New Syndrome?
Authors: Z. M. Hall, R. R. Wilson
Journal: BMJ (1961)

This report describes the case of a man who has had for at least five years, and probably twelve years, numerous focal sclerosing lesions in the lungs and a few in the bones.He has been in excellent health throughout, and would never have been investigated but for a chance x-ray examination.No diagnosis has yet been made, in spite of repeated radiographs, three successful biopsies, and other investigations.The case presents two outstanding problems: firstly, the relationship between the lung and bone lesions, and, secondly, the nature of the disease.We hope that this report may be followed by others so that in time the condition may be better understood. Case HistoryThe patient, a man then aged 42, had a routine mass x-ray examination in 1956, because the unit happened to be in his locality.He had no symptoms.The radiograph showed multiple foci of low density and blurred outline.The patient was referred to the local chest clinic and admitted to St. Charles' Hospital for investigation.Past History.-In 1942-3when in North Africa he had an attack of dysentery.Otherwise he had never been out of England.However, in 1945 he had a short attack of benign tertian malaria.Apart from these illnesses he had always had excellent health.In 1949 he had a routine mass x-ray examination which was reported as normal.On re-scrutiny, however, three small round shadows were found in the right lower zone, and other less obvious shadows, scattered in both lungs, were also seen.Having previously been a messenger, a footman, a funfair attendant, a cook, and an electro-plater, the patient became a dustman in 1950.Examination.-He was a lean but fairly muscular man of medium build and healthy appearance.Respiratory system: no clubbing or cyanosis; chest movements normal; percussion' and auscultation normal; diaphragm moved normally on screening.Cardiovascular system: heart rate and rhythm normal; no murmurs; B.P. 120/80.Alimentary system: liver not palpable; rectal examination normal; no other abnormality found.Haemopoietic system: spleen not palpable; a few small glands in axillae and groins; no clinical anaemia.Urogenital system: kidneys not palpable; genitalia normal.Nervous system: no abnormality found; fundi normal.Osseous system: no bony tenderness.Investigations.-Mantoux 1/10,000 negative, 1/1,000 positive.Histoplasmin skin test negative (1/100).Histo- plasmin complement-fixation test negative.Hb, 85%.W.B.C. normal.E.S.R. 5 mm./hour.Urine normal.Chromatography showed no abnormal amino-acids.Plasma protein, 7.8 g./100 ml.(albumin 4.2 g., globulin 3.5 g.);A: G ratio 1.2: 1. Serum acid phosphatase, 2.3 units; alkaline phosphatase, 4.7 K-A units; inorganic phosphorus, 4.3 mg./100 ml.; calcium, 10.5 mg./100 ml.W.R. and G.C.F.T. negative.Repeated sputum and laryngeal swab cultures: no tubercle bacilli grown, no fungi grown.Scalene node biopsy: only fatty tissue obtained.Radio- active iodine studies: no evidence of increased uptake by lungs or lumbar spine after an oral dose of 50 mg. of 13lI.Bronchoscopy (1959): no abnormality.Lung-function tests (1960): Ventilatory function is good but a very slight degree of airway obstruction is present.Diffusion is slightly