A Case of Unknown Pulmonary Nodules.

A 54-year-old female with history of underlying asthma and 10 pack-year smoking history was seen in interventional pulmonology clinic for evaluation of multiple scattered pulmonary nodules incidentally found on chest computed tomography (CT). Given the central location of the dominant left upper lobe (LUL) nodule and its proximity to an airway, bronchoscopic biopsy was felt to be the right approach. The IonTM Endoluminal System robotic-assisted navigational bronchoscope (Intuitive Surgical, Sunnyvale, California) was used to sample the LUL nodule under fluoroscopic guidance. Together with clinical and radiological findings, the histological and immunophenotypic findings are supportive for Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH). The DIPNECH is a rare condition first described in a case series published in cancer in 1953. This highly atypical condition highlights the utility of modern navigational bronchoscopy in safely securing a diagnostic bronchoscopic biopsy in locations not previously reachable. This is especially relevant given the challenge and risk to percutaneous CT-guided biopsy. Complications are known to scale with depth from skin site, emphasizing benefits of the bronchoscopic approach in obese patients.