Solitary Pulmonary Nodule: A Diagnostic Dilemma.

This case describes a woman with a history of tobacco abuse who presented with a dry cough and was found to have an enlarging, 4 cm right upper lobe nodule without lymphadenopathy on CT imaging of the chest. Initial biopsies of the nodule suggested follicular lymphoma, but after obtaining more tissue, the pathology was negative for malignancy and instead showed necrotizing pneumonia. She proceeded to have negative infectious serology and cultures. She had negative rheumatological testing including MPO ANCA, PR-3 ANCA, and rheumatoid factor. She did not have renal failure, hemoptysis, weight loss, arthralgia, or upper airway inflammation. She ultimately underwent a right upper lobectomy, as the nodule was enlarging on repeat imaging. The pathology of the lung showed necrotizing granulomas with giant cells and fibrosis, but lacked active vasculitis or palisading histiocytes, further obscuring the diagnosis. She was conservatively managed with intranasal steroids, cough suppressants and antihistamines given her lack of severe symptoms. The diagnosis was most consistent with granulomatosis with polyangiitis (GPA) presenting as a solitary pulmonary nodule with pathology reflecting a mild degree of disease activity. The patient may manifest further signs of the disease while being monitored clinically.

SSRI Facilitated Crack Dancing.

Choreoathetoid movement secondary to cocaine use is a well-documented phenomenon better known as "crack dancing." It consists of uncontrolled writhing movements secondary to excess dopamine from cocaine use. We present a 32-year-old male who had been using cocaine for many years and was recently started on paroxetine, a selective serotonin reuptake inhibitor (SSRI) for worsening depression four weeks before presentation. He had been doing cocaine every 2 weeks for the last three years and had never "crack danced" before this episode. The authors have conducted a thorough literature review and cited studies that suggest "crack dancing" is associated with excess dopamine. There has never been a documented case report of an SSRI being linked with "crack dancing." The authors propose that the excess dopaminergic effect of the SSRI lowered the dopamine threshold for "crack dancing." There is a communication with the Raphe Nucleus and the Substantia Nigra, which explains how the SSRI increases dopamine levels. This is the first documented case of an SSRI facilitating the "crack dance."