A 59 year old male, former smoker, with a past medical history of congestive heart failure presented to the local emergency department with complaints of dizziness and confusion for the past two days. In this time frame, he endorses experiencing melena; he has never had a colonoscopy. Upon admission to the ED, the pertinent clinical findings include tachycardia, hemoglobin of 9.4, and a Hemoccult positive test. A Chest X-ray revealed a mass in right lung base, not present on prior imaging. A CT of the chest was obtained and revealed a right lower lobe pulmonary mass (6 x 5.3 cm) with surrounding satellite nodules, multiple left pulmonary nodules (largest is 1.5 cm), multiple endobronchial lesions in the trachea and right mainstem bronchus, and mediastinal and hilar lymphadenopathy.

Additionally, a CT of the head was obtained and revealed multiple masses scattered throughout the brain concerning for metastatic disease in the setting of a patient with known lung masses.  A large intraparenchymal hematoma in the right cerebellum with surrounding edema was noted.

An endobronchial ultrasound (EBUS) and bronchoscopy was performed and revealed the right lower lobe airways were filled with an endobronchial tumor as well as enlarged mediastinal lymph nodes at 11L and station 7. Transbronchial needle aspirates were obtained from the enlarged lymph nodes and endobronchial lesion and tissue biopsies were obtained from the tracheal lesion along with a bronchoalveolar lavage.