C.B. is a 60-year-old Italian male who presents to your clinic with the chief complaint of a cough with thick, creamy, reddish colored phlegm for the past two months. He denies any chest pain, shortness of breath or fevers, but has noted an unusual increase in salivation.

There is no abdominal pain, nausea, vomiting, dysuria, diarrhea, or other symptom.

Past medical history is significant for hyperlipidemia and obesity. He had his gallbladder removed in 1988.

He admits to having smoked a pack of cigarettes a day since the age of 15. Denies alcohol. He continues to work as head chef at a local Italian eatery. He is married, with three children.

Family history is noncontributory.

On exam, he is awake and alert.
Vital signs: BP 140/70, HR 90, R 20, T 98.8F.
Lungs are clear bilaterally.
Heart exam is normal.
Abdomen is soft with normo-active bowel sounds. No mass, rebound or guarding.
Extremities are without edema.

You obtain some labs, which reveal normal CBC, electrolytes, and coagulation studies.

A chest x-ray is performed, which shows nonspecific increased bilateral interstitial markings.

Despite ardent consideration, you are are unable to arrive at a suitable differential diagnosis for the patient's constellation of signs and symptoms.

Just when you are about to give up and leave medicine altogether, you experience a sudden grumbling in your abdomen, triggering a recollection of something you saw once in medical school.

"It's freakin' crazy, but it just might be it!," you exclaim.

You have the patient expectorate into a paper cup. Sprinting down to the lab, you prepare a slide and elbow your way onto the microscope.

As you rotate the focusing knobs, your excitement mounts. At 40X magnification, you discover:

What's going on?

Answer:
BronchoRaviolar Carcinoma

This patient, a 60-year-old male smoker, has BronchoRaviolar Carcinoma.

The finding of BronchoRavioli on sputum smear under light microscopy is pathognomonic for the disorder. Note also the absence of meat, which rules out the dreaded BronchoBeefaroni.

Despite being one of the most challenging pulmonary neoplasms to detect, BronchoRaviolar carcinoma is also one of the most delicious, with dozens of mouth-watering Bronchoravioli per gram of sputum, each caseating morsel filled with only the freshest, highest quality ricotta cheese available.

In retrospect, the triad of smoking, Italian heritage, and creamy reddish sputum, plus the fact that the man works in an Italian eatery, should have alerted you immediately to the possibility of BronchoRaviolar carcinoma.

Luckily, treatment is simple and efficacious, consisting of BronchoRaviolar Lavage using 0.9% Ragu Old World Style Traditional, followed by microwaving or baking of the lavage specimen until well-cooked. This should result in four to six servings in most cases.

This patient underwent lavage without incident, and remains healthy and disease-free two years later. You remember the case fondly, as it taught you to always trust your hunches ... and your taste buds!

Kudos ... to another job well done.