Decoding Dyspnea: Unveiling Malignancy Disguised as Asthma

We present two patients who presented with symptoms that overlap with asthma, but upon further diagnostic evaluation, were revealed to have underlying malignancy. These cases highlight the importance of objective evidence-based evaluation in unveiling diagnoses previously mislabeled as asthma. The first patient was a 51-year-old with one year of cough and waning albuterol responsiveness, with worsening orthopnea and exertional dyspnea. Spirometry demonstrated a mixed obstructive/restrictive pattern without a bronchodilator response. Chest radiograph, which was not previously obtained, revealed left-sided nodules and right-sided consolidation, with computed tomography and specialist evaluation leading to the diagnosis of aggressive lung cancer. The second patient was a 24-year-old with one month of new dyspnea with marginal response to albuterol, improvement on oral steroids, and dysphagia. Spirometry revealed a fixed obstructive pattern without a bronchodilator response. Chest radiograph was within normal limits. Neck computed tomography revealed a large neoplasm involving the esophagus, resulting in tracheal displacement and compression. In addition to detailed history, exam, and spirometry, diagnostic evaluation of asthma should include consideration of other possible causes for obstruction. The first patient highlights how presumptive diagnoses can endure and delay accurate diagnosis and treatment, thereby increasing morbidity. The second case highlights that although asthma is a more likely diagnosis than malignancy in a healthy young adult, systematic evaluation may reveal critical previously missed findings. These cases remind clinicians that uncommon and sinister diseases can masquerade as diseases that we commonly manage, and illuminate the importance of methodical evaluation with objective evidence to diagnose and treat asthma.