A 56-Year-Old Honduran Man With Fever, Weight Loss, and Pleuritic Chest Pain (original) (raw)

2008, Infectious Diseases in Clinical Practice

A 56-year-old man Honduran man presents to a US hospital with a 2-month history of hemoptysis, pleuritic chest pain, night sweats, cough, fever, and back pain associated with a 30-lb weight loss and occasional headaches. He has been in the United States for 20 months and has no knowledge of prior exposure to tuberculosis. On physical examination, he is a cachectic-appearing Hispanic man with a temperature of 37.8-C, a respiratory rate of 20 breaths per minute, and a saturation of 99% on room air. No skin or mucosal lesions were encountered. No organomegaly or adenopathy was noted. Pulmonary examination demonstrated right, lower lobe crackles with decreased breath sounds. The chest radiograph demonstrated multifocal, nodular airspace disease with foci of cavitation (Figs. 1A, B). Chest computed tomography (CT) confirmed the presence of multiple nodules, some of which were cavitary, irregular foci of airspace disease that appeared more confluent in the lower lobes, and extensive mediastinal and hilar adenopathy (Figs. 2AYC). The clinical and radiographic manifestations at the time of admission were suggestive of tuberculosis, and the patient was placed in isolation in a negative-pressure room. Multiple sputum samples were negative for acid-fast bacilli. A purified protein derivative (tuberculin) skin test performed in the emergency room showed 2-mm induration. In addition, the patient was negative for cryptococcal antigen and cytomegalovirus early antigen. Bronchoscopy revealed 3 raised polypoid endobronchial lesions: one along the right lateral trachea, a second in the right mainstem bronchus near the right upper lobe bronchus, and the third at the entrance of the superior segment left lower lobe bronchus (Fig. 3). A biopsy of the lesions in the right upper and left lower lobe bronchi was performed. Pathological examination of the lung biopsies from the right upper and left lower lobe endobronchial lesions showed similar morphological findings. The biopsies consisted of multiple bronchial wall fragments infiltrated by a mixed acute and chronic inflammatory infiltrate composed of neutrophils, eosino-Radiology in ID