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Answers on p 792.
A 42 year old man developed upper respiratory symptoms that were accompanied by a marked decrease in appetite, severe fatigue, and the later appearance of arthralgia of the ankles and of drenching night sweats. He was admitted in January 2000, after he had been ill for one month, showed no response to cefuroxime, and had a chest x ray which revealed multiple pulmonary nodules (fig 1). The patient was a gardener who smoked heavily and had a distant history of drug abuse but was otherwise healthy. On examination low grade fever (37.7°C), sinus tachycardia (104 beats/min), enlarged red tonsils, right conjunctivitis, and tenderness over one knee, were the only notable findings. The erythrocyte sedimentation rate was 109 mm/hour, haemoglobin concentration 119 g/l (mean corpuscular volume 90 fl), leucocytes 12 × 109/l with 75% neutrophils and 6% eosinophils, and platelets 461 × 109/l. The urinary sediment, renal function tests, and electrolytes were normal. Serum albumin was 29 g/l, globulins 41g/l (polyclonal), aspartate aminotransferase 87 U/l, alanine aminotransferase 240 U/l, lactate dehydrogenase 460 U/l. Serum alkaline phosphatase, γ-glutamyltransferase, amylase, creatine phosphokinase, as well as antinuclear antibodies, rheumatoid factor, and complement were normal. Blood cultures, viral serology (including hepatitis and HIV), and the tuberculin test were negative. Computed tomography of the chest and abdomen did not show any additional findings to the pulmonary nodules except for a 2.5 cm hypodense round mass in the left adrenal. Endocrine studies were normal as was a transthoracic echocardiography. On the fourth hospital day, multiple new splinter haemorrhages were found under the fingernails (fig 2), and a few hours later, the patient appeared seriously ill and had palpable purpuric lesions on the distal part of both legs.
- What is the main differential diagnosis of this patient's pulmonary nodules?
- How does the appearance of the skin signs affect the diagnosis?
- How would you proceed with the diagnosis?