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Answers on p 507.
A 48 year old man presented with cough, purulent sputum production, wheeze, and reduced exercise capacity. He described rapid weight loss of 9 kg over six months, associated with night sweats. He denied chest pain or haemoptysis. He had a 30 pack year cigarette habit and previously worked as a glazier.
Ulcerative colitis had been diagnosed 25 years previously, with rapid disease progression despite sulphasalazine treatment. This resulted in a panproctocolectomy the next year with a postoperative period complicated by a subphrenic abscess and wound dehiscence. There was no recurrence of gastrointestinal symptoms.
On examination he was cachectic with finger clubbing. There was a low grade pyrexia and functioning ileostomy. Chest auscultation revealed scattered coarse rales.
The neutrophil count was 16.5 × 109/l, the C reactive protein was 121 mg/l, and the erythrocyte sedimentation rate was 70 mm/hour. IgE was 154 U/l (normal <100), autoantibody screen was negative, and p-antineutrophil cytoplasmic antibody (ANCA) was borderline positive with MPO-ANCA titre 27 EU/ml.
What do the chest radiograph (fig 1) and computed tomogram of the upper thorax (fig 2) show?
What is the likely diagnosis and what further investigations should be performed to confirm this?
What treatment should the patient be given?
What are the pulmonary complications of ulcerative colitis?
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