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Answers on p 693
A 27 year old white man with no significant past medical history presented with progressive malaise and fatigue for one month. Two weeks before admission he had developed a cough productive of yellow-green sputum. He had also noted fevers as high as 104.9°F (40.5°C) with chills and rigors. The patient reported unintentional weight loss of approximately 20 pounds (9 kg) over the preceding six months. He worked as a computer technician, had a 10 pack year history of smoking, with modest alcohol intake and no illicit drug use. There was no history of exposure to animals or birds.
PHYSICAL EXAMINATION AND LABORATORY EVALUATION
On admission he was febrile to 102.1°F (38.9°C) with a pulse of 100 beats/min, blood pressure of 122/66 mm Hg, and a respiratory rate of 20 breaths/min. Oral examination was significant for poor dentition. Chest examination revealed dullness to percussion in the left base and crackles in the right mammary region. No clubbing or lymphadenopathy were present. The remainder of the physical examination was unremarkable. Laboratory testing revealed a white blood cell count of 16.6 × 109/l, with 85% segmented neutrophils, lymphocytes 7%, monocytes 5%, and eosinophils 2%; packed cell volume of 0.36, and a platelet count of 437 × 109/l. Serum chemistries and liver function tests were all normal. Serology for HIV and tuberculin skin testing were both negative. A posteroanterior and lateral chest radiograph showed a large right hilar mass and right middle lobe infiltrate with a left pleural effusion (fig 1). On chest computed tomography the mass was 3 × 3 cm in size with associated perihilar adenopathy. A small left sided pleural effusion was also noted (fig 2).
The left sided pleural effusion was aspirated and found to be an exudate with a protein of 43 g/l, lactate dehydrogenase of 720 IU/l, pH of 8.13, and 10.8 K/mm3 white blood cells (36% neutrophils, 46% lymphocytes, and 18% monocytes). Gram stain of the pleural fluid was negative for micro-organisms. Cultures of the pleural fluid were also negative. Fibreoptic bronchoscopy revealed a fungating mass occluding the right middle lobe bronchus. Bronchial washings and endobronchial biopsies showed Gram positive bacilli that were weakly acid fast.
What is the diagnosis?
What is the most appropriate therapy for this patient?
This work was supported by NIH grant T32 HL 07123 and by the Department of Veterans Affairs.
Answers on p 693
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