Case history
A 48-yr-old male was admitted with 6 months of nonproductive cough, fever, and weight loss. These symptoms progressed despite a course of antibiotics prescribed for presumed community-acquired pneumonia 2 months prior to admission. A chest radiograph taken at that time is shown in figure 1a⇓. The patient denied any other symptoms, including skin rash, joint pain, and extremity numbness and weakness. Past medical history was significant for infection with Hepatitis-C virus and an accidental shotgun wound. The patient had a 30-pack-yr smoking history, remote use of injected heroin and cocaine and distant ethanol abuse. There was no occupational exposure to asbestos or silica, no recent travel and he had no pets or hobbies. He was not taking any medications.
a) Normal chest radiograph 2 months prior to admission. b) Admission chest radiograph. Large nodules are seen in both lungs.
On physical examination the patient was diaphoretic with a temperature of 39.4° C, pulse 107 beat·min−1, blood pressure 133/75 mmHg, respiration 28 breaths·min−1 and oxygen saturation of 88% on room air. Chest examination revealed bilateral basilar crackles. A 2-cm lymph node that was firm, mobile and not tender was palpated in the right axilla. The rest of the examination was normal.
Laboratory studies demonstrated a white blood count of 2.4×109 L−1 (53% lymphocytes, 25% neutrophils, 15% monocytes, 3% eosinophils and 2% bands), haematocrit of 30% …
