Ten discrete nodules up to 1.8 cm were identified. Margins were smooth. Five of them (one shown here in the right upper lobe) had central necrosis or cavitation.
Radiographic Findings--11/23
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Ten discrete nodules up to 1.8 cm were identified. Margins were smooth. Five of them (one shown here in the right upper lobe) had central necrosis or cavitation. | ||||||
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Irregular posterior pleural thickening with some pleural enhancement was present. Note also the subpleural nodule on the left with an enhancing rim and central low attenuation consistent with necrosis. | ||||||
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At least three confluent subpleural nodules are seen on the left, each with central necrosis. The most anterior nodule contains central cavitary air, and the posterior nodules show central low attenuation. | ||||||
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Scattered bronchiectasis was noted, especially in the posterior basal segment of the left lower lobe (arrow). Note the cavitary nodule in the right middle lobe. | ||||||
Impression: Diffuse bilateral pulmonary nodules, some cavitary. Pleural thickening. Bronchiectasis. What is the differential diagnosis? Answer
Answer: The differential diagnosis includes pyogenic bacterial infection, including septic emboli; tuberculosis; non-tuberculous mycobacterial infection; fungal (including pneumocystis) infection, metastatic carcinoma, sarcoidosis, Wegener's granulomatosis, and pleuronodular disease of rheumatoid arthritis. See also Case 8 and Case 10.
Although forgotten by the patient, previous chest films as far back as 1991 showed multiple nodular densities and transient pleural effusions. Previous PFTs showed a mild, long-standing restrictive abnormality. The current infectious disease workup included serologic titers for coccidioides and cryptococcus, and a test for urinary histoplasma antigen, all of which were negative.
On 2/9, nodules in the RLL and RML were resected, and cultures were taken.
Clinical summary
Image 1