Radiographic Findings--11/23

 

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.

 

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.

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.

 

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

Clinical summary Image 1

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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

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