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A 27-Year-Old With a Non-Resolving Cavitary Lung Lesion

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Lokesh Venkateshaiah, MD

Fellow

Division of Pulmonary, Critical Care and Sleep Medicine

Case Western Reserve University

Cleveland, Ohio

J. Daryl Thornton, MD MPH

Assistant Professor

Division of Pulmonary, Critical Care and Sleep Medicine

Case Western Reserve University

Cleveland, Ohio

Submit your comments to the author(s).

History

A 27-year-old man presented to the pulmonary clinic for evaluation of a non-resolving lung cavity. Four months earlier, he had been diagnosed with pulmonary tuberculosis and was started on four-drug antituberculous directly observed therapy. A PPD placed at that time measured 22 mm of induration.
During the pulmonary clinic visit, the patient stated that over the last year and a half he had a cough occasionally productive of minimal blood-streaked sputum. He had denied other symptoms including nocturnal diaphoresis, anorexia, weight loss, or fevers. 
The patient’s past medical history was remarkable for an abnormal chest radiogram that was noted one and a half years ago and one episode of malaria. 
Other than his recent antituberculous therapy he took no regular medications. 
He smoked one-half pack daily for the past 12 years. He occasionally snorted cocaine but did not use alcohol or other recreational drugs. He emigrated from Malaysia to the United States 8 months ago. He was originally from Burma but was a refugee in Malaysia. It was in Malaysia that he was noted to have an abnormal chest radiogram. He underwent additional investigations while there but was not given a diagnosis nor treatment.

Physical Exam

The patient appeared comfortable and was in no acute distress. Vital signs were unremarkable. The cardiac exam demonstrated regular rate and rhythm, a normal S1 and S2, and no murmur, gallop or rub. Breath sounds were equal bilaterally and absent of adventitious sounds. The abdomen was soft and without organomegaly. The patient’s extremities were without clubbing or edema. There was a scar on the left upper arm from a prior BCG injection. No other skin lesions were noted.

Lab

White blood cell count was 10,000 per mm3 with 66% Neutrophils, 14% Lymphocytes and 12% eosinophils
Hematocrit 49%
Platelet count was 309,000 per mm3
Urea nitrogen was 12 mg /dl, and serum creatinine was 0.7 mg/dl
Liver function tests were within normal limits
Stools and sputum for ova and parasites were negative
Sputum for AFB times five was negative

Figures


Fig 1: Chest computed tomography 4 months prior to current presentation

Fig 2: Chest computed tomography at presentation (4 months following initiation of antituberculous therapy)

Question 1

What is the diagnosis?

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