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Clinical Images

Cavitary Lesion in the Setting of Hemoptysis and Weight Loss

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Authors: Sneha Patel MD; Payam Pourhassani DO, Dimple Patel MD 

   A 59-year-old Haitian male presented with a 3 month history of bloody sputum, worsening in frequency and quantity over several days prior to presentation. He endorsed fever, chills, night sweats, an unintentional 20 pound weight loss, and pleuritic chest pains. He immigrated from Haiti 10 years prior and was an avid cigar smoker with a total 30 pack-year history. On examination, he was tachycardic with decreased breath sounds and dullness to percussion over the posterior right upper chest wall. Laboratory tests revealed a blood glucose of 567 mg/dl with an elevated anion gap of 16, hemoglobin 14 g/dl, white blood cell count 10x109 cells/liter, and lactic acid 1.6mg/dl. Chest x-ray revealed a lesion in the right upper lung field which was confirmed on a computed tomography (CT) scan. The lesion was a 6 x 5.6 x 6 cm cavitary lesion in the right upper lobe (Figures 1 & 2).

MCQ 1: Given the propensity for transmission and time sensitive treatment modalities, which diagnosis should immediately be considered?

a.   Lung cancer with lymphangitic spread

b.   Necrotizing bacterial pneumonia

c.   Aspergillosis

d.   Pulmonary Tuberculosis 

MCQ 2: In a patient with the above symptoms and cavitary lesion on imaging, what treatment should be initiated?

a.   Gram positive, gram negative, and anaerobic bacterium coverage

b.   Rifampin only with 2 month initiation and 4 month continuation phase

c.   Isoniazid, rifampin, ethambutol, pyrazinamide for 2 month initiation phase with 7 month continuation phase

d.   Resection

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Figure 1: Side by side comparison of sagittal view of chest x-ray (left) and CT chest (right) right upper lobe cavitary lesion.

Figure 2: Axial view of Spiral CT Chest. Moderate-sized 6x5.6x6cm cavitary lesion with thick irregular wall that extends to the pleural surface, posteriorly to the right minor fissure and oblique fissure, and towards the right hilium with constriction of the right upper lobe.


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 2. YF Tsai, YH Ku. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med. 2012 May;18(3):246-52. doi: 10.1097/MCP.0b013e3283521022.

 3. Mitnick CD, McGee B, Peloquin CA. Tuberculosis pharmacotherapy: strategies to optimize patient care. Expert opinion on pharmacotherapy. 2009;10(3):381-401. doi:10.1517/14656560802694564. 

4. Treatment for TB Disease. (2016, August 11). 

5. Aspergillosis. (2016, January 21). 

Author Information: 

Sneha N. Patel, MD is currently an internal medicine resident at Drexel University College of Medicine/Hahnemann University Hospital in Philadelphia. She completed her Bachelor of Science from Boston University in 2011 and received her Medical Degree from St. George’s University in 2015. 

Payam Pourhassani, DO is an internal medicine resident at Drexel University College of Medicine/Hahnemann University Hospital in Philadelphia. He received his Degree of Osteopathic Medicine from Philadelphia College of Osteopathic Medicine, Georgia Campus in 2015. 

Dimple Patel, MD is an assistant professor of medicine in the Division of Internal Medicine at Drexel University College of Medicine. She received her Medical Degree from St. George’s University in 2008.