40 yo M with 6 months of SOB

Original case provided by Lauren Brown, MD.
Edits, graphics and teaching points by Yilin Zhang, MD.


OBJECTIVES:

  • Evaluation of a patient with nonresolving pulmonary infiltrate

CASE:

A 40 yo M presents with a 5 month history of nonproductive cough. He reports chest congestion and the feeling of a “rattling” in his chest. He reports a possible aspiration episode at the start of his symptoms. He denies any fevers, chills, night sweats or weight loss. He has no other PMH and takes no medications. He was never a smoker, works in a lab working with microbiology plates. He grew up in the Pacific Northwest and has traveled to ID. He denies any international travel.

On exam, his vital signs are normal, SaO2 99% on RA. Lungs are clear to auscultation.

His CXR shows:

He was treated with a 5 day course of azithromycin for presumed pneumonia. When should you repeat imaging to ensure resolution of this consolidation? 


CASE CONTINUED:

He had minimal change in his symptoms after antibiotics. Repeat CXR was obtained 4 weeks later:


He subsequently underwent a chest CT: 

What is your differential for this CT finding? 

What would be your next step in evaluation? 


FINAL DIAGNOSIS AND OUTCOME:

TAKE HOME POINTS:


REFERENCES:

  1. Low, DE, Mazzulli, T & Marrie, T. Progressive and nonresolving pneumonia. Current Opinion in Pulmonary Medicine. 2005; 11: 247-252.
  2. Lim, WS, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009; 64(Suppl III): iii1-iii55.
  3. Johnson, JL. Slowly resolving and nonresolving pneumonia: Questions to ask when response is delayed. Postgraduate Medicine. 2000. 108(6): 115-122.