Clinical presentation:
A 42-year-old African-American man with a history of HIV presented with a 3-week history of dry cough, fatigue, muscle weakness, and discoordination. He reported occasional subjective fevers, nocturnal sweats, and weight loss.
Past medical/surgical history:
HIV: Diagnosed 4 years ago, currently not receiving treatment
Hand surgery
Social history:
26 pack-year history of tobacco use
Recent crack cocaine use, no IV drug abuse
Previous incarceration
Family history:
Noncontributory
Allergies:
No known drug allergies
Physical exam:
Temperature = 97.9°F, HR = 80, BP = 99/56, RR = 12/min, room air Spo2 = 99%
General: thin man, no distress
CVS: regular rate and rythmn, no gallops
Pulm: dry rales at bilateral upper lung zones, minimal expiratory wheeze
Abdomen: soft, nontender, normoactive bowel sounds
Lymph: no adenopathy
Extremities: no clubbing or cyanosis
Pulmonary function testing:
Moderate obstruction with mildly reduced Dlco
Diagnostic testing:
Chest radiograph and CT scan of the chest (Fig 1, 2)
Figure 1. Patient chest radiograph.
Figure 2. Representative images from CT scan imaging.
Bronchoscopy revealed an intact and normal-appearing oropharynx and vocal cords without significant mucosal abnormalities. The right bronchial tree was normal in appearance without evidence of endobronchial masses or lesions. A bronchoalveolar lavage of the right upper lobe apical subsegment was performed with adequate return. Evaluation of the left bronchial tree revealed a large gray lingular mass (Fig 3) associated with hyperemia but without bleeding. The endoluminal mass was debulked without incident.
Case Puzzlers are a brief clinical vignette on various educational topics. Developed by members of the American College of Chest Physicians' NetWorks, it provides you an opportunity to sharpen your skills.
