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A 38-year-old man with a history of urethral and esophageal strictures, as well as smokeless tobacco use, was referred to the pulmonary clinic for a suspicious nodule in the right upper lobe seen on a CT scan. He had a history of oral squamous cell carcinoma stage III (T1N1M0) treated with wide local excision and bilateral neck dissection. Surgery was followed by one cycle of a planned three cycles of cisplatin complicated by severe pancytopenia requiring hospitalization. The patient subsequently received adjuvant radiation therapy to the neck. A follow-up CT scan demonstrated a suspicious nodule in the right upper lobe for which he was referred to a pulmonary medicine specialist. On exam, he has stable vital signs, including pulse oximetry. He has well-healed incisions on his neck and skin changes consistent with radiation therapy. His cardiac and lung examination results are normal. The only other noteworthy finding is that he has significant dystrophic fingernails. He states that he has had them all of his life.

The patient was noted to have a lesion with central lucency in the right upper lobe (Fig 1). The patient was also noted to have another smaller lesion in the periphery of the right upper lobe and in the periphery of the left lower lobe.

Figure 1. CT scan demonstrating lesion with central lucency in the right upper lobe.

The patient underwent bronchoscopy under electromagnetic navigation with bronchoalveolar lavage, cytology brush, and transbronchial biopsy. The cytologic and tissue findings demonstrated no malignancy, but the lavage culture grew methicillin-resistant Staphylococcus aureus. He was placed on doxycyline as an outpatient and a repeat CT scan was performed 6 weeks later.

The patient’s CT scan demonstrated significant anlargement of the right uper lobe nodule (Fig 2), noted previously. The patient also had enlargement of the left lower lobe nodule and peripheral right upper lobe nodule, as well as numerous other nodules noted bilaterally.

Figure 2. CT scan demonstrating significant enlargement of the right upper lobe nodule.

The repeat CT scan demonstrated significant enlargement of the right upper lobe nodule noted previously, as well as enlargement of the left lower lobe nodule and peripheral right upper lobe nodule, as well as numerous other nodules noted bilaterally.

What is the diagnosis?