A man with upper respiratory tract infections, general weakness and fever.

A 56-yr-old man was referred by his general practitioner with complaints of recurrent upper respiratory tract infections, 17 days of fever, general weakness, and a stinging pain in his right axilla with radiation to his right shoulder and chest that was provoked by movement of his arm. The complaints had begun after an infection around his left eye. The patient had undergone a right-sided pneumonectomy with postsurgical radiotherapy for T1N2 squamous cell carcinoma 16 yrs earlier and had suffered a myocardial infarction 12 yrs earlier. He had been taking ranitidine 150 mg b.i.d. and digoxin 0.25 mg daily. He smoked 10 cigarettes a day and had recently been diagnosed as suffering from chronic obstructive pulmonary disease (COPD) for which he took inhaled salbutamol as required. On examination, the abnormal findings were an elevated temperature of 38.68C, a low blood pressure of 100/70 mmHg and a rapid pulse of 112 beats.min. There was a dull percussion over his right chest with absent breath sounds, and resonant percussion over his left lung with expiratory wheezing. Initial investigations showed an erythrocyte sedimentation rate (ESR) of 110 mm.h, white blood cell count 13.3610 cells.L with a left shift on cytometry, haemoglobin (Hb) 8.8 mmol.L, thrombocytes 591610 cells.L, sodium 136 mmol.L, potassium 4.0 mmol.L, urea 6.2 mmol.L, creatinine 74 mmol.L, asparate aminotransferase (ASAT) 24 U.L, alanine aminotransferase (ALAT) 47 U.L, c-glutamyl transpeptidase (cGt) 74 U.L, and glucose 6.6 mmol.L. The resting electrocardiogram showed signs of an old inferolateral myocardial infarction. A chest radiograph was taken (fig. 1). The patient was diagnosed as having bacterial bronchitis and sent home with antibiotic treatment. Eleven days later he was still ill. On examination there were no additional abnormal findings so he was sent home again with altered antibiotic treatment. Fourteen days later he was still suffering from fever and complained of a painful swelling between his old pneumonectomy scar and his right nipple. Because of the persistent complaints, with fever accompanied with a very high ESR, pain in the axilla and general weakness in a patient who had a history of bronchogenic carcinoma, he was admitted to hospital. A computed tomography (CT) scan was performed to exclude the recurrence of bronchogenic carcinoma in the mediastinum and left lung, and showed a relatively large postpneumonectomy space. Additionally, a magnetic resonance imaging (MRI) scan (fig. 2) was made. A percutaneous biopsy of the swelling between the patient's old pneumonectomy scar and his right nipple was taken and sent to the pathology department to exclude bronchogenic carcinoma, and biopsy material was sent for culture.