Rapidly progressing pulmonary nodules in a 14 yr old boy.

A caucasian male aged 14 yrs was referred to our Institute in December 1996 for the presence of diffuse pulmonary nodules. He had a history of a few viral infections of the upper airways in early childhood, without lower airway involvement. On September 9, 1996 the patient complained of a sudden chest pain, localized in the left mammary region, worsening during respiration. A chest radiograph was taken (fig. 1). Routine blood tests were within normal values and skin tests to mycobacterial antigens were negative. Anti-inflammatory treatment with nimesulide was prescribed and in 3 days the chest pain disappeared. In the following 2 weeks the patient had intermittent, low degree fever, (37.2–37.4°C). Two additional chest radiographs, performed on October 10 and November 12, demonstrated a rapid progression of the pulmonary lesion. A computed tomography (CT) scan was performed and, in addition to the large nodular infiltrate in the mid portion of the left lung, showed multiple lesions of various sizes in the lower lobes (fig. 2). A fibreoptic bronchoscopy did not detect abnormalities of the airways. Bronchoalveolar lavage (BAL) analysis did not show any cytological change suggesting malignancies and BAL cultures remained negative for various micro-organisms. A needle biopsy was performed, but the cytological evaluation of the aspirate demonstrated only necrotic debris. On admission the patient appeared in good clinical condition. Decreased sounds to percussion were noted over the middle third of the left hemithorax, anteriorly. Transcutaneous blood gas determination in room air showed normoxia (arterial oxygen tension (Pa,O2) 12.6 kPa) and normocapnia (Pa,CO2) 5.5 kPa). Chest radiograms showed further progression of the pulmonary lesions (major diameter of 9.0 cm). Peripheral blood smear showed a white cell count of 7.96×109 cells·L-1 (neutrophils 5.91×109 cells·L-1 lymphocytes 1.16×109 cells·L-1, monocytes 0.52×109 cells·L-1, eosinophils 0.14×109 cells·L-1, basophils 0.05×109 cells·L-1). Erythrocyte sedimentation rate was 52 mm·h-1, C-reactive protein was 0.06 g·L-1, while serum protein electrophoresis and immunoglobin (Ig) levels were normal. Biochemical tests were in the normal range. Blood urea nitrogen and creatinine levels were normal, and urine examination did not show any abnormality. Samples of blood, pharyngeal aspirate and urine yielded negative cultures for various micro-organisms. Antinuclear antibodies, anti-neutrophil cytoplasmic antibodies (ANCA), rheumatoid factor and lupus erythematosus (LE) cell test were negative, serum immune complexes were absent; C3 and C4 levels were within normal values and no abnormalities in lymphocyte