Multiple pulmonary nodules with cavitation and fever in a 48-year-old man.

(Chest 1992; 101:1679-80) A 48-year-old man was admitted for evaluation of general malaise and a nonproductive cough of seven days’ duration. He smoked 20 cigarettes a day and consumed 120 g of alcohol per day. His medical history was unremarkable. On examination, his temperature was 38.5#{176}C, and his blood pressure was 120/80 mm Hg. There was a systolic murmur in the apex. The white blood cell count was 12.0 x 10 /cu mm, and the erythrocyte sedimentation rate was 2 mm/h. The electrocardiogram (ECG) was normal. A chest x-ray film revealed three nodules in the right hemithorax and two in the left hemithorax, with diameters of 1 .5 to 3 cm (Fig 1). Linear tomography showed cavitation in two of them. An otolaryngologic examination and a paranasal sinus x-ray study were normal. Bacterial and mycobactenal cultures were negative, as were serologic and immunologic study. The echocardiogram showed no signs of endocarditis. Fiberoptic bronchoscopy was carried out, and no endobronchial lesions were found. The findings from BAS cytologic and bacteriological studies were normal. Abdominal ultrasound examination and computed tomography (CT), barium examination of the upper gastrointestinal tract, barium enema, and bone scintigraphy were also carried out, with no abnormal findings. The patient was questioned again, and he remembered that one month before admission he had fallen down the stairs and had chest pain for two days. He did not consult a physician for this. Fifteen days after admission the patient was still feverish, and a purulent fetid sputum appeared. Consecutive blood tests revealed a white blood cell count of 24.0 x 10 /cu mm with one metamyelocyte, seven band cells, 80 polymorphonuclear leukocytes, ten lymphocytes, and two monocytes; the hemoglobin level was 10.5 g/dl, and the erythrocyte sedimentation rate was 108 mm/h. A chest x-ray film demonstrated that the nodules were increasing in size, with cavitation and air-fluid levels in all of them (Fig 2). A diagnostic procedure was performed.