Upper lobe fibrocavitary disease in a patient with back pain and stiffness.

A 37-year-old white man presented with a productive cough, anorexia, weight loss, and night sweats of 4 months’ duration. He also complained of back pain with stiffness. The back pain was worse at night. He was treated for pneumonia 3 years ago and had a 20 pack-year history of smoking. He was a thin man in no distress. His vital signs were stable and temperature was 38.6°C (101.6°F). Bilateral enlarged firm but nontender axillary and inguinal lymph nodes were noted. Chest wall expansion was limited, but otherwise the thoracic examination was unremarkable. There was kyphosis of the lumbar spine with limited forward bending, The range of motion of the cervical spine was severely limited, and there was no lateral motion of the neck. The pelvis was anteverted, and there was a flexion deformity of both knees. Laboratory findings were as follows: WBC count, 11,300 cells/mL; and erythrocyte sedimentation rate, 30 mm/h. There was a positive human leukocyte antigenB27 antigen. Sputum smears and cultures for acid-fast bacilli were negative. Smears of BAL fluid and bronchial washings revealed rare acid-fast bacilli. The purified protein derivative skin test was negative. A chest radiograph (Fig 1) revealed bilateral upper lobe cavitary lesions. The remainder of the lungs were hyperinflated. There was mild upward retraction of the hilar structures indicating upper lobe volume loss. Contrast-enhanced chest CT (Fig 2) showed distortion of the lung architecture with