Endgames Case Report

A persisting puzzling pneumonia in a young man

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2690 (Published 08 May 2012) Cite this as: BMJ 2012;344:e2690
  1. John Baker, foundation doctor,
  2. David McClelland, specialty registrar,
  3. O J Dempsey, consultant in respiratory medicine
  1. 1Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
  1. Correspondence to: J Baker john.baker1{at}nhs.net

A 23 year old immunocompetent man with a history of childhood asthma was referred to the respiratory physicians with a four week history of productive cough, painful throat, fever, rigors, generalised myalgia, and vague discomfort in his left chest. He also had slight abdominal tenderness in the left upper quadrant.

He was a non-smoker, with no history of recent foreign travel, seizures, or misuse of alcohol or drugs. There was no family history of note.

A chest radiograph organised by his general practitioner showed multiple cavities and consolidation in the left lower lobe. A radiological diagnosis of cavitating pneumonia in the left lower lobe was made.

On examination he had a fever (39°C), looked unwell, and had a respiratory rate of 16 breaths/min, resting oxygen saturation of 96% on air, and blood pressure of 130/72 mm Hg. He was tachycardic (112 beats/min), with reduced chest expansion, dullness on percussion, and reduced breath sounds over his left lower lobe.

Blood tests confirmed an acute phase response, with a raised C reactive protein of 187 mg/L (normal range 0-4), white cell count 17.2×109/L (4.0-10) (with neutrophilia 15.3×109/L), urea 4.7 mmol/L (3.4-7), and albumin 35 g/L (37-49). The results of urinalysis and electrocardiography were normal. Blood and sputum cultures were consistently negative.

Despite antibiotics (oral amoxicillin) given as per regional guidelines, his fever continued over the next four days and he underwent computed tomography of the chest. This confirmed left lower lobe basal segment consolidation, with multiple air and fluid filled cavities, and associated left hilar and subcarinal lymphadenopathy. In addition, an 18 mm lesion was seen in his left lower lobe bronchus. Bronchoscopy was performed and the lesion biopsied.

The bronchoscopic biopsy samples confirmed a diagnosis of pulmonary carcinoid tumour.

Questions

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