Haemoptysis, weight loss, and pulmonary shadowing in a smoker

A 53 year old white man was referred with a four week history of productive cough and right sided chest pain. He had chronic obstructive pulmonary disease and was a retired upholsterer who smoked 30 cigarettes a day and consumed 140 units of alcohol a week. Clinical examination was normal. Sputum culture yielded Haemophilus influenzae, but despite several courses of antibiotics he failed to improve, developing weight loss, exertional dyspnoea, and haemoptysis.

Blood investigations showed normocytic anaemia, with mild neutrophilia and an erythrocyte sedimentation rate of 86 mm in the first hour. Serum electrolytes, calcium, and liver profile were normal. Computed tomography showed opacities in the right middle and lower lobes involving the chest wall but with no bony destruction, with right hilar and axillary lymphadenopathy (fig 1⇓). A fibreoptic bronchoscopy was unremarkable, but bronchial washings confirmed the presence of H influenzae.

The patient then developed smooth firm non-fluctuant but warm tender swellings on both sides of his chest. Core biopsies and aspirations of the lung lesion, chest wall masses, and axillary lymph node showed inflammatory changes with no evidence of malignancy or infection. Culture for tuberculosis was negative. Excision biopsy of the chest wall lesion was sent for haematoxylin and eosin staining (fig 2⇓) and later Grocott’s silver methenamine staining (fig 3⇓).