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Rash and dyspnoea in a 39 year old man

BMJ 2011; 343 doi: (Published 29 December 2011) Cite this as: BMJ 2011;343:d8256
  1. Joel B Raffel, foundation year 2 in acute medicine,
  2. Adil Al-Lawati, overseas specialist registrar in acute medicine,
  3. Nick Murch, locum consultant physician in acute medicine
  1. 1Royal London Hospital, London E1 1BB, UK
  1. Correspondence to: J B Raffel joelraffel{at}

A previously well 39 year old man of Bengali origin presented with a three day history of fever, pleuritic chest pain, progressive dyspnoea, and non-productive cough. Six days previously he had developed a widespread centripetally distributed pruritic rash. He was employed as a chef and was an ex-smoker (20 pack year history); he had no history of misuse of drugs or alcohol. His only recent foreign travel was a brief visit to Bangladesh six months earlier. His wife and child had had similar rashes five days ago, although they were afebrile and systemically well.

His pulse was regular at 98 beats/min, blood pressure was 109/67 mm Hg, temperature was 38.4°C, and respiratory rate was 38 breaths/min. He was using his accessory muscles to breathe. Auscultation of the chest showed dry crackles increasing from the mid to the lower lung zones bilaterally. He had mildly tender hepatomegaly. He had several hundred widespread exanthematous vesicles, pustules, and crusted lesions on his skin, which extended into the oral cavity.

Arterial blood gas on room air showed a partial pressure of oxygen of 9.62 kPa, partial pressure of carbon dioxide of 5.45 kPa, pH of 7.44, bicarbonate of 25.3 (reference range 21-28), and base excess of 3.5 (±2). His lymphocyte count was 3.7×109/L (1.0-3.5) and alanine aminotransferase was 112 U/L (0-40), but urea, creatinine, electrolytes, other liver function tests results, and full blood count parameters were within normal ranges. Chest radiography was performed (figs 1 and 2 ).

Fig 1 Chest radiograph

Fig 2 Detailed view of chest radiograph


  • 1 What does the chest radiograph show?

  • 2 What is the most likely diagnosis given the overall clinical picture?

  • 3 How should this patient be managed acutely?

  • 4 What potential long term sequelae should he be counselled about?


1 What does the chest radiograph show?

Short answer

Multiple small nodules …

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