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Endgames Picture Quiz

An unusual case of pneumonia

BMJ 2012; 345 doi: (Published 09 August 2012) Cite this as: BMJ 2012;345:e5272
  1. Andrew W Barritt, neurology registrar,
  2. Mark B Jackson, consultant respiratory physician
  1. 1Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton BN2 5BE, UK
  1. Correspondence to: A W Barritt awb{at}

A 28 year old woman presented with a one week history of increasing shortness of breath on exertion, which was associated with a dry cough and mild pain on the right side of the lateral chest wall. She had also felt feverish and experienced night sweats for three days. Her medical history included mild asthma for five years, which was well controlled on twice daily inhaled beclometasone, and a caesarean section three months before. Her postoperative recovery was uneventful. She was an ex-smoker, rarely drank alcohol, and denied any illicit drug use. In addition, her only recent foreign travel was a trip to France six months ago.

On examination, she was fully alert and oriented but was febrile (38.2°C), with a peripheral oxygen saturation of 95% on room air. On auscultation she had right sided lower zone lung crackles but no wheeze. The lymph nodes were not palpable. Her blood pressure was 96/60 mm Hg and her pulse was 84 beats/min. Initial blood tests showed haemoglobin 127 g/L (reference range 115-165) and the total white cell count 9.3×109/L (4.0-11.0), with an eosinophil count of 2.3×109/L (0.0-0.4). C reactive protein and erythrocyte sedimentation rate were raised at 172 mg/L (<5) and 102 mm in the first hour (0-15), respectively. Renal and liver function tests were normal and HIV serology was negative. A plain posterior-anterior radiograph is shown in fig 1.


  • 1 What does the chest radiograph show?

  • 2 What is the differential diagnosis?

  • 3 Which further investigations would you perform?


1 What does the chest radiograph show?

Short answer

The radiograph shows bilateral, particularly right sided, peripheral air space consolidation. Consolidation is also seen posteriorly and peripherally in the right lower zone, below the level of the right hilum. The cardiac outline is normal and no pleural effusion or pneumothorax is seen.

Long answer

The plain …

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