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Endgames Picture Quiz

A man with fever, a productive cough, and a striking chest radiograph

BMJ 2014; 348 doi: (Published 02 April 2014) Cite this as: BMJ 2014;348:g2212
  1. Edward Davies, foundation year two doctor1,
  2. Imran Aziz, consultant respiratory physician2
  1. 1Department of Medicine, Royal Albert and Edward Infirmary, Wrightington, Wigan, and Leigh NHS Foundation Trust, Wigan WN1 2NN, UK
  2. 2Department of Chest Medicine, Royal Albert and Edward Infirmary, Wrightington, Wigan, and Leigh NHS Foundation Trust, Wigan, UK
  1. daviesej7{at}

A 41 year old man presented to the emergency department with a two week history of worsening shortness of breath. Associated symptoms included a cough productive of green sputum, intermittent fevers, night sweats, and non-pleuritic pain in the right side of the chest wall. He had a history of chronic pancreatitis secondary to alcohol excess, which was complicated by diet controlled type 2 diabetes. He also smoked 40 cigarettes a day.

His regular drugs included pancreatin and omeprazole. At triage, his heart rate was 135 beats/min, blood pressure was 133/84 mm Hg, respiratory rate was 24 breaths/min, oxygen saturations were 82% on room air, and temperature was 38.5°C. On examination he did not have finger clubbing, but air entry was reduced in the right mid and lower zones and he had inspiratory crackles at the left base. The rest of the respiratory and general examination was unremarkable.

A full blood count on admission showed: total white blood cell count 14.8×109/L (reference range 4.0-11.0), neutrophil count 12.1×109/L (1.8-7.8), haemoglobin 124 g/L (130-180), platelets 689×109/L (150-450), and C reactive protein 144 mg/L (<5.0; 1 mg/L=9.52 nmol/L). Electrocardiography demonstrated sinus tachycardia at a rate of 128 beats/min. Figure 1 shows his chest radiograph at admission.

Fig 1 Admission chest radiograph


  • 1. What does the chest radiograph show?

  • 2. What further history needs to be gained from the patient?

  • 3. How would you further investigate this patient?

  • 4. What is the likely cause of this man’s condition and how would you manage it?


1. What does the chest radiograph show?

Short answer

The large thick walled cavitating lesion in the right lower lobe with an air fluid level is in keeping with a pulmonary abscess given the history of fevers, night sweats, productive cough, and raised inflammatory markers.

Long answer

The chest radiograph shows a thick walled cavitating …

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