Correct!
Community acquired pneumonia remains a consideration in a 60 year old previously healthy man although the presentation and the chest x-ray are unusual. Coccidioidomycosis is common in the Southwest and remains in most differentials of chest disease. Tuberculosis is possible especially with his previous history of a +PPD and a + family history. However, the patient’s subacute course and chest x-ray with lower lobe predominance would be unusual. Pneumonitis from smoke inhalation this long after exposure would be extremely unusual. His presentation would also be very unusual for pulmonary embolism.
The patient was treated with Levaquin and Tessalon Perles and scheduled for follow up in 2 weeks. His fever and cough improved although the later remained unproductive.
However, 7 days after being seen he went to the emergency room with new onset of pleuritic pain and right shoulder and flank pain. His chest X-ray was repeated (Figure 2).
Figure 2. Repeat chest x-ray showing increasing size of several nodules and the development of new nodules.
He was admitted to the hospital and treated with ceftriaxone and azithromycin. Repeat of his CBC revealed his hemoglobin and WBC to be minimally changed at 11.3 and 13.8 respectively. Urinanalysis revealed microscopic hematuria. Coccidioidomycosis enzyme-linked assays revealed a negative IgM but a positive IgG at 1.1 IV (normal <1.0). CT abdomen was done for flank pain but was interpreted as being unremarkable. CT of the chest was performed (Figure 3).
Figure 3. Representative images from the thoracic CT scan proceeding caudally A-C. (Click here for a movie of the CT scan)
Which of the following would be indicated?
