Contributed by Douglas R. Johnson, MD, A. William Pasculle, ScD and John Sheaffer, MS
Published on line in October 1999
This 39 year-old female presented to an outside institution with a 2 week history of chills and non-productive cough. She also reported episodic "bronchitis" once or twice a year, and a smoking history of 1 ½ to 2 packs of cigarettes per day. The patient received a course of Amoxicillin with apparent resolution of symptoms; however, a routine chest radiograph revealed a 3 cm cavitary lesion in the right upper lung lobe ( IMAGE 1 ). She was subsequently referred to a pulmonary medicine specialist for further evaluation. The patient later reported that she had resided in Arizona for a ten years where she worked as an apprentice electrician in a "dusty desert environment." Serologic studies for Coccidioides were negative, however; and multiple sputum cultures and a PPD were also negative. A lung CT scan confirmed the presence of the right upper lobe cavity and showed adjacent bronchial distortion and fibrosis, raising the possibility of a cavitating neoplastic process. Several additional small nodules identified in the left upper lung lobe were interpreted as typical for the appearance of a mycobacterial infection ( IMAGE 2, IMAGE 3, and IMAGE 4 ).