Correct!
4. Thoracic CT shows new, multiple, poorly defined, randomly distributed bilateral pulmonary nodules
The contrast-enhanced thoracic CT shows interval development of (arrowheads) superimposed on the previously noted lingular and left lower lobe consolidation (arrow) and left pleural effusion (*). While a left pleural effusion is still present, the effusion is not enlarged compared to the prior CT (Figure 3). There is no significant pericardial fluid collection. No evidence of endobronchial obstruction is noted. No foci of gas in the pulmonary interstitium are seen.
Further clinical course: The patient’s mental status continued to worsen, and focal left-sided weakness became more apparent, suggesting that the acute head CT findings more likely reflected stroke rather than encephalitis. Repeat head CT confirmed this impression- an area of low attenuation, consistent with cytotoxic edema, conforming to the right middle cerebral artery vascular territory, was recognized. Transthoracic echocardiography was performed which disclosed a finding that was felt to explain the patient’s fever, stroke and new pulmonary nodule; this finding is also present on the repeat enhanced thoracic CT (Figure 6: Panels I-O)-
What abnormality on the thoracic CT provides an explanation for the patient’s symptom complex? (Click on the correct answer to proceed to the last of 7 panels)