Correct!
1. Aspiration pneumonia
The presence of recurrent bilateral lower lobe pneumonias in an older patient raises concern for aspiration pneumonia. Neither lymphoproliferative disorder nor bronchogenic malignancy would be expected to regress following antibiotic therapy directed towards community-acquired pneumonia. Similarly, while amyloidosis could produce nodular pulmonary opacities, this patient has no history of renal disease and pulmonary opacities due to amyloidosis would not wax and wane in this fashion, nor would they be expected to respond to antibiotic therapy. Langerhans cell histiocytosis typically produces upper lobe nodular and cystic disease, typically nearly completely cystic in a patient of this age, and the patient has not been an active smoker for 30 years.
The patient underwent maxillofacial CT to assess for sinus disease, which was negative, and pulmonary medicine felt there was nothing else to do as regards possible recurrent aspiration pneumonia at this point. About one month following pulmonary medicine consultation, the patient again presented to the Emergency Room with the same symptoms as before and underwent repeat chest radiography (not shown), which showed possible right lower lobe pneumonia. He was treated with clarithromycin and was not seen for about 10 more months. He then re-presented to his primary care physician with complaints of asthma-like symptoms, for which his inhaled steroids were re-started, his ipratropium bromide inhaler dose was increased, and he was again encouraged to use his adrenergic bronchodilator as needed. A repeat chest radiograph was performed (image not shown) and was interpreted as negative for acute disease. Over the ensuing year the patient was seen by various consultants, such as an ophthalmologist for cataracts, an allergist for his atopic symptoms, and a dermatologist for resection of a localized squamous cell carcinoma on one of his forearms. After nearly a year, the patient re-presented to the Emergency Room for complaints of generalized weakness, progressive exertional dyspnea, and cough productive of white sputum, for which repeat thoracic CTA (Figure 9) was performed.
Figure 9. Upper panels: representative images from thoracic CTA performed for pulmonary embolism. Lower panel: video of thoracic CTA.
Which of the following represents the most accurate assessment of the thoracic CTA findings? (Click on the correct answer to proceed to the ninth of nineteen pages)