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4. Disseminated infection
Pulmonary hemorrhage typically appears as multifocal or diffuse lung opacity, not small circumscribed nodules. Lymphoproliferative disorders within the thorax may present in numerous ways, most commonly lymphadenopathy and/or mediastinal mass. The solitary pulmonary nodule or multiple pulmonary nodules (the latter particularly in the context of immunocompromise) are less common intrathoracic manifestations of lymphoproliferative disorders. Lymphoproliferative disease can also manifest as pleural abnormalities or osseous lesions. Lymphoproliferative disease can manifest as small pulmonary nodules, but this manifestation is rare, whereas disseminated infection commonly presents in this manner. Pulmonary manifestations of inflammatory bowel disease are numerous, but most commonly manifest as airway disorders (bronchiectasis and small airway obstruction, uncommonly tracheal inflammation or airway stenoses) or organizing pneumonia. Fibrotic disease and/or alveolitis may also be a thoracic manifestation of inflammatory bowel disease or the medications used to treat the disorder. Rare necrobiotic nodules may be a presentation of inflammatory bowel disease within the thorax, but usually such nodules are larger and less numerous than those present at chest radiography in this patient. Finally, histiocytic disorders, such as Langerhans cell histiocytosis, commonly present with upper small nodules with lobe cystic abnormalities, although rarely Langerhans cell histiocytosis may manifest with small nodules, typically upper lobe predominant, without accompanying cysts. Other histiocytic disorders are very rare, such as Rosai-Dorfman disease, and are more commonly associated with lymph node enlargement. Some histiocytic disorders can present with small nodules that may resemble sarcoidosis, but such a manifestation is exceedingly rare and far less common than disseminated infection presenting with small nodules.
The rash the patient presented with was improving with the use of topical steroid cream. General surgery was consulted for possible repeat retroperitoneal lymph node biopsy, but deferred, advising cardiothoracic surgery consult for mediastinoscopy. Testing for coccidioidomycosis was negative. Hematology / Oncology was consulted regarding the possibility of a second superimposed process in addition to the ulcerative colitis, namely potential malignancy. The consult team could not identify a palpable lymph node to target for another biopsy, and they recommended against a bone marrow biopsy given the normal white blood cell count, normal white blood cell differential count, and normal platelet count and anemia attributable to chronic disease. The consultant advised 18FDG-PET scan (Figure 5) for selecting a target for additional tissue sampling.
Figure 5. 18FDG-PET scan shows multifocal mediastinal and supraclavicular metabolically active lymphadenopathy as well as metabolically active lesions within the thoracic spine and spleen. A small right and trace left pleural effusions show no metabolic activity. Hypermetabolism is also seen in the right upper lobe laterally.
Which of the following statements regarding the chest radiograph is most accurate? (Click on correct answer to be directed to the seventh of ten pages)