Correct!
3. Unenhanced chest CT shows evidence of old granulomatous infection
Unenhanced chest CT shows calcified mediastinal and left peribronchial lymph nodes, but no lymphadenopathy otherwise, and no evidence of abnormal lung opacity or pleural abnormality is seen. No chest wall gas collections are seen.
The patient developed diarrhea at admission. CT of the abdomen and pelvis was largely unremarkable, and the patient responded to intravenous hydration. Ultrasound of the liver showed no liver transplant dysfunction. Stool cultures were positive for Clostridium difficile and the patient was treated with oral vancomycin. One blood culture was positive for Citrobacter freundii for which the patient was treated with meropenem. The patient was discharged with a plan for outpatient endoscopic retrograde cholangiopancreatography (ERCP) given the history of biliary strictures and recent positive gram-negative blood cultures, and oral ciprofloxacin was initiated in preparation for this procedure.
Over the course of the next two years the patient remained relatively stable. She was seen by neurology for left arm numbness and diagnosed with a small subcortical infarct, but no large stroke or residual deficit was noted. She also saw pulmonary medicine several times for asthma-like symptoms for which a steroid inhaler was prescribed, and several short courses of prednisone were employed.
About 2 years after her initial presentation, she underwent renal transplantation for her chronic progressive renal insufficiency.
About 6 months following her renal transplantation, the patient resented to the Emergency Room with complaints of productive cough for the previous 2 months, now complicated by dyspnea on exertion and orthopnea. She had presented to an urgent care facility about one week earlier and had been presumptively treated with doxycycline, an albuterol inhaler, and a corticosteroid taper, but without effect. She stated that nothing had changed to precipitate her Emergency Room presentation, but she simply got tired of her shortness of breath.
The patient denied any associated fever, sinus pressure, hemoptysis, chest pain or pressure, or peripheral edema. Just prior to this presentation, a surveillance liver biopsy was performed and read as indeterminate for acute cellular rejection with focal interstitial inflammation and tubulitis, with the recommendation for corticosteroid taper. In the Emergency Room, the patient’s vital signs were normal, she was afebrile, and her room air oxygen saturation was 95%. Her physical examination disclosed slight expiratory wheezing posteriorly bilaterally. Frontal chest radiography (Figure 4) was performed.
Figure 4. Frontal (A) and lateral (B) chest radiography performed about 2 years following initial Emergency Room presentation, and about 6 months after renal transplantation. To view Figure 4 in a separate enlarged window, click here.
Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the sixth of 12 pages)
