A Young Man with Fever, Pleuritic Chest Pain, and a Lung Mass

Abstract

A young male cigarette smoker was hospitalized with a 2-week history of fever, dyspnea, hemoptysis, and left pleuritic chest pain. Radiographic chest imaging revealed a large left lung mass with a loculated pleural effusion. Routine cultures of sputum, blood, and urine were negative.A 24-year-old man was admitted to community hospital 2 weeks after onset of fever with chills and night sweats, dyspnea, hemoptysis, and left pleuritic chest pain. He had a history of mild intermittent asthma and was currently smoking cigarettes. The patient's initial chest radiograph at the other hospital reportedly showed left-sided consolidation with an air-fluid level. After initiation of treatment with vancomycin, piperacillin-tazobactam, and levofloxacin for a presumed lung abscess, he was transferred to our facility in Indianapolis, Indiana for further management.At the time of transfer, he was afebrile. The heart rate was 77 beats per minute. He was breathing comfortably at 16 breaths per minute with an oxygen saturation of 98% on ambient air. Chest examination revealed diminished breath sounds over the left hemithorax with associated dullness to percussion. The rest of the examination was unremarkable. Laboratory studies disclosed a hemoglobin level of 9.9 g/dl and a white blood cell count of 8,600 cells/ml with a normal differential. Results of routine bacterial cultures of blood, urine, and sputum were negative. The initial chest radiograph at our facility revealed complete opacification of the left hemithorax ( Figure 1A). Chest computed tomography scan demonstrated a left-sided multiloculated effusion associated with a large mixed-density mass showing focal areas of necrosis and endobronchial extension into the left main bronchus (Figures 1B-1D).A thoracentesis was performed. Pleural fluid analysis revealed an exudative pleural effusion with total nucleated cells of 381,500/ml (100% polymorphonuclear cells). The fluid pH was 7.25, glucose level Figure 1. Imaging studies. (A) Chest radiograph shows complete opacification of the left hemithorax. (B-D) Contrast-enhanced computed tomography scan of the chest shows a large left-sided multiloculated pleural effusion (black arrows) with a large mixed-density lesion (white arrows) in the lung showing areas of necrosis and endobronchial extension into the left mainstem bronchus.