Case 35-1996

Abstract

A 57-year-old woman was admitted to the hospital because of fever, sweats, neuropathy, and multiple pulmonary nodules.The patient had been well until nine months earlier, when weakness developed in the left ankle. During the following month, she had fevers, night sweats, and fatigue. Electrophysiologic testing performed elsewhere revealed a posterior tibial neuropathy of mixed demyelinative type. The fevers and night sweats waxed and waned, and the fatigue persisted. Three months before admission, the fevers and night sweats increased, with a rise in the temperature to 38.3°C and rigors. She lost 4.5 kg in weight.Five weeks before admission, the patient entered another hospital, where laboratory examinations were performed. The values for creatinine, uric acid, electrolytes, and bilirubin were normal. The results of other laboratory tests are shown in Tables 1, 2, and 3. Radiographs of the chest showed multiple pulmonary nodules. A computed tomographic (CT) scan of the chest (Fig. 1), obtained without the administration of contrast material, showed multiple nodules, 4 to 20 mm in diameter, predominantly at the periphery of the lung bases but also in the left upper and right middle lobes. Many of the lesions were ill defined, and several contained air bronchograms. A CT scan of the abdomen revealed multiple small hepatic lesions. Microscopical examination of a bone marrow-biopsy specimen showed no abnormalities. She was referred to this hospital.The patient was a housewife. She had a 30-year history of cigarette smoking but had stopped smoking 6 years earlier. She had recently noted a rash on her buttock that was neither pruritic nor painful. There was no history of exposure to industrial dusts, risk factors for human immunodeficiency virus (HIV) infection, cough, dyspnea, hemoptysis, epistaxis, coryza, or sinus infections.On examination, the pulse was 80, the respirations were 18, and the blood pressure was 100/60 mm Hg. A rash on the right buttock was consistent with herpes zoster. A white exudate was present on the right tonsil, and a few crackles were heard at both *Five weeks before admission, leukopenia and lymphopenia were reported.