Both noninfectious and infectious conditions can cause cavitary lesions in the lung. Such lesions are a rare complication of
A 24-year-old male presented to our emergency department with worsening cough, fever, and chills of one-day duration. The patient reported cough for one week that progressively worsened, with mucoid phlegm associated with low-grade fever, chills, and shortness of breath of 1-day duration. He denied hemoptysis, gastrointestinal symptoms, and chest pain and reported no bird exposure, skin rash, arthralgia, recent travel, or sick contacts. His medical history was significant for mild persistent asthma and schizophrenia. He had no prior surgeries and had resided in a psychiatric facility for 2 years with no occupational exposure to chemicals or toxins. He was a former polysubstance abuser and was in abstinence for 2 years. He denied smoking cigarettes, using illicit drugs, or abusing alcohol and had no reported allergies. His medications included divalproex sodium, clozapine, zolpidem, albuterol, and fluticasone aerosol inhaler. He had a negative tuberculin skin test 6 months prior to admission for the current complaint.
A physical examination revealed a young man of average built, with a temperature of 100.4 F, pulse rate of 78/min, respiratory rate of 20/min, and blood pressure of 110/66 mmHg; he also showed 96% saturation on ambient air. He appeared lethargic, with no conjunctival pallor, cyanosis, nuchal rigidity, skin eruptions, or palpable lymphadenopathy. Bilateral air entry was evident on auscultation of lungs, with fine rales on the right side. A precordial examination revealed normal heart sounds, with no murmur, rub, or gallop. An abdominal exam revealed no organomegaly, and a neurological examination showed no motor or sensory neurological deficits. An initial laboratory examination showed neutrophilic leukocytosis (white blood cell count, 18,000/mm3 with 74% neutrophils) and elevated blood urea nitrogen (25 mg/dL) with lactic acidosis (2.5 mmol/L). He had no anemia (hemoglobin, 13.5 g/dL), thrombocytopenia (157,000/
Pertinent laboratory findings.
Serum anti-RSV IgM | 0.64 |
Serum anti-RSV IgG | 1.4 |
Nasal influenza A/B swab | Negative |
Anti-ribosomal P antibody | Negative |
Anti-nuclear antibody | Negative |
Anti-DNA antibody | Negative |
Smooth muscle antibody | Negative |
Anti-scleroderma 70 antibody | Negative |
Myeloperoxidase | Negative |
Proteinase 3 antibody | Negative |
Cold agglutinin antibody | Negative |
Rheumatoid factor | Negative |
Anti-cyclic citrullinated antibody | Negative |
HIV | Negative |
|
<1 : 20 |
Chlamydial pneumonia IgG | <1 : 64 |
|
Negative |
|
Negative |
Blood, urine, and respiratory culture | Negative |
BAL cultures and acid fast bacilli stains | Negative |
Cryoglobulin level | Negative |
|
1 : 1,280 |
Cold agglutinin titer | 1 : 320 |
(a) Chest X-ray performed on admission, showing right upper lobe consolidation. (b) Chest X-ray performed at 2-month follow-up, showing right upper lobe scarring and improvement in consolidation.
(a) Chest axial view of CT performed on the day of admission, showing a thick-wall cavitary lesion (6.0 × 1.6 × 3.5 cm) in the right upper lobe of the lung. (b) Chest axial view of CT performed at 2-month follow-up, showing foci with ground glass opacity in the anterior right upper lobe of the lung surrounding a 9.9 mm nodular density. (c) Chest axial view of a CT performed at 3-month follow-up, showing complete resolution of the right upper lobe cavitary lesion.
Cavitary lesions associated with specific diseases are frequently described as being “thick walled” or “thin walled” and of noninfectious or infectious origin. Some noninfectious causes are squamous cell carcinoma of lung, lymphoma, Kaposi sarcoma, and metastatic disease. Other noninfectious conditions include Wegener’s granulomatosis, sarcoidosis, and Langerhans cell histiocytosis. Infectious causes of cavitary lesions include necrotizing pneumonia, lung abscess caused by
In our case, there was no renal involvement, and a lung biopsy revealed no tumors or granulomas. These results effectively exclude Wegener’s granulomatosis, sarcoidosis, and malignancy. All of our patient’s bacterial, viral, and fungal cultures were negative, excluding most infectious etiologies. Cultures were negative for typical and atypical mycobacteria, but the patient had elevated cold agglutinin and
There were no distinguishing clinical or radiographic manifestations that confidently diagnose
The therapeutic mainstays for suspected
Computed tomography
None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the manuscript.
Misbahuddin Khaja and Muhammad Kashif searched the literature and wrote the manuscript. Misbahuddin Khaja conceived and edited the manuscript. Rizwan Ahmed Dudekula and Muhammad Kashif were involved in patient care along with Misbahuddin Khaja. All authors have made significant contributions to the manuscript and have reviewed it before submission. All authors have confirmed that the manuscript is not under consideration for review at any other journal. All authors have read and approved the final manuscript.