Necrotic Mass-like Upper Lobe Opacity

Abstract

48-year-old woman presented with a 1-month history of left anterior chest wall pain, dyspnea, productive cough, and night sweats. She denied having fever but admitted weight loss of approximately 15 lb over the past 2 months. Her medical history was unremarkable except for alcohol abuse and a 74-pack-year smoking history. Her vital signs and physical examination were also unremarkable, except for bilateral wheezing and dullness to percussion over the right upper lobe. She had no known exposure history for tuberculosis. The chest radiograph showed an ill-defined opacity at the right upper lobe (Fig 1). She was admitted to the hospital and placed in respiratory isolation. A purified protein derivative was administered, and sputum was sent for cultures, cytology, and acid-fast bacilli test, all of which were negative for tuberculosis and/or malignancy. A chest CT without contrast was obtained that revealed a necrotic mass-like opacity in the right upper lobe, measuring 4.7 cm in diameter (volume, 31,871 mm 3 ), as well as patchy ground-glass opacities. A 1.9-cm pretracheal lymph node was also present (Fig 2). Fine-needle aspiration of the mass was performed, and specimens were sent for stains/culture and cytology. The patient was treated empirically with levofloxacin, 500 mg qd, for 3 weeks, during which time she had symptomatic improvement. A follow-up CT scan 4 weeks later demonstrated clearing of the ground-glass opacities and pretracheal lymphadenopathy, with reduction in diameter of the masslike opacity to 3.1 cm (volume, 24,646 mm 3 ).