SCVIR Annual Meeting Film Panel Session: Diagnosis and Discussion of Case 1

Abstract

A previously healthy 22-year-old Colombian man presented with recurrent fevers, cough, hemoptysis, and weight loss. He was treated with various antibiotics for presumed pneumonia without clinical response. Noncontrast high-resolution CT of the chest was performed (Fig 1.1). An empiric course of steroids produced only transient improvement. Multiple HIV tests and blood cultures were negative, as were bronchoscopy and bone marrow biopsy. Blood work demonstrated an elevated erythrocyte sedimentation rate (.90 mm/h). Lower extremity Doppler sonography revealed no evidence of deep venous thrombosis. Transesophageal echocardiography identified an 8 mm right atrial mass. Contrast-enhanced CT (Fig 1.2) was performed. The patient then underwent limited right thoracotomy with resection of the posterior segment of the right lower lobe. Pathologic examination revealed chronic pleuritis, hemorrhagic infarct, and organizing thrombus within the small pulmonary arteries. The right atrial mass was resected. Pathologic examination showed it to be composed entirely of thrombus. No organisms were seen and all cultures were negative. Postoperatively, the patient continued to experience fevers to 105°F that did not resolve with parenteral antibiotics. After receiving cyclosporine, his fever decreased and he experienced no further hemoptysis. Repeat CT showed no change in the size of the left pulmonary artery aneurysm, but the thickness of the wall diminished, and there was apparent improvement in the right pulmonary artery aneurysm, with a decrease in size and thickness of the aneurysm wall. He remained symptom-free for 3 months while undergoing empiric immunosuppression; however, he developed recurrent fevers and blood-tinged sputum, which progressed to frank hemoptysis, requiring hospitalization. Corticosteroid therapy was initiated and CT demonstrated an increase in the size of the left lower lobe pulmonary artery aneurysm with interim aneurysmal dilation of several sub-