Coughing Up a Diagnosis

Coughing Up a Diagnosis: A Cavitary Lung Lesion with Worsening Eosinophilia

A 37-year-old woman from Botswana appeared to have community-acquired pneumonia, but in fact, she had a more exotic infection. She was hospitalized with a productive cough and dyspnea of 2 days' duration. Right lower lobe consolidation was seen on a chest x-ray. Her past medical history was unremarkable. Laboratory testing revealed a leukocyte count of 9.5 × 103 cells/μL with neutrophil predominance (8.6 × 103 cells/μL; 91%), and an eosinophil count of 0.19 × 103 cells/μL (2%). She did well on levofloxacin therapy and was discharged. Four days later, she was rehospitalized with recurrent symptoms.

On physical examination, the patient had a blood pressure of 124/73 mm Hg, a pulse rate of 110 beats per minute, a respiratory rate of 40 breaths per minute, and a temperature of 102.2° F (39° C). Her oxygen saturation was 100% on room air. Decreased breath sounds and egophony were noted at the right lung base. Laboratory testing demonstrated a leukocyte count of 13 × 103 cells/μL with a neutrophil count of 8.5 × 103 cells/μL (65%) and an eosinophil count of 1.2 × 103 cells/μL (9%).

A chest x-ray disclosed persistent right lower-lobe consolidation with a new air lucency (Figure 1). Chest computed tomography (CT) showed a cavity measuring 6 × 5 × 7 cm within the right lower-lobe consolidation and a floating membrane inside the cavity (Figures 2 and 3). The tracheal and right main-stem bronchial mucosa had an irregular cobblestone appearance on bronchoscopy; purulent secretions were evident in the right lower-lobe bronchus. Mucosal biopsy of the carina revealed eosinophilic infiltrates without additional diagnostic features.

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-- Hiroshi Sekiguchi, MD, Jun Suzuki, Bobbi S. Pritt, MD, Jay H. Ryu, MD

This article originally appeared in the April 2013 issue of The American Journal of Medicine.