History of Present Illness
An 82-year-old man presented to the outpatient pulmonary clinic because in the past 4 weeks he had worsening breathlessness and low-grade fever. He also had a mild, chronic, cough without sputum and had a weight loss of about 3 kg in 3 months. Chest radiography, ordered by his general practitioner, revealed bilateral calcified pleural plaques, more on the right than on the left, and further opacity in the right mid-zone ( Fig. 4.1 ).
Past Medical History
The patient had never smoked and had worked as a truck driver. When he was 25 years old, he had been diagnosed with pulmonary tuberculosis and had undergone artificial right pneumothorax. His medical history also included arterial hypertension and prostatic hypertrophy.
Physical Examination and Early Clinical Findings
The patient was hemodynamically stable, with oxygen saturation of 93% in room air and body temperature of 37.2° C [98.9° F]. Physical examination revealed widely reduced breath sounds, mainly on the right side, and fine crackles at the lower zones. Recent blood tests had shown slight leukocytosis (white blood cell [WBC] count: 12,500 cells/μL, with 59.6% neutrophils and 31.8% lymphocytes) and a small increase in the inflammation indices (C-reactive protein [CRP]: 28 mg/L, normal values < 5 mg/L). No results of previous chest computed tomography (CT) or x-ray were available. Chest ultrasonography ( Fig. 4.2 ) showed narrowed intercostal spaces, whereas the pleural line and the gliding sign were difficult to observe. At the right base, an anechoic area compatible with fluid collection was appreciated.
Chest CT showed a round mass with smooth margins and a nonhomogeneous fluid content, located in the posterior region of the right lower lobe, contiguous with the calcified fibrothorax ( Figs. 4.3 , A–C ).
The patient was admitted for further investigations. Thoracic ultrasonography allowed for identification of a space among the pleural calcifications, through which a 14-gauge needle was introduced until it reached the fluid collection. Passage of the needle through the thickened and calcified pleura was difficult. Only 5 mL of odorless, beige-colored liquid was extracted. In this sample, microscopic examination for acid-fast bacilli (AFB) yielded negative results, as did polymerase chain reaction (PCR) amplification of relevant DNA sequences of Mycobacterium tuberculosis. Sputum and urine smear microscopy results were also negative for AFB.
Whole-body 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) was performed ( Fig. 4.4 ). The lesion in the right lower lobe showed intense uptake in its peripheral part, with a maximum standard uptake value (SUV max ) of 6. No abnormal accumulation of the 18 FDG was found in other parts of the body.
