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Pulmonary puzzles
A rapid change in a patient's chest radiograph appearances
  1. Joseph Hutton,
  2. Claire McBrien,
  3. Zafeiris Sardelis,
  4. Garrett McGann
  1. Department of Respiratory Medicine, Cheltenham General Hospital, Cheltenham, Gloucestershire, UK
  1. Correspondence to Dr Joseph Hutton, Department of Respiratory Medicine, Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire GL53 7AN, UK; Jh7480{at}my.bristol.ac.uk

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Clinical presentation

A 72-year-old man with a history of rheumatoid arthritis (on multiple immunosuppressants: leflunomide, etanercept and hydroxychloroquine) was admitted with headache and fever. He had no other symptoms or relevant medical history. Clinical examination demonstrated coarse crepitations throughout the right upper zone. Chest radiograph revealed consolidation in the right upper zone, peripherally (figure 1A).

Figure 1

(A) Admission chest radiograph. (B) Repeat chest radiograph following episode of pleuritic chest pain and haemoptysis.

The patient's immunosuppressive agents were stopped and he was treated with intravenous benzylpenicillin, clarithromycin and a single dose of gentamicin. After several days of treatment, he improved clinically. Unfortunately 7 days into the admission, he awoke feeling dyspnoeic. He coughed and experienced right-sided pleuritic pain, which resolved following an episode of haemoptysis (a few millilitres only). Clinical examination demonstrated decreased air entry in …

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