JMG (junior doctor) and KB (respiratory specialist trainee)

A 44-year-old Polish man attended the emergency department complaining of cough and pleuritic chest pain. He had a fever of 38.6°C and his oxygen saturation (SpO₂) was 97%. His medical history included childhood asthma. He took no medication or over-the-counter remedies. He was a smoker with a 60-pack year history and consumed 200 units of alcohol a week for 16 years, but reported he stopped drinking 1 month ago. He migrated from Poland 15 years ago and worked as a manual labourer. He denied any recent foreign travel. A chest X-ray (CXR) showed a cavitating lung lesion, and a subsequent urgent CT scan of the chest performed to rule out malignancy demonstrated a cavitating consolidation in the left posterior upper lobe and consolidation of the right lateral middle lobe (figures 1–4). Cavitating pneumonia in those with alcohol excess usually occurs in the posterior segments of the upper lobes. He was prescribed a 1-week course of co-amoxiclav for suspected bacterial pneumonia and was referred to the respiratory outpatient clinic to investigate these lesions further. At that time, his full blood count was normal.

We met this patient 1 month later when he re-presented to the emergency department, with a 1-day history of moderate-volume haemoptysis and epistaxis on a background of left lateral chest pain, dry cough and exertional dyspnoea. He was apyrexic and his SpO₂ was 95% at rest. He reported loss of appetite and 40 kg weight loss over the past year. Weighing 93 kg on admission with new onset lethargy …