Right Upper Lobe Consolidation Simulating Pulmonary Neoplasm

A 35-year-old man, a smoker, had right pleuritic pain, productive cough, and fever for 3 days. His pulse rate was 107 beats per minute; respiratory rate, 14 breaths per minute; blood pressure, 136/80 mm Hg; and temperature, 37.7°C (99.9°F). There were signs of right upper lobe consolidation. Laboratory studies showed hyponatremia. Chest films (A, B) showed a homogeneous density in the right upper lobe.

The patient was treated with IV antibiotics. Twenty-four hours later, while awaiting chest CT to rule out a right upper lobe mass, he was found to be in respiratory distress and required ventilatory support. A chest film demonstrated right pneumothorax, and thoracotomy was performed. Examination of chest tube drainage revealed empyema, and culture of pleural fluid and sputum grew Streptococcus pneumoniae.

The patient's hospital course was complicated by sepsis and pericardial effusion, which required drainage through a pericardial window. Chest CT was not carried out because of hemodynamic instability. A follow-up x-ray study (C) showed resolving of the right upper lobe pneumonia, without masses. On the 20th day, the patient died of cardiac arrest due to fulminant septicemia and disseminated intravascular coagulation.

Writes Dr Samer Alkhuja of Greenwich, Conn, pneumococcal pneumonia may present radiographically as a noncavitating lobar consolidation simulating a pulmonary neoplasm. Empyema and pericarditis are uncommon, however, and occur in only 1% of cases. Pneumothorax rarely develops. The discovery of these abnormalities warrants a search for other complications, which often coexist.