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A Male with Pleuritic Chest Pain, Dry Cough, Progressive Dyspnoea, and Weight Loss

A 39-year-old white male presented with a 2-day history of severe right-sided pleuritic pain. He was unwell for 6 months prior to this, reporting a dry cough, exertional dyspnoea, night sweats, and 10-kg weight loss. He was a non-smoker, and had no recent foreign travel. He was a heavy goods vehicle driver, and had no known exposures to chemicals, fumes or dust. He had no prior medical history and was on no medication. Physical examination revealed normal vital signs, and SaO 2 was 96% on room air. He had no fever, clubbing, skin lesions, cervical lymphadenopathy or joint swelling. Auscultation of the lungs revealed diminished breath sounds bilaterally with crepitations over the posterior left chest. Cardiovascular, abdominal and neurological system examinations were unremarkable. A chest X-ray showed a spontaneous rightsided pneumothorax, with bilateral peripheral infi ltrates ( fi g. 1 ). A computerized tomographic scan of the chest, performed on the same day as the chest X-ray, showed the bilateral peripheral infi ltrates to represent subpleural consolidation. No mediastinal lymphadenopathy or pleural effusion was seen ( fi g. 2 ). The parameters of his laboratory test results including a full blood count and differential, renal and liver function tests, and measurement of serum calcium level were all normal. The erythrocyte sedimentation rate was 37 mm/h and C-reactive protein 50 mg/l. What is your diagnosis? What is your next diagnostic step? Received: November 14, 2005 Accepted after revision: December 21, 2005 Published online: March 31, 2006