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Progressive dyspnea in a 49-year-old woman with long-standing epilepsy.

A 49-year-old woman presented with a 3-month history of progressive breathlessness on exertion and occasional hemoptysis. She had complained of intermittent pleuritic pain, which had deteriorated prior to hospital admission. She received lamotrigine and sodium valproate for epilepsy. On examination, she had a raised erythematous facial rash. She was afebrile, normotensive, and had a normal peripheral pulse. Examination of her chest revealed no abnormality. ECG findings were normal. Arterial blood gas indexes on room air were as follows: pH, 7.39; Pco2, 34 mm Hg; Po2, 90 mm Hg; HCO3 , 25.6 mmol/L; hemoglobin, 9.0 g/dL, WBC count, 13.7 10 g/dL; and platelets, 1,158 10/L. Urea and electrolyte levels were normal. A chest radiograph showed a left pneumothorax. There was reticulation in both lungs without loss of lung volume. There was sclerosis of the upper thoracic vertebrae (Fig 1). High-resolution CT (HRCT) of the lungs (Fig 2, top) showed welldefined, thin-walled cysts in both lungs. The intervening lung parenchyma was normal. A view of the upper abdomen with soft-tissue settings (Fig 2, bottom) showed huge masses composed of fat and soft tissue replacing both kidneys. A large highattenuation area occupied the right kidney. Results of a ventilation perfusion lung scan were unremarkable.