A 52-year-old male has an unremarkable past medical history. He has a 100 pack-year histor and is an alcoholic. He noticed a "boil" over his "right collar bone". He thought maybe he was bitten by an insect. Since then has had progressivesymptoms resulting in chest pain and difficulty breathing.
Blood pressure 120/70, heart rate 120, respiratory rate 22, temperature 36.4. 99% on four liters nasal cannula. General appearance: This is a cachectic male. Lungs sounds were significant for good air entry bilaterally with vesicular breath sounds, no rhonchi or wheeze appreciated. Cardiovascular significant for a tachycardia. otherwise unremarkable. b Over the mid sternum at around T3 is a 1 cm round red maculopapular lesion; no pus from the site.
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I didn't put up a lot of the slices, but essentially we have 1. loculated fluid collection in anterior mediastinum and also some enhancement seen posterior to the right sternoclavicular joint 2. moderate sized pericardial effusion. 3. left upper lobe collapse with air bronchograms.
We have himn on broad coverage abx.
update: CT surg consult drained the "boil" and sent off purulent-appearing fluid for micro. They said it did NOT communicate down into the mediastinum which is what I was originally concerned about.
An echo is pending. Again, he is quite hemodynamically stable but cachectic appearing. More to follow...
He has 3 negative AFB's. He is to be bronched today....
Would still be concerned for actinomycosis.(alcoholic)vs Nocardia. Looks like a necrotizing pneumonia with parapneumonic loculated effusion/pericardial eff.with left lower lobe atelectasis on CT. Will likely need a VATS. FOB to address LLL collapse and cultures.
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