A 29-year-old male with malaise, chest pain and night sweats

Abstract

A 29-yr-old male was seen in clinic for apparent mediastinal lymphadenopathy. While in the USA, 1 month previously, he became unwell, with night sweats, malaise, cough and pleuritic chest pain. He attended hospital, where the unusual appearance of his chest radiograph was noted. Subsequently, computed tomography (CT) of the thorax was undertaken and he was advised that he would need a mediastinoscopy. He declined the intervention and returned to the UK for continued management. No other information was available from the hospital in the USA. When reviewed in clinic, his constitutional symptoms had resolved, leaving only a complaint of ''clicking'' during inspiration.The patient had previously enjoyed good health, apart from developing bilateral primary spontaneous pneumothoraces, followed soon after by a recurrent left pneumothorax, 7 yrs previously. The latter was successfully managed by thoracoscopic insufflation of 4.95 g of iodised asbestos-free talc. No further imaging of the chest was carried out until this presentation. He had a 15-pack-yr smoking history and drank 10 units of alcohol per week. On examination there were a few shotty axillary lymph nodes, the largest being 1.5 cm on the right medial wall. In the chest, dullness to percussion was noted over the left clavicle, where breath sounds were also diminished.Laboratory studies demonstrated a normal full blood count, erythrocyte sedimentation rate (ESR) of 2 and C-reactive protein (CRP) of 5 mg?L -1 (0-9). Serum biochemistry, liver function tests and immunoglobulins were normal.Chest radiography ( fig. 1) and CT scans of the lungs and mediastinum (figs 2-4) were performed. FIGURE 2. Computed tomography chest scan cut through the superior mediastinum.