Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 76 year old man with history of moderate-to-severe COPD who presented with three days of fever, breathlessness, and productive cough. Past surgical history is significant for vagotomy and partial gastrectomy 16 years earlier and a cholecystectomy 10 months prior to admission. On exam, the patient appeared acutely ill with a blood pressure of 75/45 mmHg, tachycardia, marked hypoxemia and course breath sounds throughout all lung fields. Labs revealed a white count of 2.7 K with 53% bands. The creatinine was elevated to 3.0 mg/dl from a baseline of 1.0 mg/dl. ABG showed pH 7.00, pCO2 61 mmHg, pO2 79 mmHg on 100% O2, and arterial lactate 5.2 mmol/L.
Image 1 – Baseline Chest Radiograph 10 months prior to admission
Image 2 – Admission Chest Radiograph
The patient required pressors for hypotension unresponsive to IV fluids, mechanical ventilation, and broad spectrum antimicrobial therapy.
Image 3 – Chest Radiograph from HD 1
Six days later, the chest radiograph revealed:
Image 4 – Chest Radiograph HD 6