A 74-Year-Old Man With Easy Bruising and Fatigue

Arunabh Talwar, MD; Craig E. Devoe, MD; Nick Patel, DO


February 09, 2017

Physical Examination and Workup

Upon physical examination, the patient has a blood pressure of 136/60 mm Hg. His heart rate is 92 beats/min, he is febrile, with a temperature of 101.2°F (38.4°C), has a respiratory rate of 28 breaths/min, and his pulse oximetry reading is 93% on a nonrebreather face mask. The patient appears to have increased respiratory effort and diminished breath sounds; additionally, rhonchi are detected in the right upper lung field. He also has minimally decreased breath sounds at the lung bases bilaterally. The remainder of his examination is unremarkable.

Figure 1.

Figure  2.

Figure 3.

Figure 4.

New laboratory studies are obtained which show that the patient remains pancytopenic. He has 27.0 × 103/μL (27.0 × 109/L) platelets and an absolute neutrophil count of 800 cells/mm3. Plain-film radiography and CT scanning of the chest (Figures 1 and 2) show a dense right upper-lobe consolidation, with narrowing of the right upper-lobe bronchus and mediastinal lymphadenopathy.

The patient then undergoes flexible bronchoscopy that reveals a necrotic endobronchial lesion completely obstructing the anterior segment of the right upper lobe (Figure 3). Endobronchial biopsies are taken of this lesion. Histology slides are provided (Figure 4). Rigid bronchoscopy is subsequently performed, with electrocautery of the endobronchial lesion and near-complete reestablishment of the right upper lobe anterior segment lumen, without complications.


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