Case Presentation:

A 51–year–old female with history of anxiety, depression, and tobacco abuse was admitted to the ICU due to severe respiratory distress, hypoxia, productive cough, fever and chills. Her symptoms began 8 days prior with a mild productive cough. It progressively worsened to a persistent cough with thick green sputum streaked with blood, associated with right sided pleuritic pain. The auscultation revealed crackles and coarse respiratory sounds on the right lung. There was leukocytosis of 23.5k cells/mL. A chest CT scan revealed multiple cavitary lesions with areas of alveolar infiltration in the right lung (Figure 1). Patient was started on broad spectrum antibiotics. After 1 day of noninvasive positive pressure ventilation, adequate saturation was maintained. She was sent to the general medical floor where she persisted febrile for 10 days. The fact that the lesions were located only in the right lung called the attention of clinicians, pulmonologists and radiologists. An extensive work up was done to find the etiology. Blood cultures were negative as well as sputum samples for AFB. A transesophageal echocardiogram was negative for endocarditis. Fungal serologies and histoplasma urinary antigen were negative. A CT–guided biopsy of the most superficial cavitary lesion showed active inflammation but no organisms. A Bronchoscopy had been attempted initially but could not be completed due to inability to properly sedate the patient due to history of high dose psychotropic medications use. This latter piece of information brought forth further questioning which yielded that the patient increased her nightly quetiapine dose from 400 mg to 800 mg, feeling “sedated” in the morning and having difficulty awakening. It was discovered that patient always sleeps on her right side due to a severe and chronic lower back pain. Patient was discharged with a long course of antibiotics. Follow up showed significant clinical and radiologic improvement.

Discussion:

Multiple cavitary lung lesions represent a broad differential diagnosis. The fact that they were multiple (more than 10) and located only in the right lung made this case unique. After a very extensive and expensive work up, the most logical explanation was obtained through detailed history taking. This was a case of aspiration pneumonia in a heavily sedated patient who might not have protected her airway during her sleep and who always sleeps on her right side due to severe and chronic back pain. The confirmation of this hypothesis was done with clinical and radiologic improvement after a long course of antibiotics for aspiration pneumonia.

Conclusions:

A rare presentation of a common disease could be explained through a detailed history more than a very expensive laboratory work up or invasive procedures.

Figure 1Chest CT scan at presentation. It shows multiple cavitary lesions with areas of alveolar infiltration in the right lung. The left lung is spared.