A 31-year-old man is admitted to your facility with presumed cryptococcal meningitis. He has a one-month history of progressively worsening headaches, malaise, weight loss, and blurred vision.
A lumbar puncture demonstrates an extremely elevated opening pressure and yields samples that are positive for Cryptococcus on microscopic examination.
The patient denies any significant medical history. Specifically, there is no history of HIV, which was confirmed by recent serologic testing at another hospital.
As a result of poor peripheral access and with anticipated need for lengthy IV antifungal therapy, a PICC (peripherally inserted central catheter) line is ordered. It is placed without incident at the bedside, and as per protocol, a post-placement portable chest radiograph is obtained. What is your impression?
ANSWER
The radiograph demonstrates a right PICC line terminating at the superior vena cava. There is no evidence of pneumothorax.
Of note, however, is a large oval density within the right upper lobe, measuring 4.5 x 7 cm. This lesion could represent a loculated mass such as an abscess or hematoma. Further workup with additional imaging is warranted.
The working theory on this patient was that the density likely represented abscess or infection. Contrast-enhanced CT of the chest suggested likely abscess. The patient then underwent successful CT-guided needle biopsy, which returned positive results for Cryptococcus.
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