A Woman With Dyspnea, Weight Loss, and Splenic Lesions

The patient is a 37-year-old hospital employee and current smoker with a 10 pack-year smoking history, who presented with dyspnea, chest pain, and weight loss. She was in her usual state of health until 4 months prior to admission when she developed intermittent left-sided chest pain, cough productive of scant yellow sputum, fevers, and anorexia. Initial chest radiograph was normal and her outpatient physician prescribed azithromycin, which she took without improvement. One month prior to admission, a follow-up chest radiograph revealed a left-sided upper lobe consolidation; she received a course of levofloxacin without improvement. At follow-up, given her occupation, 13.6-kg unintentional weight loss, and persistent pulmonary symptoms and infiltrate despite treatment for pneumonia, her provider referred her for admission with particular concern for exclusion of active TB. As a hospital employee with clinical exposure, she underwent annual TB screening, which was always negative. She had no known exposure to patients with TB. Her most recent travel was to the Midwestern United States, without significant outdoors exposure. Review of systems was positive for wheezing, anorexia, and arthralgias of both knees and the left ankle and wrist. There was no hemoptysis, leg swelling, visual changes, palpitations, or muscle weakness.