Fig 1. — Posterior-anterior chest radiograph demonstrating upper lobe-predominant consolidation and ground glass opacification with some small nodules. Left hilar prominence is due to anatomic distortion from prior surgery.

Case Description

A 41-year-old woman with the posterior-anterior chest radiograph shown in Fig 1 presented with worsening dyspnea. Her past medical history included essential thrombocythemia diagnosed on bone marrow biopsy nine years earlier and surgical left lung biopsy five years prior to presentation that yielded a diagnosis of Mycobacterium avium complex pulmonary infection. The chest radiograph demonstrates perihilar consolidation with areas of ground glass opacification and nodularity that are upper-lobe predominant. Subsequent high-resolution computed tomography (HRCT) shows geographic regions of ground glass opacification with smooth interlobular septal thickening and hazy nodules in the upper lobes peripheral to more confluent areas of lung disease (Fig 2A-B). The ground glass opacities spare some secondary pulmonary lobules, yielding a mosaic pattern of abnormality.

Fig 2A and B. — Selected HRCT images of the right (A) and left (B) lung obtained using 1-mm collimation, high spatial frequency reconstruction algorithm, and targeted reconstruction to a 23.7-cm field of view. These images demonstrate geographic areas of ground glass opacification with smooth interlobular septal thickening and some hazy nodules. The findings are more severe in the upper lobes.

Which of the following choices is the most likely diagnosis?

1. lymphoma

2. Pneumocystis carinii pneumonia

3. sarcoidosis

4. alveolar proteinosis

5. nontuberculous mycobacterial pulmonary infection

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Turn to the next page for the answer and discussion.

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