An 84-year-old woman with a past medical history significant for hyperlipidemia and hypertension presented with one month of anorexia, right upper quadrant pain, nausea, night sweats and a weight loss of 5.9 kg over three months. One week before presentation she developed a cough with purulent sputum production and occasional streaks of blood. She was a nonsmoker and her surgical history was significant for a cholecystectomy five years ago. Physical examination revealed a thin woman with no respiratory distress. Vital signs were stable and auscultation of the chest revealed crackles over the right lower posterior hemi-thorax.
There was tenderness in the right upper quadrant of the abdomen, with hypoactive bowel sounds and no peritoneal signs. There were no palpable masses or hepatosplenomegaly; the remainder of the physical examination was normal. Laboratory tests revealed a white blood cell count of 21×109/L (differential of 72% granulocytes, 16% lymphocytes, 8% monocytes and 4% bands), an aspartate aminotransferase level of 199 U/L (normal 14 U/L to 48 U/L), an alanine aminotransferase level of 89 U/L (normal 8 U/L to 50 U/L), an alkaline phosphatase level of 123 U/L (normal 40 U/L to 120 U/L) and a serum bilirubin level of 30.78 pmol/L (normal 0 pmol/L to 22 pmol/L). The total protein and gamma glutamyl transferase levels were normal, as were the remainder of the routine laboratory tests. A chest radiograph at the time of admission (Figure 1) showed a cavitary lesion present in the right lower lobe. ventolin inhalers
Figure 1) A posteroanterior chest radiograph taken at the time of admission showing a cavitary lesion in the right lower lobe