A 66-year-old man with dyspnea, left lower lobe infiltrate, and abnormal imaging.

A 66-year-old nonsmoking man was referred to the pulmonary clinic for workup after abnormal findings on chest radiograph were discovered during his evaluation for cardiac disease. The patient had a history of mitral regurgitation and atrial fibrillation, and he had lived in China at an altitude of 1,900 m all of his life. He traveled to the United States for evaluation of dyspnea. Over the past 1 year, he had been hospitalized three times for dyspnea, which was thought to be secondary to cardiac disease. His exercise tolerance included two flights of stairs or brisk walking. He had a chronic cough productive of approximately 50 mL of white sputum per day. He denied hemoptysis, fever, chills, or sweats. At age 20, the patient was treated for a chest infection. Since that time, he has been treated with Chinese medications for recurrent bronchitis. He denied a history of tuberculosis. The physical examination revealed a BP of 110/65 mm Hg; pulse rate, 80 beats/min; and respiration rate, 18 breaths/min. Cachexia was present, but the patient was in no acute distress. The jugular venous distention was 7 cm, without hepatojugular reflux. There were diminished breath sounds bilaterally and crackles in the left lower lung field. The cardiac examination was notable for a normal S1 and S2, and a grade II/VI systolic murmur at the apex. There were no gallops, opening snap, or diastolic murmurs. His extremities were without clubbing, cyanosis, or edema. The patient’s chest radiograph and thoracic CT scan are shown in Figures 1–3.