A 47 year old man with nonproductive cough and right-sided chest pain.

A 47 yr old man was admitted to our hospital because of persisting nonproductive cough, dyspnoea on exer-tion and right-sided chest pain of several weeks duration. He was febrile (37.5°C) and had noticed a weight loss of 5 kg within the last 2 months. The only pertinent medical history was a cluster headache, for which he was treated intermittently with methysergide. He had taken a cumulative dose of approximately 630 mg over a 21 month period. He was working as a clerk, had no history of asbestos exposure, and smoked one packet of cigarettes per week. Clinical examination was normal, except for a dullness on percussion, diminished breath sounds, and pleural friction at the right base of the tho-rax. Laboratory studies showed an erythrocyte sedimenta-tion rate (ESR) of 120 mm·h-1 , a normochromic normo-cytic anaemia with haemoglobin of 103 g·L-1. Arterial oxygen tension (Pa,O 2) and arterial carbon dioxide tension (Pa,CO 2) were normal. A chest radiograph revealed a moderate pleural effusion in the right base, with a mass-like lesion in the dorsobasal part of the lung. Adeno-pathies were absent. Pleural fluid analysis showed a white blood cell count (WBC) of 5,200×10 6 cells·L-1 , with 99% lymphocytes, glucose 0.46 g·L-1 , pH of 7.37, total protein 40 g·L-1 , and lactate dehydrogenase (LDH) 1,520 U·L-1. Search for malignant cells was negative, as were stains and cultures for bacteria, mycobacteria and fungi. Bronchoscopy was normal, except for an erythematous mucosa in the right lower lobe. Transbronchial biopsies and subsequent open lung biopsy disclosed nonspeci-fic parenchymal fibrosis. Computed tomography (CT) of the thorax was taken on admission (fig. 1) and after 5 months (fig. 2). Pleuroscopy revealed a marked diffuse, white thickening both of the parietal and visceral pleura, with multiple fibrinous adhesions. Biopsies yielded only nonspecific fibrosis. There were no signs of malignan-cy, granulomas or vasculitis. Stains and cultures for bacteria , mycobacteria and fungi remained negative. Fig. 1. – Computed tomographic (CT) scan of the thorax on admission at level D10. Fig. 2. – Computed tomographic (CT) scan of the thorax 5 months after a therapeutic procedure.