A 44-year-old man, a nonsmoker, has experienced a 3-kg weight loss over the past 3 months. He recently developed a low-grade fever and cough with mucoid sputum production, and after 1 week, he noticed blood-streaked sputum. On physical examination, his temperature is 37.7deg C. There are bilateral crackles in the left upper lobe on auscultation of the chest. Chest CT scan shows a 3-cm left upper lobe nodule with decreased attenuation centrally. Laboratory studies show hemoglobin, 14.5 g/dL; platelet count, 211,400/ mm3; and WBC count, 9890/ mm3 with 40% segmented neutrophils, 2% bands, 40% lymphocytes, and 18% monocytes. Which of the following findings in his sputum sample is most likely to be present?
This "coin lesion" on imaging of his lungs could be an infectious granuloma, a neoplasm, or a hamartoma. His fever suggests infection, and the CT finding of decreased central attenuation in the nodule suggests necrosis in a neoplasm or caseous necrosis in a granuloma. The lymphocytosis and monocytosis are consistent with tuberculosis. Nonsmokers are unlikely to develop primary lung neoplasms, and adenocarcinoma is the most common in that setting. Smokers are most likely to develop squamous cell carcinomas and small cell anaplastic carcinomas. Individuals who are immunocompromised are most likely to develop fungal infections, particularly with Aspergillus spp., which have branching septate hyphae. Charcot-Leyden crystals form from eosinophil granules in individuals with allergic asthma. Foreign body giant cells can be seen with lipid pneumonias. Gram stain is most useful for determining which bacterial organisms may be present, and gram-negative bacilli such as the Enterobacteriaceae produce acute pneumonias and abscesses with neutrophilia.
Acid-fast bacilli
Branching septate hyphae
Charcot-Leyden crystals
Foreign body giant cells
Respiration