CASE 55: RECURRENT CHEST INFECTIONS
History
A 45-year-old woman is admitted to hospital with pneumonia. She has had three episodes
of cough, fever and purulent sputum over the last 6 months. One of these was associated
with right-sided pleuritic chest pain. These have been treated at home by her general prac-
titioner (GP). In addition she has a 5-year history of difficulty with swallowing. Initially
this was mild but it has become progressively worse. She says that food seems to stick in
the low retrosternal area. This applies to all types of solid food. She has lost 5 kg in weight
over the last 2 months. Sometimes the difficulty with swallowing seems to improve during
a meal. Recently she has had trouble with regurgitation and vomiting of recognizable food.
Three years ago her GP arranged for an outpatient upper gastrointestinal endoscopy which
was normal. She was reassured, but the problem has increased in severity. There is no other
relevant medical history or family history. She lived in the north-west coast of the United
States for 4 years up until 10 years ago. She works as a shop assistant. She has never smoked
and drinks less than 5 units of alcohol each week. There has been no disturbance of mic-
turition. She has always tended to be constipated and this has been a little worse recently.
Examination
She looks thin. In the respiratory system there are some crackles at the right base. There
are no abnormalities to find in the cardiovascular system, abdomen or other systems.
Her chest X-ray is shown in Fig. 55.1.INVESTIGATIONS
Questions
- What is the likely diagnosis?
- How would you establish this?
Figure 55.1Chest X-ray. (repro-
duced with the kind permission
from Curtis and Whitehouse,
Radiology for the MRCP,
Arnold, 1998.)