A 43-Year-Old Man With Persistent Fever and Sudden Shortness of Breath Giovanni Leuzzi, MD, Alfredo Cesario, MD, Filippo Lococo, MD, Riccardo Inchingolo, MD, Gianluigi Petrone, MD, Frediano Inzani, MD, Maria Teresa Congedo, MD, Giuseppe Maria Corbo, MD, Salvatore Valente, PhD, Pierluigi Granone, PhD  CHEST  Volume 144, Issue 3, Pages 1066-1071 (September 2013) DOI: 10.1378/chest.12-2075 Copyright © 2013 The American College of Chest Physicians Terms and Conditions

Figure 1 A, Chest radiograph revealed a hypertensive, right-sided hydropneumothorax with mediastinal shift (arrow) and a moderate (about one-third of the hemithorax) pleural effusion. B, Ventral, transverse ultrasound scan of the chest revealed an encapsulated lesion (arrow) with inhomogeneous, hypoechoic content (third and fourth intercostal spaces, midclavicular and anterior axillary lines) adjacent to a persistent, localized, apical pneumothorax (circle). The image also shows the lung point (star). C, Chest CT scan using multislice spiral technique without administration of iodinated contrast material: The scan shows a multiloculated lesion of the middle lobe (6.4 × 7.3 × 9.8 cm) with multiple foci of low density. The pleural effusion is associated with partial atelectasis of the right, lower lobe. The arrow indicates the chest tube emergently placed. D, MRI carried out with true fast imaging with steady-state free precession sequences, T2 half-Fourier acquisition with single shot turbo spin echo, and multiplanar T1-weighted two-dimensional fast-low angle shot after oral administration of a superparamagnetic contrast agent (sagittal section): the basal medium field of the right-sided hemithorax is occupied by an hyperintense cavitary lesion with overall area 10 × 10 cm, encapsulated by a thin and regular membrane 4 to 5 mm thick. The lesion adheres, without cleavage plane, to the diaphragm (arrow). CHEST 2013 144, 1066-1071DOI: (10.1378/chest.12-2075) Copyright © 2013 The American College of Chest Physicians Terms and Conditions

Figure 2 Macroscopic finding: middle lobe (12 × 10 × 7 cm) and unilocular parenchymal cavitary lesion (10 cm on the major axis). CHEST 2013 144, 1066-1071DOI: (10.1378/chest.12-2075) Copyright © 2013 The American College of Chest Physicians Terms and Conditions

Figure 3 A, Histologic features of the inner cavitary wall: chitinous layer (arrow) and proliger layer with atrophic features on the left (arrowhead) (hematoxylin and eosin, original magnification × 200). B, Fibrous capsule from the host with chronic and acute inflammation, and associated, large, occluded, recanalized vessel (hematoxylin and eosin, original magnification × 20). CHEST 2013 144, 1066-1071DOI: (10.1378/chest.12-2075) Copyright © 2013 The American College of Chest Physicians Terms and Conditions