Chest radiography (Figure 1) showed opacities in the apexes bilaterally along with left hilar lymphadenopathy. The patient was documented to have a normal chest x-ray six months before presentation. Multiple investigations had been completed at the time of transfer to the intensive care unit. The computed tomographic (CT) head scan, bone scan, carotid Doppler, magnetic resonance imaging of the spine, serum protein electrophoresis, tuberculosis skin test, urinalysis and vasculitic screen were normal. The lumbar puncture, V/Q scan and bronchoscopy were nondiagnostic.A CT scan of the chest confirmed multiple bilateral opacities, in particular, apical masses (Figure 2), small left hilar nodes and normal abdominal viscera, and revealed small bilateral pleural effusions. A CT-guided fine needle lung aspiration of one of the apical masses was nondiagnostic. Blood work revealed nor-mocytic anemia with elevated acute phase reactants. An ultrasound of the abdomen showed gastric distention with no evidence of pyloric obstruction. The differential diagnoses included primary lung cancer with an associated paraneoplastic syndrome, systemic vasculitis and drug-induced lung disease.

Figure 1) A chest radiograph showing apical pulmonary lesions and left hilar lymphadenopathy

Figure 2) A computed tomographic scan showing masses in both apexes