A Young Dentist with Fever, Mediastinal Lymphadenopathies and Pulmonary Infiltration

A 40 year-old dentist with no history of disease presented with fever, pleuritic chest pain, cough, myalgia and weight loss (4 kg) from one month before admission. No abnormality was found on physical examination except for expiratory coarse crackles on the base of the right lung. Initial clinical work up showed elevated ESR (ESR=128), positive CRP with hypochromic normocytic anemia (Hemoglobin: 12.0 gr/dl MCV=81.6 MCH=25.6 MCHC=30.7), total leukocyte count of 9.900 cell/μl with normal differentiation and abnormal liver function tests (mild elevation in ALT:59, AST=31 and Bil total=0.7) with highly elevated ALP: 477. Other biochemistry and electrolytes tests were normal. Anti –nuclear antibody(ANA), anti-dsDNA, antineutrophil cytoplasmic antibody (C,P-ANCA),rheumatoid factor (RF), Wright, Coombs Wright and serologic studies for HIV,HCV and HBV as well as the PPD test were all negative. Sputum smear and PCR for acid fast bacilli and culture for routine bacteriology were negative. Chest-x ray (Figure 1), lung CT-scan (Figure 2) and bronchoscopy were also performed.