A 42-year-old male presented with multiple upper back masses that had been enlarging for 3 months and were associated with positional discomfort. He was also having intermittent nondrenching night sweats during this 3-month time frame, but no fever, weight loss, or respiratory symptoms.
The patient was an Illinois native, never lived outside the United States, and denied any recent travel within the past 5 years. He was employed at a warehouse, lived with his girlfriend, and reported no sick contacts. He was an active cigarette smoker but denied alcohol abuse or illicit substance use.
He had a past medical history of Bell’s palsy (with residual left-sided facial droop), but no prior surgical history. He was not on any chronic medications.
Assessment
On physical examination he was afebrile, had stable vital signs, and his oxygen saturation was 99% on room air. He was well-appearing, lungs were clear to auscultation, and his examination was remarkable for multiple large, fluctuant, nontender subcutaneous masses of his mid- to upper-back bilaterally, each measuring approximately 10 cm × 10 cm, without any open skin lesions or overlying rash (Figure 1). These were not warm to touch and had no overlying erythema. Left-sided facial droop was present.
Initial workup included normal routine labs, negative human immunodeficiency virus (HIV) Ag/Ab screening, and blood cultures, which had no growth. Chest radiography showed a right upper lobe reticular opacity (Figure 2). A computed tomography (CT) scan of the thorax revealed a right upper lobe 2-cm cavitary lung lesion with surrounding tree-in-bud and centrilobular nodularity (Figure 3) and also multiloculated, subcutaneous and intramuscular abscesses of the back (Figure 4), the largest collection measuring 12.2 × 3.2 cm.
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-Matthew Enriquez, MD, Moira McNulty, MD
