35 year-old hispanic male with history of Diabetes Mellitus and inguinal hernia presented with two-week history of productive cough and weight loss. He denied hemoptysis, fevers, chills, recent travel or sick contacts. Initial physical exam was significant for left-sided rhonchi. Chest radiograph revealed a lingular opacity with associated effusion. He was started on broad-spectrum antibiotics, and subsequent chest CT (Fig. 1) showed a left upper lobe consolidation with a large multi-locular cavitation and air-fluid levels. On our evaluation patient appeared older than stated age, with noted temporal wasting, poor dentition and gynecomastia. Additionally, subtle signs of atrophy were seen in the upper extremities with abdominal obesity and a left inguinal hernia. He answered questions appropriately but with slowed mentation and mini-mental exam was 25. Bilateral ptosis was evident with normal pupillary reflexes. Cranial nerves were intact. Motor strength was grossly 4/5 without fasciculations. When shaking his hand, a delay in relaxation of the thumb was seen, and percussion of the thenar eminence elicited a contraction of the thumb. Furthermore a delayed grip release was evident. Laboratory investigations resulted negative for HIV and Tuberculosis, however respiratory cultures grew gram-negative bacilli and gram-positive cocci in pairs. Later, a barium swallow (Fig. 2) showed laryngotracheal aspiration. Based on the described findings a clinical diagnosis of DM (Steinert's disease) was made. He was started on an eight-week course of antibiotics, improved significantly and was discharged with Neurology and Pulmonology follow-up.
CT Chest: Left upper lobe consolidation with multilocular cavitation.