A patient with fever and an abnormal roentgenogram

A 38 year old white woman was admitted to hospital with a one week history of right leg cellulitis, that had progressed despite treatment with dicloxacillin, 500 mg orally, 4 times daily. She had been diagnosed as hav-ing acquired immune deficiency syndrome (AIDS) 4 years prior to admission, with sexual contact being the risk factor as there was no history of intravenous drug abuse or transfusions. Two years prior to admission, she developed immune thrombocytopenic purpura requiring splenectomy and the continued use of oral steroids. Four months prior to admission, she was diagnosed as having non-Hodgkins lymphoma and received two courses of chemotherapy with good response. Her medication at the time of admission included: dicloxacillin, flucona-zole, zidovudine and prednisone 60 mg daily, in addi-tion to monthly inhaled pentamidine. She denied exposure to tuberculosis in the past and there was no history of recent travel. The patient appeared acutely ill. Blood pressure was 100/60 mmHg; pulse rate was 110 beats·min-1; and oral temperature 40.5°C. Examination revealed a 3×4 cm abscess of the right calf and surrounding cellulitis. The Hb was 128 g·l-1 with a white blood cell (WBC) count of 7.3×109·l-1; with 71 % neutrophils, 8 % band cells and 21 % lymphocytes. The CD4 count was 0.184×109·l-1. The platelet count was 11×109·l-1. The lactate dehy-drogenase (LDH) was normal. Blood, urine and spu-tum cultures were negative as was the Cryptococcal serology. The patient was anergic. Chest X-ray and computed tomographic (CT) scan are shown below. Note that the findings did not change with the CT scan repeated in the prone position