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OpenAthens Shibboleth
Special Feature
June 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgery, UPMC Mercy Hospital, Pittsburgh, Pennsylvania.

Arch Surg. 2012;147(6):573. doi:10.1001/archsurg.2011.843

A 63-year-old man underwent splenectomy, partial wedge resection of the stomach, distal pancreatectomy, and repair of a small diaphragmatic laceration for non-Hodgkin B-cell lymphoma of the spleen. Pathological analysis revealed negative resection margins. The patient received no postoperative chemotherapy or radiation.

Twelve months following surgery, the patient began to have fatigue, weight loss, recurrent sepsis, chronic pulmonary infections, and intermittent foul-smelling spu-tum. Chest radiography and computed tomography repeatedly revealed left lower lobe infiltrate (Figure 1). Alveolar lavage documented an Escherichia coli pneumonia that failed to improve following multiple courses of antibiotics. Findings on positron emission tomography were normal other than increased uptake in the left lower lobe. Colonoscopy results were unremarkable. Subsequently, a barium enema was completed (Figure 2).

Image not available

Figure 1. Computed tomographic scan of the chest revealing left lower lobe pneumonia. A indicates anterior; L, left; P, posterior; and R, right.

Image not available

Figure 2. Abdominal radiograph taken shortly after completion of the barium enema, revealing contrast extravasation into the left lower lobe lung field and stomach. R indicates right.

What Is the Diagnosis?

A.  Aspiration pneumonia

B.  Colobronchial fistula

C.  Recurrent lymphoma

D.  Postobstructive pneumonia from lung cancer