32 Wallace RJ Jr, Brown BA, Griffith DE, et al. Initial clarithro- mycin monotherapy for Mycobacterium avium-intracellulare complex lung disease. Am J Respir Crit Care Med 1994; 149:1335–1341 33 Wallace RJ, Brown BA, Griffith DE, et al. Clarithromycin regimens for pulmonary Mycobacterium avium complex: the first 50 patients. Am J Respir Crit Care Med 1996; 153:1766 – 1772 34 Dautzenberg B, Piperno D, Diot P, et al. Clarithromycin in the treatment of Mycobacterium avium lung infections in patients without AIDS. Chest 1995; 107:1035–1040 A 37-Year-Old Woman With Multiple Pulmonary Nodular Opacities and Hemoptysis* Sebastia ´ n Gando, MD; Fernando Villarejo, MD; Bernardo Maskin, MD; and Carlos M. Luna, MD, FCCP (CHEST 2006; 130:1241–1243) Key words: human chorionic gonadotropin; hydatiform mole; massive hemoptysis; pulmonary metastases; trophoblastic tumor Abbreviations: EMA/CO = methotrexate, actinomicyn D, eto- poside, cyclofosfamide and vincristin; GTD = gestational tropho- blastic disease; HCG = human chorionic gonadotropin; PAH = pulmonary hypertension A 37-year-old woman was admitted to the internal medicine department with a 20-day history of cough- ing and 15 days of hemoptysis. She had previously con- sulted with the emergency department, where communi- ty-acquired pneumonia was diagnosed, and a sputum examination was performed that was negative for acid-fast bacilli. Thereafter, she was treated with amoxicillin, 500 mg tid, for 7 days without improvement. Her medical history was irrelevant; she had had five children and an unremarkable medical history except for pregnancy-in- duced hypertension during her last three pregnancies and hydatiform mole 5 years before. At physical examination, she was afebrile, her respira- tory rate was 34 breaths/min, and diffuse bilateral rales were present; examination of the abdomen was normal. A chest radiograph showed multiple bilateral pulmonary nodules with overlapping ill-defined alveolar-interstitial opacities (Fig 1). A CT scan demonstrated the presence of bilateral diffuse nodules (Fig 2). Laboratory findings showed the following: hemoglobin, 9.1 g/dL; WBC count, 18,600/L; platelets, 166,000/L; activated partial thromboplastin time, 39.5 s; prothrombin time, 14.5 s; and prothrombin activity, 63% (international normalized ratio, 1.33). Blood gases analysis (fraction of inspired oxygen, 50%) revealed pH 7.42; Pco 2 , 29 mm Hg; Po 2 , 90 mm Hg; and HCO 3 , 18.5 mmol/L. Renal function and electrolytes were normal. Antibiotic therapy was started with ceftriaxone plus clarithromycin. Eighteen hours after hospital admission, she continued to be hypoxemic (Pao 2 /fraction of inspired oxygen ratio = 194) and was admitted to the ICU requir- ing mechanical ventilation. What is the diagnosis? *From the Critical Care Division (Drs. Gando, Villarejo, and Maskin), Department of Internal Medicine, Hospital “Profesor Alejandro Posadas,” Haedo, Buenos Aires; and Pulmonary Divi- sion (Dr. Luna), Department of Medicine, Hospital de Clı ´nicas “Jose ´ de San Martı´n,” University of Buenos Aires, Argentina. The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Manuscript received February 1, 2005; revision accepted March 8, 2006. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Sebastia ´n Gando, MD, Julian Alvarez 2092 Dto. 6° C, Buenos Aires, Argentina; e-mail: sgando@hotmail.com DOI: 10.1378/chest.130.4.1241 Figure 1. Radiograph of the thorax showing multiple bilateral nodular opacities. Figure 2. High-resolution CT showing multiple nodules with smooth margins and ground-glass areas. www.chestjournal.org CHEST / 130 / 4 / OCTOBER, 2006 1241