An Abnormal Chest Radiograph

T HE PULMONOLOGIST was consulted because the patient, a 64-year-old male physician, had severe thoracic pain dorsally and on the left for 4 days. The pain was more intense when he was lying down. Some nights, he had to sit up in a chair for hours to get some sleep. He had also been coughing for 4 weeks. He had no fever, and the blood leukocytes and C-reactive protein were normal. The patient had been a regular smoker (10 cigarettes per day) from 20 to 35 years of age, but he stopped smoking in 1967. For more than 30 years, he had prolonged periods (8 to 12 weeks) of bronchial hyperreactivity because of an allergy to bil"ch, with coughing after common colds, sometimes twice a year. His medication for 2 years was budesonid (Pulmicort; Draco L~kemedel AB, Lund, Sweden), 0.8 mg one to two times daily. Earlier chest radiographs had been essentially normal. Look at the radiograph of the lungs (Fig 1). What is the probable diagnosis?