A 40 year old Caucasian man presents with dyspnea, productive cough, and wheeze. He has no known history of pulmonary diseases. He does not take any medications, has no allergies, and does not smoke, drink, or do any drugs.
He is adopted so he does not know his family history. He gets tearful when he says this, and you find out that his parents abandoned him in the hospital when he was diagnosed with neonatal hepatitis with cholestasis. He was once told as an adult he has cirrhosis. On review of systems, he notes a new hot painful red nodule on his thigh.
CXR shows predominantly basilar hyperlucency so a CT is done showing the following:
Challenge: What are you worried about?
Image shown under Creative Commons Attribution 2.0 License.