Pancytopenia and Progressive Breathlessness in a 48-Year-Old Man With a Reversed Halo Sign on Imaging

A 48-year-old man with no prior medical comorbidities was admitted to our pulmonology department with progressive breathlessness, dry cough, and low-grade fever of 2 months’ duration. Breathlessness was of insidious onset and progressed gradually from level 1 to level 4 on the modified Medical Research Council scale over 2 months. He did not report any orthopnoea or paroxysmal nocturnal dyspnea. The cough did not have any allergic triggers and had no diurnal variation. He had on-and-off low-grade fever with no specific pattern. He had no history of smoking and had no other substance dependencies. He was evaluated initially at a primary care centre with a chest CT scan, which showed patchy distribution of ground-glass opacities (GGOs) with no lobar predilection and random nodules in the left upper lobe. It also showed round lesions in the right upper lobe with central GGOs surrounded by a rim of consolidation suggestive of reversed halo sign (RHS). Routine blood investigation findings (complete blood count and kidney and liver functions tests) were normal. He was advised to undergo a lung biopsy for definite diagnosis, but he declined to do so. A provisional diagnosis of organizing pneumonia was made based on the CT scan findings of RHS and oral glucocorticoids administration was started. No clinical improvement was seen after 1 month of steroid therapy, and he was referred to us.