A 51-year-old man with a long history of alcohol abuse and heavy cigarette smoking presented to our hospital with worsening of a chronic cough, which had become productive of thick green sputum and was associated with posttussive emesis. He denied fevers and chills but had a recent and unintentional weight loss of about 5 kg. He had a history of squamous cell carcinoma of the right tonsil, which remained in remission for more than 4 years after chemotherapy, radiation therapy, and resection. There was no recent history of travel or any occupational exposures or known contacts with tuberculosis or animals (wild or domestic).
Significant physical examination findings included a general appearance of cachexia. The patient's temperature on admission was 37.3[degrees]C (99.14[degrees]F). He had an erythematous rash with spider veins on his face that was consistent with rosacea. The chest examination was notable for an increased anterior-posterior diameter and, on auscultation, coarse breath sounds throughout that resonated from the upper airway. He was unable to ambulate because of ataxia and deconditioning and was tremulous with marked left-sided dysmetria on finger-to-nose testing.
Notable abnormal laboratory values included a white blood cell (WBC) count of 2400/[micro]L, with a differential of 77% polymorphonuclear leukocytes, 7% lymphocytes, and 16% monocytes. His hemoglobin level was 9.7 g/dL and platelet count was 67,000/[micro]L. The initial metabolic profile revealed an anion gap of 26 and hyponatremia (sodium level, 132 mEq/L). The aspartate aminotransferase and alanine aminotransferase levels were 46 U/L and 14 U/L, respectively.
A chest radiograph suggested only scarring in the apex of the right lung (Figure 1); however, a CT scan revealed a thin-walled cavity, measuring approximately 3.9 cm in diameter, with several small adjacent satellite nodules (Figure 2). Acid-fast smears of 3 expectorated sputum samples showed no organisms, and Gram staining showed normal upper respiratory tract flora with a few WBCs.
Shortly after the patient was admitted, he lapsed into delirium tremens and then required intubation and vasopressor support after a presumed aspiration event. Specimens from bronchoalveolar lavage (BAL) of the right upper lobe were submitted for Gram, acid-fast, methenamine silver, Papanicolaou, and modified Wright stains, all of which had unremarkable results for any organisms or malignancy. A Fite stain, however, revealed...