The case presented here illustrates the diagnostic challenges and potential severity of a fungal infection.
A 53-year-old man with a history of hypercholesterolemia presented to the hospital with fever (temperature of 38.6[degrees]C [101.5[degrees]F]) and productive cough. His illness started 4 months earlier when, after a long stay at his summer home in Canada, a cough developed. The cough initially was dry, and then became productive of scant, clear sputum.
Two weeks later, the patient began to experience low-grade fevers. Six weeks later, he presented to his primary care physician. A chest radiograph showed consolidation in the superior segment of the left lower lobe. He received sequential courses of azithromycin and levofloxacin for presumed community-acquired pneumonia (CAP), with only a transient improvement of symptoms. Follow-up chest radiography and CT scanning showed persistent consolidation.
Three weeks later, he underwent bronchoscopy, which showed no endobronchial lesions. Gram stain of the bronchoalveolar lavage (BAL) fluid yielded 2+ white blood cells (WBCs) and no bacteria. The BAL fluid was sent for bacterial, fungal, and mycobacterial cultures. Early culture results revealed 5000 colony-forming units of mixed respiratory flora, but the results were negative for Legionella pneumophila, Pneumocystis jiroveci, and acid-fast bacteria (AFB).
Five days after bronchoscopy, the patient was admitted to the hospital with fever, weakness, malaise, and dry cough. On physical examination, he was febrile with an oral temperature of 38.6[degrees]C (101.5[degrees]F), a heart rate of 108 beats per minute, a respiration rate of 28 breaths per minute, and a blood pressure of 126/74 mm Hg. Pulse oximetry indicated an oxygen saturation of 95% on room air. Other physical examination findings were unremarkable except for mild obesity and inspiratory crackles over the left mid-lung.
Laboratory test results showed leukocytosis (WBC count of 17,700/[micro]L, with 72% neutrophils and 2.2% eosinophils), hemoglobin level of 12.2 g/dL, and platelet count of 419,000/[micro]L. Results of a basic chemistry panel were normal. A chest radiograph displayed an improved perihilar infiltrate in the left lung (Figure 1).
Purified protein derivative (PPD) testing was done, ampicillin/sulbactam treatment was started, and a percutaneous ultrasonography-guided lung biopsy was scheduled. On day 3, the patient was still febrile and the PPD results were negative. The patient began to feel better and refused the lung biopsy. The following day, his fever intensified (temperature of 40[degrees]C [104[degrees]F]), cough worsened, and WBC count increased to 23,500/[micro]L. The results of blood cultures were negative, and findings from transesophageal echocardiography were normal.
On day 6, results of an ultrasonography-guided fine-needle aspiration biopsy of the lung showed moderate acute inflammation, with benign bronchial cells and pulmonary macrophages. A stain of the aspirate was negative for AFB and fungi.
Later that day,...