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A man with cough and dyspnea.

Article Excerpt
The case presented here illustrates the diagnostic challenges and potential severity of a fungal infection.

The case

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).

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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...

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