A 58 year old male presented to the emergency department after he was found on the floor of his apartment. The patient was unable to provide detailed history of the events, however, he was noted to have had several episodes of loose bowel movements. He denied any change in the stool color or blood in the diarrhea. There was no associated abdominal pain, nausea, vomiting, recent antibiotics use, fever, cough, chest pain or dyspnea. He was not hospitalized within the past year, moreover, he has never traveled outside the United States. He was diagnosed with Crohn's disease 40 years ago and had multiple bowel resections in the past; he is not on steroids. Currently he is being treated with Vedolizumab for the last 8 months, in addition, he was being treated with infliximab which was stopped prior to the initiation of Vedolizumab. Physical examination showed an emaciated patient, with vital signs as follows: blood pressure 78/50, heart rate 98, respiratory rate 22 & temperature 99  F, lung exam showed crackles over the right lung, abdominal and cardiovascular exam were unremarkable. Investigations were significant for elevated WBCs count to 20.9 (Neutrophils 96.1%, lymphocytes 0.8%, monocytes 2.3%, eosinophils 0%), and chest X ray with multiple opacities in the right lung field (Fig. 1); IgE level was 205, HIV was negative. Accordingly he was admitted to intensive care unit for management of septic shock caused by pneumonia, where he was started on Vancomycin, Aztreonam, Levofloxacin and vasopressors. The clinical picture didn't improve on the following days despite being on antibiotics; sputum and blood cultures were negative. Due to lack of improvement and paucity of microbiological data, patient had a CT of the chest which showed opacification within the entirety of the right lung with air bronchograms (Fig. 2). On the 4th day of admission the patient underwent a bronchoscopy that showed normal mucosa without lesions in the upper and lower airways. Bronchoalveolar lavage was obtained and cultures were negative for bacteria, tuberculosis & fungi. Bronchial washing cytology showed acute inflammation and filariform larvae (Fig. 3) and serology was positive for Strongyloides antibodies. He was started on ivermectin and his condition improved significantly and he was discharged in good condition.
CT chest showing Opacification within the entirety of the right lung with air bronchograms suggestive of a infectious process and Bilateral pleural effusion.