In July of 2002, a 36-year old obese woman [weight 200 pounds, height 5 feet 1 inch] with history of type 2 diabetes for 5 years, presented to the emergency department with 5 days history of fever, chills and cough with yellowish phlegm and sharp pain in her right lower chest that aggravated with deep breathing. Physical examination was unremarkable. She was afebrile and lungs were clear. Homen's sign was negative. Initial laboratory data showed slightly elevated d-dimer of 0.374 ug/mL [normal <0.25 ug/mL]. A chest X-ray (figure 1) showed right lower lobe infiltrate. She was diagnosed with community acquired pneumonia and sent home on oral clarithromycin 500 mg BID, cefurox 500 mg BID for 7 days and acetaminophen as required.
She continued to have symptoms of fever, chills, night sweats with productive cough and dyspnea and presented to the hospital five days later. She denied hemoptysis. Physical examination revealed a temperature of 39 degree Celsius, mild tachycardia with heart rate of 104 beats per minute, normal blood pressure of 125/74 mmHg and respiratory rate of 18. Pulse oxymetry revealed oxygen saturation of 96% on room air. There was decreased air entry with bronchial breath sounds in right lower chest. A white cell count was slightly elevated at 13.5, with normal hemoglobin of 128 g/L and d-dimer between 0.25-0.50 ug/mL. A second chest X-ray (figure 2) showed dense infiltrate in right lower lobe. She was admitted with the diagnosis of community-acquired pneumonia and started on intravenous levofloxacin 500 mg a day.
She had a positive Mantoux test in 1976. There was no history of travel save for visiting her sister's cottage at the local lake a weak before where she slept at the gazebo for two nights. There were no pets at home. She smoked one pack per day and entertained social drinks.
She continued to have temperature up to 39 degrees Celsius, productive cough and shortness of breath. Sputum Gram stain showed 4+ neutrophils and 1+ normal flora and blood cultures remained negative. She received intravenous levofloxacin and clindamycin for one week. Bronchoscopy performed on day 6 was unremarkable save for inflammatory changes in lower lungs and samples were collected for bacterial and tuberculosis cultures [in retrospect, the specimen was not sent for fungal cultures]. On 7th day because of ongoing symptoms, the antibiotics were changed to intravenous imipenem-cilastatin sodium 1 gm every 12 hour and she has had a CT scan of chest (figure 3) that showed bibasilar consolidation with sparing of the apices. The white cell count fluctuated between 13.6 to 20.2 [normal 4.0-11.0 x 109 /L]. Hemoglobin decreased to 97 g/L. BUN, serum creatinine, electrolytes, AST, ALT, GGT and ALP were normal. Urinalysis was negative. Blood, urine and sputum cultures remained negative. Sputum gram stain showed 3-4+ neutrophils without organisms. ESR on day 8 was elevated at 112 mm/hr [normal 0-15]. Antinuclear antibody was negative. Arterial blood gas on day 8 showed pH of 7.46, pCO2 of 35, pO2 of 59 and oxygen saturation of 91% on room air. She was started on supplemental oxygen by nasal prongs. Bronchoscopic specimen cultures were negative save for pending TB cultures.
After five days of intravenous imipenem-cilastatin sodium therapy, there was no improvement in her clinical condition. Another medical consult was requested, when the author got involved in her care. She had a temperature of 39 C, pulse rate of 104 and blood pressure of 114/70 mmHg. There was no lymphadenopathy and heart sounds were normal. Her chest examination showed decreased breath sounds at both bases with egophony in right lower chest. There were no pleural rubs. There was no clubbing or cyanosis. The rest of the examination was unremarkable save for an obese benign abdomen.
Chest X-ray (figure 4) now showed further deterioration of the bilateral infiltrates with nodular appearance and the radiologist remarked, "The lesions are suspicious of metastases." Sputum cytology showed a large number of acute inflammatory cells without malignant cells. The possibility of vasculitis was entertained because of markedly elevated ESR and antineutrophilic cytoplasmic antibody (ANCA) was negative.
The history of sleeping at the cottage for two nights, a week before her illness started; progressive bilateral pneumonia with ongoing high-grade fever, chills, and night sweats despite sufficient antibiotic coverage and sputum Gram stain showing a large number of neutrophils without organisms (culture negative) raised the author's suspicion for the possibility of fungal process such as acute blastomycosis pneumonia and the Public Health Laboratory (PHL) was specifically asked to perform wet preparation for blastomycosis on the sputum. The PHL laboratory confirmed the presence of 'round thick walled budding yeast like cells (figure 5) suggestive of Blastomyces dermatitidis and this was confirmed on fungal cultures. She was promptly started on intravenous amphotericin B and responded well and later switched to oral itraconazole 400 mg twice a day for 6 months and then 200 mg a day for another 6 months. She recovered fully.
A section of CT scan of chest performed 8 days after hospitalization showing bilateral consolidation of lungs, mainly of lower lung fields.