A 44-year-old male patient was hospitalized because of progressive dyspnea, cough, and fever during one month. His past medical history was unremarkable. He appeared initially with mild fever, dry cough, and night sweating but untreated. After two weeks, he felt shortness of breath and coughed up yellow sputum. He had been admitted in the general hospital where he had undertaken the first bronchoscopy which revealed the negative results of bronchoalveolar lavage (BAL) for both acid-fast bacillus (AFB) smear and M. tuberculosis polymerase chain reaction (PCR). He had been diagnosed with community-acquired pneumonia but not improvement after a 10-day course of antibiotic therapy and was transferred to our tertiary hospital.
On admission, he was alert, with body temperature 37 C, pulse rate of 84 beats/min, respiratory rate of 28 breaths/min, and blood pressure of 120/80 mmHg. He was supplied with oxygen via bag-valve mask at 10 L/min, and the result of arterial blood gas showed pH 7.38, PaO2 70 mmHg, PaCO2 32.7 mmHg, and HCO3- 19.4 mmol/L. Physical examination revealed dullness on percussion, fine crackles, and decreasing breath sound at the right lower lung field. Cell blood count with white blood cells 8.84 G/L (77.5% neutrophil and 13.3% lymphocyte) and hematocrit 38.2%, C-reactive protein level 78.4 mg/L, and mildly elevated liver transaminase level were recorded. The rapid testing for human immunodeficiency virus was negative. Chest X-ray showed consolidation in the right lower hemithorax, and the first contrast-enhanced chest computed tomography (CT) revealed small necrotizing cavities in this consolidation area (Figure 1(a)). With aforementioned information, we suspected differential diagnoses as follows: necrotizing pneumonia with particular pathogens (high-virulence bacteria, tuberculosis, or fungal infection) or noninfectious diseases (autoimmune disease, malignancy, or vascular disease). The antinuclear antibodies test was negative and the histopathological result of transthoracic lung biopsy showed an inflammatory process. He was treated with the combination of broad-spectrum antibiotics (meropenem, ciprofloxacin, and vancomycin) during four days but he still had fever. The adjunctive therapy with corticosteroid (40 mg methylprednisolone intravenous once daily) was commenced, and his condition improved spectacularly (defervescence, breath normally without oxygen) but the fever reoccurred on the fourteenth day after hospitalization. The second chest CT undertaken showed a significant regression of the consolidation (Figure 1(b)). The second bronchoscopy showed the positive BAL results for AFB smear and M. tuberculosis PCR. The treatment with a six-month antituberculosis regimen resolved his condition completely on follow-up.