A 54-year-old nonsmoker male presented with 3 weeks of cough productive of small amounts of clear to yellow-colored phlegm, fatigue and malaise. He reported persistent fever with temperature up to 102  F and weight loss of 20 pounds over 2 weeks. He was repeatedly evaluated for these symptoms and multiple courses of outpatient antibacterials failed to improve his symptoms. He worked as a truck driver in a dumpster yard, had not traveled out of the state of West Virginia, and denied sick or animal contact or recent hospitalization. Physical examination and basic lab workup including complete blood count, chemistry panel, sputum culture, viral respiratory panel by PCR, HIV screen, Streptococcus pneumoniae and Legionella urine antigens, Histoplasma antibody panel and serum QuantiFERON TB Gold all within normal. Chest x-ray showed mild interstitial prominence and CT chest showed multiple subpleural nodular opacifications involving all lobes bilateral (Fig. 1A).
The differential diagnosis included chronic infection, connective tissue disease or interstitial lung disease. Serologic evaluation for connective tissue etiologies showed no evidence of systemic lupus erythematosus, scleroderma, mixed connective tissue disease or vasculitis. Bronchoscopic sampling with lavage was nonrevealing. Video assisted thoracoscopic biopsies from the three right lobes were then obtained. Tissue samples cultured showed growth of Paecilomyces species in all three wedge biopsies and pathology consistent with organizing pneumonia and emphysematous changes (Fig. 1 B). Specialty lab identified Paecilomyces formosus infection sensitive to amphotericin B and posaconazole Due to the unusual presentation, immune deficiency as a contributing factor was sought and ruled out (Table 1). The patient completed a 2-week course of intravenous amphotericin B followed by 6 weeks of oral posaconazole, with resolution of symptoms. 3 months after, symptoms completely abated, and dyspnea resolved. Chest CT revealed marked improvement.