A 66-year-old man presented with fever, cough, excess sputum, and shortness of breath for 1 week. He was given intravenous antibacterial (cephalosporin) treatment for 4 days, but his condition did not improve and dyspnea became more serious. Therefore, the patient came to our hospital where chest CT showed diffuse centrilobular nodules in both lungs, some with a "tree-in-bud" appearance (Figure 1), and multiple enlarged lymph nodes in mediastinum and bilateral axilla (Figure 2). He was then admitted to the hospital.
The patient had a history of CLL for 9 years and had received several chemotherapies in the past. His condition was stable in the past year. He has a history of smoking for 30 years. Other medical history was denied. He had no bird exposure and no history of travel outside Wuhan, Hubei, where he lived.
At admission, physical examination revealed that temperature was 37.8 C, peripheral blood oxygen saturation (SpO2) was 87% on room air, respiratory rate was 31 breaths/min, and wet rales could be heard on auscultation of both lungs. Multiple soy-sized enlarged lymph nodes could be palpable on both sides of the neck and armpits. Laboratory tests revealed that arterial blood gases at 29% fraction of inspiration O2 (FiO2) showed partial pressure of oxygen (PaO2) 65.6 mmHg, partial arterial pressure of carbon dioxide (PaCO2) 22.8 mmHg, pH 7.43, and oxygenation index (OI; PaO2/FiO2) 226 mmHg. Blood cell analyses, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were examined (Table 1). T-cell spots of tuberculosis infection (T-SPOT.TB) were positive. The detection of mycobacterium tuberculosis in bronchoalveolar (BAL) fluid by polymerase chain reaction (PCR) was negative. Sputum and BAL fluid acid-fast staining were negative. Procalcitonin, immunoglobulin (Ig) E, Mycoplasma pneumoniae IgM, Chlamydia pneumoniae IgM, and 1, 3-beta-D glucan/galactomannan tests were normal. No pathogenic bacteria or fungi were detected in blood, sputum, and BAF fluid cultures. Lymphocyte typing were noted as follows: total T cell 6% (normal, 50-87%), total T-cell number 803/mul (normal, 955-2,860/mul), CD4 + Th-cell proportion 1% (normal, 21-51%), CD4 + Th-cell number 151/mul (normal, 550-1,440/mul), total B-cell 89% (normal, 3-19%), and total B-cell number 12,603/mul (normal, 90-560/mul).
The patient was diagnosed with severe pneumonia and type 1 respiratory failure. BAL fluid was collected and sent to the Shenzhen BGI Medical Test Laboratory for metagenomic next-generation sequencing (mNGS), which only supported a diagnosis of S. pneumoniae infection.
After admission, the patient's condition improved gradually by giving antimicrobial treatment (moxifloxacin injection, 0.4 g, qd) and other comprehensive treatment measures, including airway clearance and oxygen support. Before discharge, SpO2, blood cell analyses, and related inflammatory markers were reexamined (Table 1), in which SpO2, CRP, and ESR were normal finally, and reexamination of the chest CT showed visible absorption of diffuse centrilobular nodules in both lungs (Figure 1). Three weeks after discharge, a follow-up CT showed that the diffuse centrilobular nodules in both lungs absorbed completely (Figure 1).