A 45-year-old African-American male was brought to our institution from the county correctional facility with fever, cough, and blood-streaked sputum of four weeks' duration. The remainder of his review of systems was unrevealing. He was a never-smoker but a former user of multiple intranasal recreational drugs. On admission, he had a temperature of 38.3C and was tachycardic to 108 beats/min. His physical examination was notable only for crackles over the left upper chest anteriorly. Routine laboratory evaluation was unremarkable. HIV testing and IGRA-MTB were both negative. His chest radiograph revealed a dense left upper lobe (LUL) consolidation (Fig. 4A). Chest CT illustrated the same finding with no additional abnormalities present (Fig. 4B). Bronchoscopy with transbronchial biopsy and BAL of the LUL was performed. Biopsy material showed non-necrotizing granulomatous inflammation with negative stains for microorganisms. Rare fungal forms were visualized in the BAL fluid cytology specimen stained with Gomori methenamine silver (Fig. 5). KOH preparations of neither the BAL fluid nor lung tissue demonstrated the fungus, but both BAL fluid and tissue fungal cultures grew B. dermatitidis, an identification that was later confirmed by polymerase chain reaction in the NYS Department of Health (DOH). The patient responded well to a six-month course of oral itraconazole. When questioned about his incarceration history, he reported a recent stint at the Adirondack Correctional Facility in Rye Brook, NY located more than 200 miles north of our institution and about 60 miles from the Canadian border. His daily routine there included outdoor activities.
B, Axial image from a CT scan of the chest set to lung window demonstrating the consolidation to be located in the apicoposterior segment of the left upper lobe. A small focus of cavitation (black arrow) is evident within the consolidation.