The case presented here illustrates the diagnostic challenges and potential severity of a fungal infection.
The case
A 53-year-old man with a history of hypercholesterolemia presented to the hospital with fever (temperature of 38.6°C [101.5°F]) and productive cough. His illness started 4 months earlier when, after a long stay at his summer home in Canada, a cough developed. The cough initially was dry, and then became productive of scant, clear sputum.
Two weeks later, the patient began to experience low-grade fevers. Six weeks later, he presented to his primary care physician. A chest radiograph showed consolidation in the superior segment of the left lower lobe. He received sequential courses of azithromycin(Drug information on azithromycin) and levofloxacin(Drug information on levofloxacin) for presumed community-acquired pneumonia (CAP), with only a transient improvement of symptoms. Follow-up chest radiography and CT scanning showed persistent consolidation.
Three weeks later, he underwent bronchoscopy, which showed no endobronchial lesions. Gram stain of the bronchoalveolar lavage (BAL) fluid yielded 2+ white blood cells (WBCs) and no bacteria. The BAL fluid was sent for bacterial, fungal, and mycobacterial cultures. Early culture results revealed 5000 colony-forming units of mixed respiratory flora, but the results were negative for Legionella pneumophila, Pneumocystis jiroveci, and acid-fast bacteria (AFB).
Five days after bronchoscopy, the patient was admitted to the hospital with fever, weakness, malaise, and dry cough. On physical examination, he was febrile with an oral temperature of 38.6°C (101.5ºF), a heart rate of 108 beats per minute, a respiration rate of 28 breaths per minute, and a blood pressure of 126/74 mm Hg. Pulse oximetry indicated an oxygen saturation of 95% on room air. Other physical examination findings were unremarkable except for mild obesity and inspiratory crackles over the left mid-lung.
