A 38-year-old female native of Rochester, NY, with medical history significant for Crohn disease, treated with infliximab, azathioprine, and prednisone (20 mg daily) was admitted on September 4, 2020 for a flare of her illness. Computed tomography (CT) angiography of the chest obtained to evaluate right upper chest pain showed patchy infiltrate surrounding an irregular focal consolidation in the right upper lung. Upon discharge, the chest pain disappeared, and the patient was advised to repeat imaging in 3 months. Her prednisone dose was doubled for her Crohn disease. On October 1, her chest pain returned, worsened by inspiration. She was seen in the emergency department where repeat CT angiography revealed enlargement of the previous right upper lung consolidation. She was given a 7-day empiric course of amoxicillin-clavulanate pending a follow-up pulmonology appointment. In the interval, her chest pain worsened, and she developed a nonproductive cough and night sweats. On October 21, she underwent outpatient bronchoscopy. Bronchial washings and right upper lung bronchoalveolar lavage (BAL) Gram stains showed greater than 25 neutrophils and less than 10 squamous cells. Gram-positive cocci were present in the Gram stain of the cytospin smear. No acid-fast bacilli grew in culture. The fungal smear of fluid from the BAL was negative during hospitalization. The aerobic culture of the BAL grew less than 10,000 colonyforming units of contaminating flora from the upper respiratory tract. None of the samples grew Legionella species.The patient was admitted on October 25 with worsening chest pain, production of brown sputum, onset of chills, and poor oral intake. Her temperature was 39.9°C, with a heart rate of 126 beats per minute, blood pressure of 116/64 mm Hg, respiratory rate of 28 breaths per minute, and oxygen saturation of 98% on room air. Physical examination was significant for diminished breath sounds in the right upper lung field without signs of consolidation. The complete blood cell count was 25.4 cells/μL, with 88.1% granulocytes, 1% lymphocytes, 4% monocytes, and 0.2% eosinophils. She had a hemoglobin level of 11.6 g/dL and platelet count of 648,000 elements/μL. Her lactate level was 3.4 mmol/L; sedimentation rate, 130 mm/h; and C-reactive protein level, 487 mg/mL. She was treated empirically for sepsis from presumed pulmonary source with intravenous piperacillin-tazobactam, vancomycin, and azithromycin. Repeat CT angiography of the chest revealed interval increase in size of the right upper lobe consolidation, with new central cavitation, and extensive patchy ground glass and consolidative opacities throughout both lungs (Fig. 1).
