A 66-year-old Hispanic man was evaluated in the Emergency Department for a 2-week history of nonproductive cough and shortness of breath. He reported intermittent experience of fever, but denied chills, fatigue, night sweats, purulent sputum, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, or chest pain. He had no recent exposure to others who were acutely ill and no recent travel or hospitalization.The man was known to have hypertension, diabetes mellitus, and coronary artery disease and had undergone a prostatectomy for treatment of prostate cancer. He was retired. He denied any significant animal or environment exposures except that he had repaired his washing machine about a month earlier and remembers inhaling dust at that time. He was raised in California and lived subsequently for several decades in Arizona. There was no history of allergies or asthma. His medications were aspirin, amlodipine, metoprolol, ezetimibe, sitagliptin, metformin, and insulin. He was prescribed azithromycin 1 week earlier with no improvement in his respiratory symptoms.In the Emergency Department, the man's temperature was 98.2 8 F, heart rate 104 beats/min, and blood pressure 107/56 mm Hg. By pulse oximetry, his arterial oxygen saturation was 94% while he breathed supplemental oxygen at 2 L/min via nasal cannula. He was alert, articulate, and appeared in good health. There was no cervical lymphadenopathy, oral lesions, or ulcers. He appeared mildly tachypneic. Auscultation of the chest revealed rhonchi, which were most pronounced in the right upper lobe, but no wheezing. Auscultation of his heart disclosed a regular heart rhythm with III/VI aortic systolic murmur and normal S1 and S2. There was no peripheral edema, skin rash, or joint swelling. No motor or sensory abnormality was noted.The white blood cell count was 24.8 1,000/mL with 28% eosinophils and 42% neutrophils. The hemoglobin was 14 g/dL, and the platelet count was 254 1,000/mL. The serum sodium was 138 mmol/L, potassium 4.3 mmol/L, chloride 102 mmol/L, bicarbonate 22 mmol/L, BUN 14 mg/dL, creatinine 0.7 mg/dL, bilirubin 0.4 mg/dL, AST 17 IU/L, ALT 15 IU/L, alkaline phosphatase 117 IU/L, serum calcium 9.7 mg/dL, and serum glucose 175 mg/dL.A chest radiograph revealed ill-defined bilateral upper lobe hazy opacities. Computerized tomographic (CT) imaging of the chest showed multilobar opacities with bilateral upper lobe ground glass infiltrates and peripheral areas of consolidation (Figure 1).The man was admitted to the hospital and was treated with empiric intravenous vancomycin and piperacillin/tazobactam. All of the following tests were negative or normal: blood culture, sputum culture, serum coccidioidomycosis antibodies, 1-3 b-D-glucan, Aspergillus galactomannan antibodies, Strongyloides antibodies, stool for parasite testing, Legionella urinary antigen, and HIV and autoimmune screening tests.Bronchoscopy was performed. A sample of fluid obtained by bronchoalveolar lavage of the right upper lobe revealed a leukocyte count of 1,782/mL with 4% neutrophils, 6% lymp...