PMC1112595_01
PMC1112595_02
PMC1112595_03
Chest X-ray (PA view) at initial presentation showing early right lower lobe consolidation.
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F1
A chest X-ray (figure 1) showed right lower lobe infiltrate.
Chest X-ray (PA view), 5 days later, showing progression of disease with infiltrates in right and left lower lobes.
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F2
A second chest X-ray (figure 2) showed dense infiltrate in right lower lobe.
A section of CT scan of chest performed 8 days after hospitalization showing bilateral consolidation of lungs, mainly of lower lung fields.
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F3
On 7th day because of ongoing symptoms, the antibiotics were changed to intravenous imipenem-cilastatin sodium 1 gm every 12 hour and she has had a CT scan of chest (figure 3) that showed bibasilar consolidation with sparing of the apices.
Chest X-ray (PA view) - after 8 days of intravenous antibiotic therapy, showing further worsening of bilateral lower lung disease with nodular pattern - raising suspicion of metastatic disease.
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F4
Chest X-ray (figure 4) now showed further deterioration of the bilateral infiltrates with nodular appearance and the radiologist remarked, "The lesions are suspicious of metastases." Sputum cytology showed a large number of acute inflammatory cells without malignant cells.
Wet preparation of sputum [25% NaOH with 5% Glycerol as the mounting medium, 40x magnification] showing budding yeast [blastocyst]
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F5
The PHL laboratory confirmed the presence of 'round thick walled budding yeast like cells (figure 5) suggestive of Blastomyces dermatitidis and this was confirmed on fungal cultures.
PMC1112595_04
PMC1112595_05
Chest X-ray (PA view) at initial presentation showing consolidation within the right mid and both lower lobes.
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F6
In February of 2004, a 57-year old woman with morbid obesity [weight over 350 pounds] with history of hypertension and type 2 diabetes presented with one month history of fever, night sweats and cough and was admitted to the hospital with right sided community acquired pneumonia [figure 6] and started on intravenous levaquin.