Photo Quiz: A Farm Worker with Cavitary Pneumonia

A 51-year-old Spanish-speaking female with a history of diabetes mellitus and hypertension presented to the emergency department with dyspnea, pleuritic chest pain, night sweats, and fever. She noted 10 years of intermittent cough, productive of clear phlegm, that had worsened over the past year. She had undergone a lung biopsy 6 years earlier and was diagnosed with a “dormant tumor.” She denied a history of tobacco or illicit substance use. The patient was born in Mexico, moved to Arizona at the age of 23, and had been living in central Washington State, east of the Cascade Mountains, for the past 8 years. She had been employed as a farm worker in both Arizona and Washington. Laboratory studies were notable for a white blood cell count of 12,030 cells/μl (73% neutrophils), a serum glucose level of 462 mg/dl, and a positive QuantiFERON-TB Gold Plus gamma interferon release assay. A computed tomography (CT) scan showed a cavitary left upper lobe mass with apical sparing and mediastinal lymphadenopathy (Fig. 1A). Bronchoscopy was performed, and a bronchoalveolar lavage (BAL) specimen contained predominantly neutrophils and eosinophils and occasional hyphal elements (Fig. 1, arrows), with a negative acid-fast bacillus (AFB) stain (Fig. 1B and C). BAL specimens were positive for Aspergillus galactomannan, with indices of 1.553 and 1.149 (normal, <0.499) from the left upper and right upper lobes, respectively.