A 47 yo Native American female was admitted to the hospital in March 2009 for shortness of breath.

This patient with history of closed head injury, alcoholism, IV methamphetamine use, hypertrophic cardiomyopathy, and chronic renal insufficiency had previously been hospitalized in May 2008 for abdominal pain, nausea, and vomiting. During hospitalizations at the time she had been noted to have cavitary lung disease (see upper CXR at left) and cough. Symptoms appeared to respond to clindamycin and levofloxacin; it was thought that perhaps she may have had an aspiration pneumonia.

In late May 2008 (after hospital discharge) a Quantiferon-TB Gold test was performed and was reported as positive. Two sputa obtained in July 2008 were negative for AFB smear and culture. The patient exhibited a tendency to be non-compliant with medical follow-up and was jailed one or more times in the interval prior to her current hospitalization.

Her March 2009 hospitalization occurred after she became increasingly short of breath. She complained of a several week long worsening of respiratory symptoms including cough prior to seeking medical care. At the time of her ER presentation she was described as smelling of alcohol but to not appear to be in distress. Examination was notable for clear lung fields and a harsh grade III/VI systolic ejection murmur. Laboratory data included WBC 11.4, Hgb 10.6, creatinine 2.5 (her baseline), and results of ABG on room air were pH 7.35, pCO2 28, pO2 72, O2Sat 97%. HIV antibody was "indeterminate." CXR is at lower left. She was begun on broad spectrum antibiotic therapy with ceftriaxone, clindamycin, and azithromycin. Sputum cultures grew Staphylococcus aureus, Streptococcus pneumoniae, and Group B streptococcus.

The patient developed signs and symptoms of alcohol withdrawal, was treated with sedation, and became obtunded necessitating endotracheal intubation to protect her airway. To further evaluate her cavitary lung disease she underwent bronchoscopy. Multiple specimens were submitted for laboratory analysis.