Diagnoses 2 & 3: Coagulative necrosis (transbronchial biopsy). Organizing, interstitial pneumonia with focal granulomas, stains for fungi and acid-fast organisms negative (open lung biopsy)

Comment: The cause of the coagulative necrosis was not recognized. The interstitial pneumonia was consistent with acute interstitial pneumonia, but its cause and the nature of the granulomas remained a puzzle.

Course continued: Following initiation of high-dose corticosteroids (Solumedrol, 60 mg IV/day) his respiratory status improved, as did the radiographic abnormalities. He was discharged 10 days later with a steroid taper, pneumocystis prophylaxis, and INH/rifampin for tuberculosis.

Ten days after discharge, he presented again with sudden onset of shortness of breath and left-sided chest pain. Examination revealed tachypnea, hypoxemia, and respiratory distress with decreased breath sounds in the left chest. A chest film confirmed a 60%, left-sided pneumothorax.

Clinical SummaryRadiology

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