Physical exam revealed a tachycardia, fever (101°F), bronchial breath sounds and course inspiratory and expiratory wheezes with good oxygenation (98%) on room air. Chest x-ray showed extensive opacification of the left upper lobe with a patchy alveolar infiltrative process. Laboratory data showed leucocytosis with lymphopenia, neutrophilia and bandemia, elevated alkaline phosphatase and erythrocyte sedimentation rate. Routine cultures of blood, sputum, and urine were negative.

Hospital course: After two days intravenous Levofloxacin, the patient had no improvement clinically. Extensive fungal, viral, bacterial and connective tissue serologic studies were negative. CT scan of the chest showed extensive infiltrate with air bronchogram present of the left upper lobe, lingula and left lower lobe with perihilar calcification. Bronchoscopy revealed friable tissue obstructing the left upper lobe bronchus with unremarkable bronhcoavelolar lavage and transbronchial biopsy. Intravenous antibiotics were changed to Cefazolin and Primaxin with no further clinical improvement by day 15. At this point a video assisted thoracoscopic lung biopsy was performed. Histopathologic findings were consistent with bronchiolitis obliterans with organizing pneumonitis (BOOP). Patient was started on IV Solumedrol with substantial resolution of infiltrates on CXR within two weeks of starting therapy. Patient was continued on outpatient oral Prednisone for three months with near complete resolution of her initial left lung infiltrate.