A 36-year-old male of Mexican descent with NK cell lymphoma and concomitant hemophagocytic lymphohistiocytosis, who had recently been treated with pulse dexamethasone for disease relapse, was brought to Rush University Medical Center by his wife for failure to thrive and worsening confusion over the last 24 h. On admission, the patient appeared cachectic and sleepy but arousable, with mild nuchal rigidity. He was afebrile (body temperature, 36.3°C) but tachycardic (heart rate, 126 beats/min) and tachypneic (44 respirations/min), with a faint petechial rash over both lower extremities and the abdomen. His laboratory findings were significant for a normal white blood cell (WBC) count (4.29 cells/liter) and chronic anemia (hemoglobin [HgB] level, 8.4 g/dl), but with new thrombocytopenia (84,000 platelets/μl), worsening transaminitis (aspartate transaminase [AST] level, 154 U/liter; alanine transaminase [ALT] level, 190 U/liter), and hypoalbuminemia (albumin level, 1.4 g/dl).
Within 24 h of admission, the patient developed worsening confusion, mumbling to himself, with increased oxygen requirement and hypotension. He underwent a brain computed tomography (CT) examination, the results of which were unremarkable. His chest X-ray (CXR) revealed diffuse bilateral parenchymal ground glass opacities in both lungs, and he was transferred to the medical intensive care unit and started on empirical antibiotics with doripenem, levofloxacin, caspofungin, vancomycin, oseltamivir, and trimethoprim-sulfamethoxazole. Because of his rapid deterioration and concern for atypical pneumonia, an urgent bronchoscopy was performed, which revealed diffuse alveolar hemorrhage. The patient became more hypoxic after the bronchoscopy and was intubated. The petechial rash had also progressed, becoming more purpuric, and was biopsied. Two sets of blood cultures on admission were positive for Staphylococcus epidermidis. The result of the bronchoalveolar lavage fluid culture is shown in Fig. 1.
FIG 1.
Blood agar plate of bronchoalveolar fluid growth.
(For answer and discussion, see page 758 in this issue [doi:10.1128/JCM.01090-13].)