Lesson of the month 1: Lobar pulmonary consolidation in an immunocompromised host

A 19-year-old male with a history of idiopathic panuveitis, currently taking methotrexate and infl iximab, presented to our institution with 6 weeks of cough, dyspnoea and fevers. He had failed outpatient antimicrobial therapy. Computerised tomography (CT) of the chest revealed the presence of a lobar pneumonia and he was treated with broad spectrum antibiotics, which did not improve his symptoms. Bronchoalveolar lavage was performed with a transbronchial lung biopsy because of the diagnostic uncertainty of the patient's presentation. Pathology revealed non-budding yeasts, consistent with Pneumocystis . Serological and urine studies were positive for both Histoplasma and Blastomyces . The diagnosis of Histoplasma pneumonia was made because of the presentation being inconsistent with Pneumocystis pneumonia, and serology, urine and pathology testing being more consistent with Histoplasma . The patient was treated with oral itraconazole and was doing well at follow-up 12 weeks after hospitalisation.