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 infliximab, 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.