A 57-Year-Old Man With a Large Left Pleural Effusion

A previously healthy 57-year-old man presented to the ED with altered mental status and severe shortness of breath. He was found to be in acute hypercapnic respiratory failure and required admission to the ICU. He reported the following: a 4-month history of progressive shortness of breath; left-sided chest pain; cough productive of brown, foul-smelling sputum; and weight loss. He had an extensive smoking history but had quit 1 year prior. The patient was born in Ethiopia but had been living in the United States for the last 20 years. His last visit to Ethiopia was in 2009, and he denied any other recent travel or exposure to TB. There was no history to suggest immune compromise. He had not seen a physician in many years and never established medical care in the United States.