Case presentation

A 67-year-old woman presented to the emergency room in acute respiratory failure. She had a 4-month history of dry cough, fever, intense fatigue, progressive dyspnoea and recent visual impairment. Her prior medical history included a mitral valve replacement in 2005 due to post-endocarditis mitral regurgitation. On examination, the patient was in hypoxemic acute distress. She was intubated and mechanically ventilated. A chest x-ray (figure 1A) just prior to endotraqueal intubation revealed bilateral air space disease and high-resolution CT of the chest (figure 1B) revealed irregular nodules, bilateral areas of conglomerate masses with air bronchograms of peribronchovascular orientation surrounded by ground glass opacities and no mediastinal lymphadenopathy. Laboratory findings indicated mild normocromic and normocytic anaemia, haemoglobin 10 g/dl, lymphopenia 168 cells/mm³, C-reactive protein 157 mg/litre (0.0–3.0 mg/litre). Tests for HIV, serum cytoplasmic antineutrophil cytoplasmic antibody, antinuclear antibody and rheumatoid factor were negative. A transesophageal echocardiogram displayed a bioprosthetic mitral valve with mild stenosis, …