Case presentation

A 76-year-old man, non-smoker, former bricklayer, was admitted to the Infectious Diseases Unit for cough and mild fever persisting for more than 1 month. The patient had no other significant medical problems and had not recently travelled abroad. There were no significant findings on physical examination.

Biochemical examinations showed an increase in inflammatory markers (CRP 7.9 mg/dl) and neutrophilic leukocytosis (14×10⁹/l). Quantiferon test was negative, as were the autoimmune and the oncological markers. Nodular opacities were seen in both lungs on chest x-ray, and a subsequent CT scan showed multiple nodules located in all areas, but particularly in the subpleural location. Some of these nodules had features of cavitation. No ground-glass opacities were present (figure 1A). Mediastinal lymph nodes were slightly enlarged with a maximum diameter of 20 mm. Two ultrasound-guided percutaneous biopsies of the peripheral subpleural nodules were performed, with histological evidence of a suppurative inflammatory infiltrate with negative culture results. A bronchoscopy with bronchoalveolar lavage and transbronchial biopsy showed an intra-alveolar proteinaceous material and no microorganisms (figure 1B); microbiological cultures …