CLINICAL PRESENTATION

A 74-year-old man of Jamaican origin residing in the USA for 20 years presented to the hospital with progressively increasing shortness of breath and low-grade fever for 3 weeks. He had been diagnosed with non-Hodgkin’s lymphoma 6 months prior to admission and started on chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisolone, with the last dose 12 days before presentation. In the hospital he was found to be hypoxic (82% saturation on room air) and required intubation and mechanical ventilation in the next 24 h. The clinical examination was unremarkable. His white blood cell count was 1100/mm³ with a normal differential. A chest radiograph and CT scan of the chest revealed diffuse bilateral nodular infiltrates (fig 1). He was started on antibiotics without improvement.

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Figure 1 CT scan of the chest showing bilateral nodular infiltrates.

Bronchoscopy with bronchoalveolar lavage was performed on the second day. The airways were found to be inflamed and the lavage revealed abundant filariform larvae about 550 μm long with a notched tail (fig 2). His stool also showed similar larvae.

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Figure 2 Bronchoalveolar lavage fluid showing filariform larva.

QUESTION

What is the diagnosis?

See page 753.

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