A 30-year-old Brazilian music-hall entertainer was admitted to the emergency department of a Berlin hospital with the following symptoms: dyspnea, cough, hemoptysis, chest pain, and a body temperature of 39.7°C. The patient was normotensive, the heart rate was 120 beats/min, and the respiratory rate was 26 breaths/min. His general condition was poor. He reported that the symptoms had occurred while fire-eating. CT and chest radiography revealed infiltrations in the right lower lobe of the lung and to the left in retrocranial direction, partly with air inclusions and, on the right side, a marginal angular pleural effusion (Fig 1
, left, A, and center, B). The cell blood count revealed elevated WBCs (13,800/μL) with a left shift. A striking finding was an increase of the C-reactive protein by 34 mg/L and an increase of creatinine-kinase by 170 U/L. Serum electrolytes, hepatic and renal function findings, as well as arterial blood gas measures, were normal. Conservative therapy was initiated, which included 1.5 g of cefuroxime IV tid, 320 mg of gentamicin IV qd, and 20 mg of prednisolone equivalent IV tid. After 5 days, the clinical symptoms had improved but the temperature was still 39°C. The WBC count had increased to 20,600/μL, as had the C-reactive protein to 337 mg/L. The patient was then transferred to our hospital. After interrupting antibiotic therapy for 24 h, bronchoscopy was performed. The macroscopic finding was an inflamed, hyperemic bronchial system, especially on the right side. Signs of bronchial purulence were not observed. The material for the demonstration of pathogens was taken from segment 10 on the right side by means of a protected specimen brush and BAL; however, pathogens, ie, bacteria, mycobacteria or fungi, could not be demonstrated, either microscopically or by culturing. Light microscopic inspection of the cell smear taken from the BAL material (Fig 2
, top left, A), which had been stained with Giemsa solution, revealed 40% alveolar macrophages, 21% lymphocytes, 33% neutrophils, and 6% eosinophil granulocytes. Immunotyping of the lymphocytes yielded a CD4/CD8 ratio of 2.4. Additionally, the BAL material was investigated in the electron microscope.