Physical examination showed diminished air entry at both bases with dullness on percussion, scattered rales, and without jugular venous distension or peripheral edema. Repeat chest radiography revealed increased bibasilar interstitial edema and alveolar opacities, now with large pleural effusions (Fig 2
). Transthoracic echocardiography findings were entirely normal. Resting room air arterial blood gas revealed pH 7.49, Paco2 of 25 mm Hg, and Pao2 of 55 mm Hg. Blood counts demonstrated an increased WBC count (9,100/μL) with > 20% bands, a decreased platelet count (33,000/μL), and increased hematocrit (40%) suggesting hemoconcentration. Blood smear showed > 10% reactive lymphocytes with immunoblastic features: metamyelocytes and bands with no toxic granulation in neutrophils and thrombocytopenia (Fig 3
). Coagulation studies were normal except for a mildly prolonged activated partial thromboplastin time (41.9 s). Blood culture findings were negative. Bronchoscopy revealed normal airways and a predominantly monocytic BAL fluid with negative bacterial, fungal, and viral stains. A diagnostic right thoracentesis revealed a monocytic (cell count, 80/μL) exudate by protein criteria: pleural fluid to serum ratios of 0.6 and 0.4 for protein and lactate dehydrogenase, respectively.