On presentation, the patient was ill-appearing, with a frequent, dry cough. She had a respiratory rate of 16 breaths/min, a temperature of 98.3°F, and bronchial breath sounds with egophony in the right upper and middle lung zones. There was no rash or palpable lymphadenopathy. The peripheral WBC count was 13,700 cells/μL (neutrophils, 88%; lymphocytes, 8%; monocytes, 3%; eosinophils, 1%). As polyarthralgias progressed to polyarthritis, a rheumatologic workup revealed a sedimentation rate if 116, negative Lyme serology, positive antinuclear antibody (ANA) test result (titer, 1:40 with a diffuse pattern), negative anti-double-strand DNA test result, and a markedly positive serum rheumatoid factor test result (titer, > 1:1,280). A chest CT scan (Fig 1
) demonstrated dense consolidations in the posterior segment of the right upper lobe and superior segment of the right lower lobe, with air bronchograms and evidence of old granulomatous disease. Bronchoscopy revealed no endobronchial lesions or significant secretions, and the findings of BAL fluid cytology and cultures (including those for acid-fast bacilli) were negative. Serology findings were negative for coccidiomycosis, histoplasmosis, blastomycosis, parvovirus, pertussis, and mycoplasma pneumoniae, as was that for the anti-neutrophil cytoplasmic antibody test. The patient was referred for video-assisted thoracoscopy for the tissue diagnosis of refractory pneumonia.