Her treatment of graft-vs-host disease included dexamethasone, 12 mg/d; cyclosporin, 100 mg bid; and pimecrolimus 1% cream. The inpatient stay was lengthy with many complications, including both cutaneous and hepatic manifestations of graft-vs-host disease, cytomegalovirus infection, and pancytopenia. She was profoundly neutropenic and thrombocytopenic, with an absolute neutrophil count ranging from 0.243 to 1.134, and a platelet count consistently below 30/μL and a low value of 6/μL. On hospital day 41, hemoptysis developed and a CT scan revealed diffuse ground-glass opacities and regions of consolidation consistent with diffuse alveolar hemorrhage. The diagnosis of diffuse alveolar hemorrhage was confirmed by BAL, which recovered many hemosiderin-laden macrophages seen on Prussian Blue staining. Culture findings from the BAL were negative for bacterial and fungal organisms. A follow- up CT obtained 4 days later revealed a marked improvement in diffuse alveolar hemorrhage, but also showed a new 0.9 × 1.0-cm nodule in the left upper lung (Fig 1
). Because of her immunocompromised status, voriconazole, 200 mg bid, was begun. Despite treatment, a chest radiograph obtained 1 week later revealed a left upper lobe pneumonia (Fig 2
). A CT scan was repeated with the left upper lobe lesion now measuring 6.6 × 5.1 cm (Fig 3
). This lesion was of heterogeneous density with ill-defined margins and a halo of ground-glass opacity. Bronchoscopy was repeated, this time with transbronchial lung biopsy (Fig 4, 5
) in addition to BAL.