A 70-year-old man presented with complaints of fever, dyspnea, and malaise. This had begun 1 year before after returning from camping in the Pacific Northwest. Subsequently, he has been having “flares” of these symptoms every 7 to 45 days. No environmental exposures were found. His wife has noticed a concurrent decline in his cognitive abilities, balance, and memory.
The patient had undergone multiple evaluations over the past year and received diagnoses of at least 10 episodes of pneumonia. High-resolution CT (HRCT) scans of the chest have shown scattered patchy ground-glass opacities throughout both lungs. A bronchoscopy with a specimen obtained by transbronchial biopsy revealed abnormal bronchial wall histology with thickened subbasal lamina, mild chronic inflammation, and increased eosinophils. A BAL fluid sample revealed increased neutrophils; cytology was negative for malignant cells. The findings of cultures from both the BAL fluid and tissue, including acid-fast bacilli and methenamine-silver stain for fungi and Pneumocystis jiroveci, have all been negative. The findings of an extensive rheumatologic evaluation were negative, as were those from evaluations for Lyme disease, HIV infection, West Nile virus infection, protozoan illness, and syphilis. The findings of an MRI of the brain, spinal fluid analysis, electromyography, and EEG have been unremarkable as well. An upper GI series with small bowel follow-through and barium swallow revealed mild esophageal dysmotility with a small amount of gastroesophageal reflux (GER). Gastric peristalsis and emptying were within normal limits.