A 57-year-old man with very severe bullous emphysema presented with fever and a history of right-sided pleuritic chest pain for 5 days. He denied an increase in cough, sputum production, or weight loss. He had a 75-pack-year smoking history and had undergone resection of the right upper lobe for non-small cell lung cancer in 1994. He had gradually worsening shortness of breath for 4 months before hospital admission; therapy with oral prednisone, 20 mg/d, had been started 2 months prior to presentation, with intermittent increases to 60 mg/d, without clinical improvement. His medications included inhaled albuterol, tiotropium, and fluticasone. There was no history of diabetes, seizures, aspiration, alcohol abuse, or recent travel outside Houston.