A 75-year-old woman was admitted to the hospital with dyspnea, fever, and sore throat. She had been healthy until 4 months prior when a cough productive of scant amounts of clear sputum developed. This was followed by 2 months of progressive exertional dyspnea. Two weeks prior to hospital admission, ear pain, sore throat, and fever developed in the patient. She sought medical attention and was found to have cervical lymphadenopathy. A CT scan of the head and neck revealed a lesion at the base of her tongue, adenopathy in the cervical chain, and multiple nodules in the lung apices. A chest roentgenogram, and then a chest CT scan confirmed multiple small, bilateral, poorly defined nodules in all lung fields (Figs 1
, left, a, and 2
, top, a). A biopsy of the tongue mass was not diagnostic, with the specimen revealing acute and chronic inflammation with mixed populations of lymphocytes and granulocytes, as well as Candida species and Actinomyces (Fig 3
). This was thought to represent a chronic infection, and the patient was prescribed fluconazole and clindamycin. Despite 2 weeks of therapy with these antibiotics, her fevers continued and her dyspnea worsened; she presented to the emergency department and was admitted to the hospital.