A 43-year-old, previously healthy man from central Indiana was admitted to the hospital with respiratory failure and fever. He denied outdoor activities or occupational exposures. Endotracheal intubation was performed in the emergency department. Arterial blood gas analysis on 100% fraction of inspired oxygen (Fio2) and positive end-expiratory pressure (PEEP) of 15 cm H2O showed pH of 7.44, Paco2 of 34 mm Hg, and Pao2 of 62 mm Hg (Pao2/fraction of inspired oxygen ratio [P/F] ratio of 62). A BAL did not recover any pathogens. An HIV test result was negative. Refractory ARDS developed despite low tidal volume ventilation, broad-spectrum antibiotics, and restrictive fluid management. A chest radiograph (CXR) and chest CT (Fig 1
) showed diffuse reticulonodular infiltrates. Methylprednisolone (250 mg IV q6h) was started empirically on day 1 for presumed interstitial lung disease. Oxygenation improved dramatically, as reflected by a P/F ratio of 182 and Fio2 of 40% on day 4. However, on day 5 oxygenation worsened. There was no significant change in the bilateral pulmonary infiltrates, and the patient remained afebrile. A repeat BAL ruled out ventilator-associated pneumonia. Interestingly, this BAL revealed yeasts of Blastomyces dermatitidis. BAL cell differential demonstrated 95% neutrophils, 4% macrophages, and 1% eosinophils. This was accompanied by peripheral neutrophilia (97%). Methylprednisolone was stopped immediately. Amphotericin B deoxycholate (AMBD) [1 mg/kg/d IV] was started. Unfortunately, the patient continued to deteriorate. On day 7, he was back on 100% Fio2 and PEEP of 15 cm H2O; P/F ratio was 68. Methylprednisolone was restarted. AMBD was continued. Again, this led to significant improvement (P/F ratio of 166 on day 8). Fio2 was decreased to 40% over the next few days. The patient started tracheostomy collar trials on day 19. A CXR at discharge showed a marked decrease in infiltrates.