Mark G Jones (MGJ): A 33-year-old woman was referred for a respiratory opinion. Three months prior she had developed a ‘bad cold’. This had persisted with intermittent rhinorrhoea, non-productive cough, pleuritic chest pain and a weight loss of 6 kg. Her symptoms had transiently improved following courses of co-amoxiclav and clarithromycin from her primary care physician and local district general hospital. The patient was previously healthy with no medical history of note. She had smoked minimally and drank little alcohol. There were no occupational or environmental exposures of note. Her family kept two cats and she had travelled to Spain 4 months prior to symptom onset.

On examination she appeared unwell. Bilateral submandibular and cervical lymphadenopathies were detected. Bilateral crackles were auscultated in the chest. Cardiovascular, gastrointestinal and neurological examinations were normal. The chest radiograph showed lingular consolidation and patchy right basal ground-glass opacities. Initial laboratory investigations identified a neutrophilia (25.2 × 10⁹/l) and a raised C reactive protein (CRP) (123 mg/l). Liver and renal function tests were within the normal range.

Katherine M A O'Reilly (KO'R): We have a previously healthy young woman who presents with pulmonary infiltrates, raised inflammatory markers, lymphadenopathy and weight loss. Although the initial presentation was suggestive of a community-acquired bacterial pneumonia (CAP), the response to broad-spectrum antibiotics is not as expected. So while CAP is unlikely, atypical infections including mycobacterial disease should be considered. The weight loss and lymphadenopathy are concerning and we should exclude an underlying malignancy such as lymphoma. In addition, HIV/AIDS, underlying inflammatory conditions such as vasculitis or cryptogenic organising pneumonia and recurrent aspiration should be considered.

MGJ: Further questioning identified no history of gastro-oesophageal reflux disease, swallowing difficulties or risk factors for aspiration pneumonia. Serologies including mycoplasma, coxiella, bartonella, toxoplasma, borrelia and histoplasma were negative. Lactate dehydrogenase level …