A 72-year-old woman with several months of weight loss and generalized weakness.

PRESENTATION OF CASE I n September, a 72-year-old woman presented to an outside emergency department with several months of dizziness, weight loss, generalized weakness and increased fatigue, present since February, when a chest radiograph revealed bibasilar pulmonary infiltrates. At that time, she denied chest pain, shortness of breath, chills or fever. A bronchoscopic examination was nondiagnostic. Over the next several months, her symptoms worsened and were accompanied by dizziness and weight loss. A repeat chest radiograph showed persistent bilateral pulmonary infiltrates with a left-sided pleural effusion. She also had a normocytic anemia, acute renal dysfunction and atrial fibrillation. The patient had chronic obstructive pulmonary disease, hypertension, hyperlipidemia, degenerative joint disease and a previous hip arthroplasty. She had been a heavy smoker previously and denied use of illicit substances or alcohol. She had not traveled recently and did not own pets or report any occupational exposures. She had 6 children, only 1 of whom was alive. The causes of the deaths of the other 5 were unknown. The living son had esophageal carcinoma for which he was receiving palliative care. The patient’s brother died in his 70s of a pulmonary hemorrhage of unknown cause. The patient was using metoprolol, acetaminophen and an albuterol inhaler as needed. Thoracentesis performed at another facility produced transudative fluid. Her kidney function worsened as did her respiratory status. She was intubated, placed on mechanical ventilation and transferred to our hospital for further care. On transfer, the patient weighed 92 kg and was 183 cm tall. Her temperature was 35.9°C, blood pressure 186/76 mm Hg, pulse 79 beats per minute, respiratory rate 12 breaths per minute and oxygen saturation 98% on FIO2 of 40%. Her head was normocephalic; pupils were equal, round and reactive to light. Mucous membranes were dry and dentition was poor; an endotracheal tube was in place. Sputum suctioned from endo-tracheal tube was bloody. Her neck was supple without thyro-megaly or lymphadenopathy. The pulse was regular. No murmurs, rubs or gallops were heard. Radial and dorsalis pedis pulses were symmetric and 2+ bilaterally. Diffuse crackles were heard in all lung fields. The abdomen was soft, nontender and nondistended. There was no hepatosplenomegaly or abdominal bruit. A Foley catheter was in place with transparent blood-tinged urine in the bag. There was marked generalized edema of both upper and lower extremities. A central venous catheter was present in the left internal jugular with a small amount of serosanginous fluid oozing from the insertion site. The patient was sedated but would withdraw from painful stimuli in all extremities. Generalized livedo reticularis and ecchymoses were present. Results of laboratory studies are listed in Tables 1–4. A renal ultrasound revealed normal-sized kidneys with normal echogenicity. Computed tomography of the chest without intravenous contrast revealed dense consolidations throughout both lungs with bilateral pleural effusions and small calcified and noncalcified mediastinal lymph nodes. A diagnostic test was performed. From the Departments of Medicine (MRW) and Pathology (CBD), University of Maryland School of Medicine, Baltimore, Maryland. Correspondence: Philip A. Mackowiak, MD, Medical Service (111), VA Medical Center, 10 N. Greene Street, Baltimore, MD 21201 (E-mail: Philip. Mackowiak@med.va.gov).