Pneumonia of unknown cause.

The patient was a man aged 38 yrs. While at work early in the day, his illness started suddenly with severe cough, which was initially non-productive and which lasted for several hours. He felt breathless but had no wheeze. He bad a small quantity of frank haemoptysis. By evening he had a hectic fever, that was initially associated with chills. He was treated by a general practitioner with parenteral penicillin. By the fourth day he had developed left-sided pleuritic chest pain. At this stage a chest roentgenogram was obtained. His fever settled gradually over three weeks, and his cough became scantily productive. He continued to have chest pain and breathlessness and was referred to us for evaluation. The patient then had moderately high grade fever, scantily productive cough, chest pain and breathlessness of three weeks' duration. He had no history of drug/ alcohol intake, unconciousness or epilepsy, head or faciomaxillary trawna or general anaesthesia. He had been treated two years previously for right middle and lower lobe pneumonia. He had his upper left premolar tooth extracted one year earlier. He was a smoker and a teetotaller. When fust seen by us, he had clinical signs of resolving pneumonia of left lower lobe and bronchiectasis of right middle and lower lobes. He also had gingivitis and periodontitis. Upper right second molar and upper left premolar teeth were missing. Laboratory findings were haemoglobin (Hb) 95 g-1·1 , leucocytes 12.5x109 cells·1· 1 , differential leucocyte count (DLC) N78 L18 E4 80 MO, erythrocyte sedimentation rate (ESR) (Westergren) 70 mm in first h. Plasma sugar fasting was 6.1 mmol-1·1 and 2 h post-prandial 6.7 mmol·l·1• Direct smear of sputum was negative for acid-fast bacilli. Review of the roentgenogram (postero-anterior view) obtained by his general practitioner revealed consolidation in left lower and mid zones; a small dense opacity was visible in the left hilar region. Fresh roentgenograms showed features of resolving pneumonia of the left lower lobe with no shift of midline structures (fig. 1). a