A 19-year-old man with nonresolving pneumonia.

A 19-year-old white man was referred to the pulmonary clinic with a 2-month history of refractory cough, low-grade fevers, night sweats, and 30-lb weight loss. He had right-sided pleuritic pain and episodic scant hemoptysis. He denied smoking and using illicit drugs. He was single and had protected sex with two female partners over the past several years. He worked as a pipe fitter and denied any unusual hobbies, hunting, or recent travel. He would frequently go on camping and fishing trips near his hometown lake in southern Indiana. Chest radiographs and CT scans over 2 months showed progressive right upper lobe consolidation. He had negative findings on purified protein derivative and HIV screening. He had undergone bronchoscopy with normal results, and BAL specimens and brushes were culture negative for acid-fact bacilli, fungi, and cytology. He had been treated with multiple antibiotics, including amoxicillin, azithromycin, ciprofloxacin, clindamcyin, and cephalexin.