Clinical Infectious Diseases

A 59-year-old Moroccan man with a history of metastatic urothelial cell carcinoma presented in May 2016 with fever, shortness of breath, and chest pain. Noninvasive urothelial carcinoma had been diagnosed in 2012 and treated with mitomycin. In 2014, the patient had received intravesicular Mycobacterium bovis BCG therapy, but invasive bladder carcinoma subsequently developed, requiring 4 cycles of chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin. Nine months before the current admission, the patient underwent a radical cystoprostatectomy with creation of a neobladder. Nonetheless, brain metastases developed, for which he received dexamethasone (4 mg orally, twice daily), and underwent neurosurgical resection 3 months before presentation, followed by whole-brain irradiation. He continued receiving intermittent dexamethasone therapy until his admission to our hospital. A staging computed tomographic scan of his chest and abdomen 2 weeks before admission showed no evidence of metastatic disease. A week before presentation, the patient experienced progressive fatigue and heart palpitations, followed by cough, dyspnea, and pleuritic chest pain. On the day before admission, he experienced acute onset of fever (39°C) with chills. On admission, his temperature was 38.1°C with a pulse rate of 93/ min, blood pressure of 101/69 mm Hg, and oxygen saturation of 92% with room air. On physical examination, crackles were auscultated at the right lung base. The patient’s total white blood cell count was 10 400/μL with 93.5% neutrophils; his hemoglobin level, 14.9 g/dL; and his platelet count, 112 000/μL. Chest radiography revealed a left lower lobe opacity. Serial chest computed tomographic scans demonstrated a right lower lobe pulmonary embolus and new bilateral, centrally necrotic nodular opacities that eventually NOTYETRECEIVED Figure 1. Computed tomographic scan of the chest demonstrating multiple cavitary lung nodules.