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A 65-year-old man with progressive shortness of breath.

65-YEAR-OLD RETIRED coal miner presented to a tertiary care center complaining of progressive shortness of breath over the past 4 months. He reported audible wheezing and intermittent cough productive of scant, thin, yellow sputum but denied fever, chills, or hemoptysis. He had been diagnosed with “black lung” and emphysema in 1992 and treated with bronchodilators, with which he had not been compliant. He also had hypertension and type 2 diabetes mellitus. He said he was up-to-date in his immunizations for influenza and pneumonia and had never had thromboembolic disease. Four months earlier, the patient had begun to experience gross hematuria. He was diagnosed with rapidly progressive glomerulonephritis (RPGN) on the basis of a renal biopsy at another hospital and was treated with cyclophosphamide and high-dose prednisone (60 mg/day). In the months that followed he was hospitalized twice for shortness of breath and treated for community-acquired pneumonia. After his last admission 3 weeks earlier, he was started on oxygen therapy (2 L/minute continuously per nasal cannula) and transferred to a pulmonary rehabilitation facility, from which he was discharged 2 days before his current admission. The patient quit smoking 4 years ago after a 20 pack-year history. He worked as a coal miner for 14 years and was disabled by his lung disease. His current home was in northern Ohio, but he grew up in rural Appalachia. He said he had not traveled outside the United States, had not been exposed to tuberculosis, and had never been in the military. He had an extensive family history of lung disease: his father had “black lung” and emphysema, and four siblings had died of lung cancer.