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69-year-old woman with dyspnea and cough productive of white sputum.

A 69-year-old woman was admitted to our institution with progressive dyspnea and cough productive of white sputum. Three months earlier, the patient was hospitalized elsewhere for evaluation of fever, headache, and fatigue. Results of a right temporal artery biopsy were consistent with giant cell arteritis (GCA). She was treated with prednisone (50 mg/d) and initially improved, but after 6 weeks of therapy, she again experienced feelings of malaise. Her erythrocyte sedimentation rate (ESR) remained elevated at 75 mm/h. The patient’s rheumatologist then added methotrexate (MTX) to her treatment regimen. One week after starting MTX, the patient developed a vesicular rash on the left side of her chest that resolved without intervention, and she did not seek medical attention. Three weeks later, she was admitted to her local facility with complaints of chest pain, dyspnea, fever, and cough productive of white sputum. An adenosine stress test yielded negative results. A ventilation-perfusion lung scan revealed low probability for pulmonary embolism. Chest radiography findings were normal. In addition to deep venous thrombosis (DVT) prophylaxis with heparin, she was treated with intravenous levofloxacin, vancomycin hydrochloride, and ceftazidime. No sputum studies were obtained. After 3 days of antimicrobial therapy, the patient was transferred to our facility because of continued fever and dyspnea.