A 65-year-old man, an important ex-smoker until 6 years ago, diagnosed with Sjögren's syndrome 6 months ago and controlled since then with oral corticosteroids (90 mg prednisone/ day).
On the day of admission she presented sudden and progressive dyspnea along with pleuritic chest pain.
She also reported odynophagia and intermittent dysphagia for 3 months.
Examination in the emergency room showed a temperature of 38oC with a global decrease in vesicular murmur and inspiratory crackles in both lung bases.
In the initial laboratory tests, 8,200 leukocytes/mm3 saturation (neutrophils), CRP was 6.7 mg/dl and in PCO3 252 it was 51.8 mm Hg, pCO2 29.7, pH 7.54, HCO2.
Chest X-ray showed increased density in LID and cardiomegaly.
The patient was admitted to hospital with continuous steroid therapy, bronchodilators, low molecular weight heparin at therapeutic doses due to suspected pulmonary thromboembolism, ß-blockers and broad-spectrum antibiotics (cefx).
Sputum samples were not suitable for culture, and the blood cultures were sterile at 5 days.
At 48 hours after admission, a fibrobronchoscopy with bronchoalveolar lavage was performed, in which numerous polymorphonuclear leukocytes and Gram-positive intra- and extracellular diphtheria-diphtheria bacilli were observed in Gramiticum.
The strain was resistant to clindamycin and susceptible to penilin, amoxicillin-clavulanate, 2nd and 3rd generation cephalosporins, ciprofloxacin and glycopeptides.
A CT scan of the chest revealed a normal mediastinum with an alveolar pattern of poorly defined contours in the RLL, and a gastroscopy showed several ulcers from the middle esophageal third to the cardia of the herpes virus group.
Pulmonary ventilation-perfusion scintigraphy did not show relevant findings.
The evolution was satisfactory, disappearing symptoms and improving blood gas and biochemical parameters with resolution of the infiltrate.
