Ill man in ED with chest pain, fever – Let’s diagnose

A 67-year-old man presented to the ED appearing ill with complaints of productive cough, dyspnea, pleuritic chest pain, and fever for the past 5 days. He noted that dyspnea had been present for years; he had been on low-dose rituximab as management therapy for pulmonary alveolar proteinosis for 8 years. On physical examination, the patient had a temperature of 103°F (39°C). Lab examination showed elevated C-reactive protein. The patient had no recent travel history and denied history of smoking and illicit drug use. He was a health care provider with a history of negative PPD skin tests. Radiographic and CT features revealed an ill-defined, solitary pulmonary nodule in the right upper lobe and focal/confluent consolidation of the bilateral lobes.

What’s the diagnosis?

    1. Acute bronchitis
    2. Pulmonary nocardiosis
    3. Community-acquired pneumonia
    4. Tuberculosis

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