Description
A 34-year-old Caucasian man with chronic renal failure on peritoneal dialysis presented with a 10-day history of productive cough, worsening dyspnoea and haemoptysis. He was a non-smoker, with no previous respiratory illnesses. There was no history of foreign travel or significant domestic or environmental exposures. He was feverish and tachypnoeic with scattered crackles throughout both lungs and mildly hypoxic (oxygen saturation 92% on air). He had no peripheral oedema.
His primary renal disease was focal segmental glomerulosclerosis with frequently relapsing nephrotic syndrome since childhood. Medication included long-term immunosuppressive therapy with tacrolimus and corticosteroids (5 mg prednisolone), and he had received cyclophosphamide and levamisole during childhood. He had started fluoxetine hydrochloride 20 mg daily for depression 6 months earlier. Renal transplantation was being considered.
A chest radiograph showed bilateral patchy consolidation. Pneumonia was diagnosed clinically, and he was treated with oral antibiotics and prednisolone dose doubled. Initially better, he was readmitted...
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