A 23 year-old man arrives at the emergency department with a three week history of dyspnea, dry cough, fevers and night sweats. Two weeks previously, he was evaluated in an outpatient clinic and given a course of azithromycin for presumed infectious pneumonia. His symptoms did not improve and he was seen one week later in an urgent care center and given a prescription for doxycycline which he has been taking without improvement. He states that he feels miserable, has severe nausea and vomiting, and has not eaten in several days. His only past medical history is childhood asthma. He reports no surgeries and takes no medications. He has no risk factors for human immunodeficiency virus (HIV), does not smoke combustible cigarettes or use intravenous drugs, and has not recently travelled. Examination shows a room air saturation of 89%, a temperature of 38.3° Celsius, respiratory rate of 22. His examination is normal and there are no rales or wheezing heard in the lungs. Chest radiograph shows bilateral, consolidative opacities (Figure 1). White blood cell (WBC) count is 14,000 with left shift. Biochemistries are normal. Erythrocyte sedimentation rate (ESR) is 104 and procalcitonin is 0.08. Urine toxicology screen is positive for tetrahydrocannabinol (THC). Asked specifically about vaping and e-cigarette use, he reports that he recently began using THC “carts” that his friend gets from an unknown supplier. What is the diagnosis and what additional steps are necessary to confirm it? Is bronchoscopy indicated?
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