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A 31-Year-Old Man With Respiratory Failure

      A 31-year-old obese (210 kg) man with recently diagnosed acute otitis externa due to Streptococcus pyogenes presented with 2 weeks of progressively worsening cough, fever, and shortness of breath. In the ED, he was normotensive, febrile to 39.8°C, with sinus tachycardia at 138 beats/min, and with a respiratory rate of 34 breaths/min. Laboratory test results were significant for leukocytosis (50 K/μL). Results of rapid viral panel, blood cultures, HIV test, urine legionella antigen, sputum cultures, and acid-fast stain were negative. CT imaging of the chest showed a 4 × 3 × 4 cm cavitary lesion in the right upper lobe, a cavitary lesion in the lingula, and a right pleural effusion (Fig 1). Empirical vancomycin, cefepime, and azithromycin were started. On hospital day 3, the patient developed worsening tachypnea and hypoxemic respiratory failure requiring endotracheal intubation with mechanical ventilation, and he was admitted to the ICU. Bedside transthoracic point-of-care-ultrasound (POCUS) was performed (Video 1).
      Figure thumbnail gr1
      Figure 1A 4 × 3 × 4 cm cavitary lesion evident in the right upper lobe, and a right pleural effusion.
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