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A 20 year old male was transferred to UMH for ongoing treatment of atypical pneumonia. One week before transfer, he had developed fever, chills, sweats, malaise, a minimally productive cough and shortness of breath. The CXR revealed a diffuse interstitial reticulonodular pattern. When he failed to respond to levofloxacin, he was placed on vancomycin and piperacillin-tazobactam and referred for further evaluation and management. He denied past medical problems. Having emigrated from the Marshall Islands in 2008, he had been living in Missouri over the past year. He denied sick contacts, recent tick bites or significant exposure to animals. He re-ported smoking 5 cigarettes per day. Initial labs revealed a WBC of 4100, with normal Hgb, Hct and platelet count. Renal function was normal but the liver transaminases were mildly elevated: AST 136, ALT 123.
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