A Patient Presenting With Shortness of Breath, Fever, and Eosinophilia.

A 70-year-old veteran with a history notable for type 2 diabetes mellitus, complicated by peripheral neuropathy and bilateral foot ulceration, and previous pulmonary tuberculosis (treated in June 2013) presented to an outside medical facility with bilateral worsening foot pain, swelling, and drainage of preexisting ulcers. He received a diagnosis of bilateral fifth toe osteomyelitis and was discharged with a 6-week course of IV daptomycin 600 mg (8 mg/kg) and ertapenem 1 g/d. At discharge, the patient was in stable condition. Follow-up was done by our outpatient parenteral antimicrobial therapy (OPAT) team, which consists of an infectious disease pharmacist and the physician director of antimicrobial stewardship who monitor veterans receiving outpatient IV antibiotic therapy.1 Three weeks later as part of the regular OPAT surveillance, the patient reported via telephone that his foot osteomyelitis was stable, but he had a 101 °F fever and a new cough. He was instructed to come to the emergency department (ED) immediately. On arrival, complete blood count (CBC) revealed leukocytosis with elevated eosinophils to 2.67 K/μL compared with 0.86 K/μL (reference range, 0 to 0.5 K/μL) 1 week earlier (eAppendix, available at doi:10.2788 /fp.0336). Renal and liver function were within normal limits. A COVID-19 test was negative. The initial examination was notable for mild respiratory distress with oxygen saturation of 90% on room air and a respiratory rate of 25 breaths/min. A lung examination showed bilateral crackles. He reported no skin rash or mucosal lesions. The patient was placed on 2 L/min of oxygen via nasal cannula. A chest radiograph showed rightsided opacities; however, further computed tomography (CT) chest imaging was significant for bilateral opacities (Figure 1).