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Blood tests that yielded abnormal results included the following: alkaline phosphatase level, 259 units/L (normal:<110 units/L); a calcium value, 8.0 mg % (normal:8.5-10.5 mg/100 ml); total protein level, 6.2 g % (normaI:6.5-9 g/100 ml); albumin value, 2.5 g % (normal:3.5-5.0). The white blood cell count was mildly elevated (13.9/cu mm/g/100 ml), with a differential cell count of 63 percent segmented neutrophils, 15 percent band cells, 15 percent lymphocytes and 7 percent monocytes. The hematocrit value was 24.7 percent with a MCV of 85.7. A posteroanterior view of the chest showed right pleural effusion, right apical infiltrates and loss of volume of the right upper lobe (Fig 1). A Gram stain of the sputum showed 3 + PMNs, 2 + Streptococcus and 1 + Gram-negative bacilli that eventually grew oral flora. The intermediate tuberculin skin test was positive. Three sputum smears for acid-fast bacilli were negative. The patient was given ampicillin and cefotaxime for treatment of a community-acquired pneumonia. Rifamate and pyrazinamide were added empirically. During the first two days of hospitalization, the patient coughed up nearly two cups of dark gray blood-streaked sputum on each day. Four days after admission, the patient continued to have a fever and leukocytosis with a temperature of 39.3°C. A thoracentesis, under ultrasonic guidance, was performed which showed a small collection of fluid in the posterior inferior right pleural space. Five milliliters of yellow fluid was obtained. Gram and acid-fast stains were negative. Figure 1. A posteroanterior view showing a right pleural effusion, right apical infiltrates and loss of volume in the right upper lobe.