Giardia lamblia in bronchoalveolar lavage fluid.

A 63-year-old man presented with recurrent episodes of acute wheezy bronchitis accompanied by fever (39 5°C). His illness had started three months before admission. After treatment with intramuscular ampicillin (1 g three times daily) fever subsided but he continued to cough and wheeze. Because of these symptoms the patient was sent for further examination. History revealed a subtotal gastrectomy at the age of 45 years for a stomach ulcer. He was a heavy smoker. Clinical examination revealed only crepitations over the right upper part of the lung. Electrocardiographic tracings showed no abnormalities. Chest radiographs and tomograms revealed a massive non-excavated infiltration of the posterior segment of the right upper lobe; an air-bronchogram was present. Laboratory tests showed a marked elevation of the erythrocyte sedimentation rate and raised serum uric acid. On fibreoptic bronchoscopy there were no signs of intraluminal tumour or foreign body. Large amounts of clear liquid were aspirated. Cytological examination of the aspirate and a brush preparation from the posterior part of the upper lobe were negative for malignant cells. Transthoracic needle puncture showed atypical cells, Papanicolaou class III. Cultures of the bronchial and lung aspirates were negative for M. tuberculosis. After these inconclusive examinations the patient left hospital on his own responsibility. He was admitted again four months later because of recurrent febrile episodes. The chest radiograph showed an additional infiltrate in the lingula. Bronchoalveolar lavage was performed of the posterior segment of the right upper lobe. During an episode of cough, yellow fluid appeared from the apex of the lower lobe and was aspirated. The aspirate was negative for tumour cells. Cultures were positive for E coli. Examination of a coloured preparation of the lavage fluid revealed 6% lymphocytes and numerous parasites, which could be identified as Giardia lamblia (figure). Subsequently the same parasite was found in massive amounts in the patient's stools and in the gastric aspirate. After the bronchoalveolar lavage the patient's temperature rose to