Nonresolving Pneumonia Developing into a Cavitary Lesion

A 29-year-old, previously healthy white female was seen 3 times by her primary care provider for upper respiratory symptoms 2 weeks after competing in an outdoor obstacle course that involved crawling on the dirt in the California San Joaquin Valley. The patient denies any recent sick contacts or travel outside of the local area. She was given 3 separate courses of antibiotics, over the course of 6-8 weeks, for the diagnosis of community-acquired pneumonia without improvement. Eventually, she presented to the urgent care clinic with worsening cough, production of malodorous sputum, anorexia, fevers, chills, sweats, nausea, vomiting, and malaise. She has lost 20 lbs since the onset of symptoms.

On physical examination, the patient is mildly ill-appearing with a temperature of 102.4°F, a heart rate of 106 beats per minute, a respiratory rate of 22 breaths per minute, a blood pressure of 118/64 mm Hg, and an oxygen saturation of 95% on room air. Lung auscultation revealed coarse rhonchi in the left upper lung field. Her heart rate is rapid, but no murmurs are appreciated. The remainder of her physical examination is unremarkable.

Laboratory tests performed in urgent care showed a mild leukocytosis of 13.4 WBC count with otherwise normal results. Chest radiograph shows a 4.2-cm diameter cavitary lesion with an air fluid level in the left upper lobe, along with mediastinal lymphadenopathy (see Images 1-2).

What is the diagnosis?

What is the diagnosis?
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The patient lives in central California and had significant dust exposure prior to developing the cavitary lesion.