Case Presentation: : A 60-year-old male with history of emphysema was admitted to the hospital because of   worsening dyspnea, cough with yellow sputum production, fever and night sweats.The patient was hospitalized 9 days before this admission and was treated with levofloxacin and methylprednisone for acute exacerbation of COPD. Of note patient had a CT of chest several months ago, which demonstrated new focal bronchopulmonary infiltrates with nodular opacity in left lower lobe and mediastinal lymphodenopathy suspicious for inflammatory/infections process, and follow-up imaging was recommended. Physical examination was remarkable for scattered rhonchi and decreased breath sounds bilaterally on chest auscultation. Laboratory investigation revealed leukocytosis (WBC 14 × 103/μL).  CT of chest during this admission showed progression of diffuse micronodular opacities bilaterally with predominant multifocal apical pulmonary nodules, suspicious for infectious bronchiolitis. Treatment with vancomycin and meropenem was initiated. Bronchoscopy revealed non-necrotizing  granulomatious inflammation; BAL for  AFB, fungal and GMS  cultures were negative. Additional laboratory investigation revealed – positive ANA (titer of 1:320) and P-ANCA (MPO 4.1).Presumptive diagnosis of sarcoidosis was made and patient was discharged on prednisone 30 mg daily. Following 12 days after discharge patient was readmitted for worsening of dyspnea, fever and generalized weakness. In the interim he followed up with his primary care physician who increased his prednisone dose from 30 mg to 60 mg daily. Vital signs were remarkable for tachychardia (HR 139 bpm), hypoxia (oxygen saturation 77% on 5 L).Patient was started on noninvasive ventilation and admitted to intensive care unit. Broad-spectrum antibiotic regimen with vancomycin , meropenem and levofloxacin was initiated. CT of chest revealed interval progression with more confluent opacities in lower lung fields and progression of nodular components in upper and middle lung fields,mediastinal lymphodenopathy  and pericardial effusion. Patient underwent video-assisted thoracoscopic surgery (VATS) with pericardial window. Lung tissue and pericardial biopsy revealed necrotizing granulomatous inflammation with wide spread pseudohyphae like fungal elements. Final culture from lung tissue was positive for Candida albicans, which was also confirmed by PCR .  His antibiotic regimen was subsequently changed to amphotericin B which was later switched to micafungin followed by fluconazole. Patient remained hospitalized for 1.5 months and was discharged to rehabilitation facility on fluconazole 200 mg daily. 

Discussion: Primary pneumonia and pericarditis due to Candida species is extremely rare. In contrast to several previous reports where isolation of Candida from respiratory specimens has shown to represent colonization, the current case demonstrates that primary pneumonia from Candida can occur in immunocompetent hosts and can be life threatening if not treated promptly with systemic antifungal therapy. Necrotizing granulomatous pneumonia can be associated with fungal infections including Histoplasma and Cryptococcus but it has not been reported with Candida 

Conclusions: To the best of our knowledge this case report is first to describe necrotizing granulomatous pneumonia caused by Candida albicans