A Woman with Depression, Suicidal Ideation, and Fever

A 43-year-old woman presented to the emergency department with subacute worsening of medical and psychiatric symptoms. Comorbidities included AIDS and cocaine use disorder in the setting of multiple psychosocial stressors. During her subsequent psychiatric admission, she became febrile, hypotensive, tachypneic, and tachycardic. Chest radiography showed diffuse pulmonary nodules (see Figure 1). A discussant builds the differential diagnosis around three main considerations: immune status, epidemiologic exposures, and clinical features. He then examines the key feature — miliary nodules — through the lens of these three considerations to come to a final diagnosis.