A 73-year-old man with a history of chronic obstructive pulmonary disease (COPD) for more than 10 years, he regularly inhaled salmeterol/fluticasone propionate (50microg/500microg) twice a day. He had 30 pack-years of smoking history and quit smoking for more than 10 years. He was a farmer by profession. He was admitted to hospital with cough and hemoptysis for more than five months.
Admission blood tests showed a white cell count of 5.8 x 109/L, C-reactive protein 3.1 mg/L and interleukin-6 16.32pg/mL. All of sputum smear acid-fast staining, tuberculin test and tuberculosis antibody test were negative. Serum biomarkers of lung cancer, such as carcinoembryonic antigen (CEA), Cytokeratin-19-fragment (CYFRA21-1), squamous cell carcinoma antigen (SCC), and neuron-specific enolase (NSE) were negative.
The images of computed tomography (CT) scan of the chest revealed large dense shadows and cavity formation in the inferior lobe of the left lung (Figure 1A). The electronic bronchoscopy showed a big and white neoplasm in the lower left lung, with a narrow opening and a lot of white necrotic material in the subsegment (Figure 2). Biopsy revealed chronic inflammation of endobronchial membrane with lymphoid follicular hyperplasia, but without any definite tumor cells (Figure 3). Acid-fast staining and Periodic Acid-Schiff (PAS) staining were both negative. Not only the traditional culture (including aerobic and anaerobic) but also the galactomannan (GM) test of bronchoalveolar lavage fluid were negative. Surprisingly, the mNGS of bronchoalveolar lavage fluid revealed 4415 sequences of Campylobacter rectus and 1091 sequences of Parvimonas micra.
Empirical antimicrobial therapy commenced immediately with intravenous tazobactam/piperacillin (4.5g three times daily) and ornidazole (500 mg twice daily) from the first day in the hospital. One week later when we got the result of mNGS, etimicin (300mg one time daily) was used in combination to enhance treatment against Gram-negative bacteria. Another two weeks later, the symptom of diarrhea in the patient was considered to be due to the imbalance of intestinal flora induced by long-term extensive use of broad-spectrum antibiotics. Therefore, the anti-infective treatment regimen was reduced to etimicin only. The patient was hospitalized for one month. The results of CT re-examination suggested that the area of infection in the inferior lobe of the left lung was significantly reduced, and the cavity was smaller (Figure 1B). After he was discharged from hospital, he was treated with oral levofloxacin (0.5g once daily) for four months. The condition of the lung was further improved than before (Figure 1C).
(B) The results of CT re-examination suggested that, the area of infection in the inferior lobe of the left lung was significantly reduced and the cavity was smaller.