A 37-year-old male, office worker, began to suffer from cough, breathing difficulty and upper back pain six months ago; afterwards, he experienced worsening shortness of breath, as well as chest wall and upper back swelling and pain. He denied expectoration, fever, or hemoptysis prior to admission. He denied any birds and poultry contact, aspiration, or recent travel. Noteworthily, he suffered from poorly controlled diabetes and severe periodontal disease for 3 years, which induced more than 12 teeth loss.
After hospitalization, he developed fever with a maximum body temperature of 39 C. He felt the left upper back haphalgesia, while the anterior and lateral chest wall swelling and pain without skin temperature arisen. Pressure sore (1 x 1 cm) on the buttock was noted by physical examination. The laboratory tests demonstrated increased blood glucose (32 mmol/L), procalcitonin (1.41 ng/mL), and white blood cell counts (18.28x109/L) with 92.0% neutrophils, but without acute hypoxemic respiratory failure on room air (arterial blood gas: PH 7.49; PCO2 43.2 mmHg; PAO2 68.7 mmHg; HCO3 26.6 mEq/L). Liver and renal function, autoimmune antibody tests, ANCA detection, as well as molecular assay for tuberculosis were otherwise unremarkable. Transthoracic echocardiography and blood culture found no evidence of infective endocarditis or bacteraemia.
The PET/CT and thoracic MRI revealed multiple cavity lesions in the middle and upper lungs, intermuscular abscess on the lateral chest and abdominal wall, as well as T3-T4 thoracic vertebral destruction (Figures 1 and 2). Transbronchial lung biopsy revealed hyperplastic epithelioid foci with numerous neutrophil infiltration, indicating pyogenic granulomatous inflammation. The mNGS in bronchoalveolar lavage fluid (BALF) and lung tissue samples detected EB virus and staphylococcus epidermidis, but no tuberculosis or aspergillosis, whereas the thoracic abscess continued to deteriorate, which had no response to empirical antifungal agents. Furthermore, the bacterial culture onsite and mNGS in thoracic wall intermuscular abscess, obtained from percutaneous puncture under ultrasound guidance, indicated Streptococcus constellatus, which was susceptible to vancomycin, penicillin G, linezolid, cefotaxime and levofloxacin by drug sensitivity test. Afterwards, his fever allayed, the thoracic swelling and pain alleviated, and the lung cavity lesions were shrunk following the treatment with piperacillin-tazobactam (4.5g q8h) and levofloxacin (0.5g qd), as well as drainage of thoracic wall intermuscular abscess (Figure 3B and E), compared with those of pre-therapy (Figure 3A and D). The duration of antibiotic use was eight weeks. Three months post-discharge, this patient was clinically stable, the chest CT showed the lung cavity lesions were mostly resolution, as well as the thoracic wall intermuscular abscess was significantly decreased (Figure 3C and F), whereas this patient refused thoracic spinal surgery for his own concern of surgical risk and financial reason.
PET/CT imaging on pulmonary cavity lesions and thoracic wall abscess. (A and B) CT imaging on multiple lung cavity lesions in the upper lobes.