A healthy 34 year old woman presented to medical attention after experiencing several days of moderately severe pleuritic chest pain without other respiratory or constitutional symptoms. She was Ecuadorian where she lived until the age of 5 and had not recently been, worked at a local supermarket (although not in food handling capacity) and had moderate persistent asthma well controlled on combination long acting beta-agonist and medium dose inhaled corticosteroid. Contrast CT scan of the chest demonstrated several bilateral pulmonary nodules without infiltrate, adenopathy or effusion. The largest was 1.5 x 1.5 cm in the left upper lobe with cavitation (Fig. 1). Active tuberculosis was ruled out. Blood cultures were negative and transthoracic echocardiogram did not demonstrate valvular vegetations. Nonspecific inflammatory markers were elevated: C-rp 61 mg/L (normal range: 0-3) and ESR 28 MM/h (normal range: 0-22) and ANA was positive with titer 1:80; however, ANCA were within the normal range. She did not have a leukocytosis (WBC 8300/uL). Serologic evaluation for fungal disease was negative. She had a mild transaminitis with alanine aminotransferase > aspartate aminotransferase and imaging of the liver via ultrasound and CT scan revealed steatosis without discrete lesions. Expectorated sputum grew Mycobacterium avium complex; however the clinical scenario seemed largely incompatible. Airway examination on bronchoscopy and bronchoalveolar lavage were also unrevealing. The patient underwent a surgical biopsy of the left upper lobe nodule - our leading diagnostic consideration of which at the time was seronegative pulmonary vasculitis. Pathology did not show granuloma, malignancy or AFB; rather, was an abscess (Fig. 3). Culture of the material grew Fusobacterium necrophorum. Notably, she had no upper respiratory symptoms, neck pain, febrile illness or dental work around the time of this presentation. On further detailed questioning she recalled a sore throat 5 months prior without fever, and enjoyed several months of good health in the intervening time. CT of sinus/neck were normal and in fact, on repeat chest CT several weeks later lung nodules contralateral to biopsy and prior to any therapy were smaller in size (Fig. 2). We elected to treat with ertapenem for 6 weeks and CT scan after therapy showed resolution of all dominant nodules. Of note, chest pain resolved well prior to initiation of therapy and has not recurred.
Rounded inferio-medial left lower lobe nodule present on CT on original CT scan.