A 75-Year-Old Female with Hemoptysis and Recurrent Respiratory Infections

This paper describes the case of a 75-year-old female who presented with significant hemoptysis over a 7–10 day period. She had a history of a left lower lobectomy 10 years prior for a “lung abscess.” She subsequently had multiple episodes of cough, fevers, and possible pneumonia treated with multiple courses of Amoxicillin and Amoxicillin/Clavulanate. Review of her chest CT upon presentation to the hospital showed a large necrotic lingular infiltrate, which had been progressively increasing in size over at least one year. Bronchoscopy showed a yellowish, soft round body in the superior lingular subsegment. Endobronchial and transbronchial biopsies showed actinomyces species. This is a very interesting case of indolent actinomycosis which we suspect had a very slow progressive course secondary to the multiple courses of antibiotics that the patient was treated with. 1. Case Report A 75-year-old female was admitted for further workup of hemoptysis. The hemoptysis started 7–10 days prior to admission and was bright red and significant in volume (often greater than half a cup). The amount increased the day prior to admission. She reported subjective fevers associated with her symptoms. She underwent a bronchoscopy at an outside hospital, which was aborted due to diffuse nonspecific bleeding in the left bronchial tree. She had a history of bronchiectasis and left lower lobectomy in 2002 for lung abscess; culture data from that infection was not available to us. Since the surgery in 2002, she experienced chronic cough and frequent respiratory infections treated with multiple rounds of antibiotics, usually Amoxicillin or Amoxicillin/Clavulanate. On physical examination, the patient was afebrile and normotensive. Heart rate was 68 beats/minute, respiratory rate 29 breaths/minute, and oxygen saturation 98% on room air. Head and neck examination showed normal dentition with no lymphadenopathy. Chest examination showed clear breath sounds bilaterally with decreased air entry in the left lower lobe. Abdominal and cardiac exams were unremarkable. Pertinent laboratory studies included an arterial blood gas analysis, which showed pH 7.34/pCO2 75？mm？Hg/PO2 92？mm？Hg/bicarbonate 40.4？meq/L. The chest radiograph showed decreased lung volume in the left base and an extensive lingular and possibly left upper lobe infiltrate. Chest CT is shown in Figures 1(a) and 1(b). Review of her chest CT one year prior showed the same lingular infiltrate with a smaller size. On bronchoscopy, a yellowish, soft round body was identified in the superior lingular subsegment. This body was