Clinical Images

Necrosis of the Pulmonary Parenchyma

Figure 1. Physical examination of chest wall

Figure 2. Chest X ray demonstrating extensive left-sided pleural effusion

Figure 3. CT chest demonstrating parenchymal necrosis 

Figure 4. Physical examination of the chest with development of infra-mammary collection

Author: Clara Miceli Alves, M.D.

A 19-year-old male presented with a 5-month history of weight loss, cough and daily fever (Tmax:39 ºC), and denied any history of comorbidities like lung disease or trauma to the chest. Physical examinaiton revealed a 5 cm, tender, mobile mass on the left infra-mamillary region of the chest wall with no evidence of erythema, edema, fluctuance, or regional lymphadenopathy with vascular engorgement on chest wall (Figure 1). Initial workup was unremarkable for HIV, while chest x-ray showed extensive left-sided pleural effusion (Figure 2). Computed tomography of the chest showed pneumonic consolidation in the left lung at superior lobe, lingula and basal segments, and excavations in the inferior lobe with necrosis of the parenchyma (Figure 3). An open lung biopsy was performed, and culture was positive for Sphingomonas paucimobilis. Antibiotic therapy was deferred. The mass increased in volume with development of pain, erythema and edema (Figure 4). Incision and drainage of the infra-mamillary collection was performed. Samples were directly cultured for Actinomyces, which later confirmed pulmonary Actinomycosis and the patient was started on intravenous amoxicillin and sulbactam for 2 weeks followed by oral amoxicillin for 6 months. Patient demonstrated complete response to treatment.

MCQ: Why did the medical staff choose not to treat Sphingomonas paucimobilis infection?

      A. There is no treatment for Sphingomonas paucimobilis infection

      B. Possibility of sample contamination

      C. The main diagnostic hypothesis was neoplasm

      D. Sphingomonas paucimobilis is not a pathogenic bacteria

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Author Information:

Clara Miceli Alves, M.D. is an endocrinologist at private practice in Florianópolis, Brazil.