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JAMA Clinical Challenge
May 22, 2020

Chest Pain and a Cavitary Lung Mass in a Woman With Diabetes

Author Affiliations
  • 1Yale School of Medicine, Section of Infectious Diseases, Department of Medicine, New Haven, Connecticut
JAMA. 2020;323(23):2421-2422. doi:10.1001/jama.2020.4111

A 55-year-old woman from the Southeastern US with a history of smoking, poorly controlled type 2 diabetes mellitus (hemoglobin A1c level, 15.5%), and chronic pain from osteoarthritis treated with inhalational medical marijuana presented with 4 months of productive cough, 22.7-kg (50-lb) weight loss, subjective fevers, and 3 days of worsening chest pain.

Chest computed tomography (CT) showed a large right upper lobe cavitary mass. She was treated empirically with intravenous vancomycin and piperacillin-tazobactam. Bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was performed. Lung tissue was sent for bacterial, fungal, mycobacterial, and Nocardia cultures and for histopathology. BAL cultures grew 100 colony-forming units (CFUs)/mL of group B streptococci and 1 CFU/mL of Aspergillus niger. Results of acid-fast bacilli (AFB) smear and GeneXpert MTB/RIF testing were negative. Voriconazole was added to her treatment. Transbronchial biopsy histopathology showed acute and chronic inflammation, granulation tissue and necrosis, and negative fungal and AFB stains.