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.
Koff A, Malinis M. Chest Pain and a Cavitary Lung Mass in a Woman With Diabetes. JAMA. Published online May 22, 2020. doi:10.1001/jama.2020.4111
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