A mycotic cave

A 50-year-old man with a long history of heavy smoking presented to the Emergency Unit of the St. Anna Hospital, Ferrara, Italy, with cough and brown expectorate since about a month. The patient was afebrile. The physical examination did not disclose major findings apart from a marked reduction of vesicular murmur. Laboratory tests showed a normal white cell count, a significant increase of C-reactive protein (22.4 mg/dl; n.v.: <0.5 mg/dl) with normal procalcitonin levels. The X-ray of the thorax revealed an excavated lesion in the upper right lobe of the lung. A high resolution computed tomography (CT) of the lung confirmed the presence of a huge abscess (maximal diameter: 6.5 cm) (Figure 1) with features indicative of fungal hyphae (arrows in Figure 1). Urinary tests for pneumococcal and legionella antigens resulted negative as well as serology for Mycoplasma pneumoniae and Mycobacterium tuberculosis. Microbiological analysis on bronchoalveolar lavage fluid detected the presence of a Candida glabrata, whereas blood cultures were negative. Because of the resistance to antifungal treatments, a right superior lobectomy was needed and successfully performed. Six days after the operation the patient was discharged in good health with the recommendation of a respiratory rehabilitation for the next three months.