What Is Your Diagnosis?

Respiration 2007;74:706709
DOI: 10.1159/000105539

Received: May 16, 2006

Accepted after revision: March 1, 2007
Published online: July 11, 2007

A 21-Year-Old Male with Productive Cough,

Hemoptysis, Chest Pain, and Weight Loss
N.D. Bakan G. Camsari A. Gur G. Ozkan M. Bayram F. Gorgulu N. Urer
Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Istanbul, Turkey

A 21-year-old male was evaluated because of a 2-month

history of productive cough, expectoration of purulent
sputum, fever, chest pain, malaise and weight loss, which
persisted despite treatment with dirithromycin. He also
noted mild hemoptysis of several days duration.
He had previously been healthy and reported no history of hospitalizations, surgical procedures, or allergic
reactions to drugs. Two months earlier, he completed an
18-month obligatory military service in Kahramanmaras, located in southeast Turkey. He was at the time unemployed. He had a smoking history of 2.5 packs/year.
His parents and siblings were healthy.
On physical examination, his body temperature was
37.8 C, blood pressure was 100/60 mm Hg, heart rate 100
beats/min, and respiratory rate 24 breaths/min. There
were inspiratory crackles on the anterior upper part of
the right lung on auscultation. Heart sounds were normal. The abdomen was soft and nontender, with normal
bowel sounds and no hepatosplenomegaly. No palpable
lymph nodes were found. Genitourinary, cutaneous, and
neurologic examinations were normal, as was the examination of his arms and legs.

Laboratory test results are shown in table 1. A chest

radiograph can be seen in figure 1.
The tuberculin skin test was negative. Fiberoptic bronchoscopy did not demonstrate any airway abnormality.
Bronchial washing of the right upper lobe and postbronchoscopic sputum analysis showed an abundance of polymorphonuclear leukocytes with no acid-fast bacilli, fungi or malignant cells. The examination of transthoracic
fine needle aspiration from the cavity wall also revealed
abundant polymorphonuclear leukocytes and gram-positive diplococci, but no growth on aerobic/anaerobic/mycobacterial/fungal cultures. No malignant cells were detected. A 3-week treatment with ampicillin/sulbactam 4
g/day resulted with remarkable improvement in clinical
and laboratory parameters (table 1) and a moderate improvement on chest radiograph.
Two weeks later, a progression on clinical, laboratory
parameters (table 1), chest radiograph (fig. 2) and CT was
detected (fig. 3).

Fig. 1. Chest radiograph on first admission shows a large, thickwalled cavitary lesion, 8 cm in diameter, with air-fluid level and
irregular inner contours in the middle zone of the right hemithorax. Lung abscess, tuberculosis, complicated hydatid cyst, septic
emboli, Wegeners granulomatosis, actinomyces infection, bronchial carcinoma and cavitary metastatic malignancies should be
considered in the differential diagnosis.

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3
2

Fig. 2, 3. A progression of the previous cavitary lesions on the right lung and additionally similar lesions on the
left lung is seen on a chest radiograph (2) and CT (3) 2 weeks after discharge on the second admission. Anterior
mediastinal, upper and lower paratracheal, prevascular multiple lymphadenomegalies up to 3 cm in diameter
are seen on CT. A consolidation is present on right upper and lower lobes. Adjacent to the consolidation and additionally on middle lobe of right hemithorax (black arrows) and upper lobe anterior segment and lower lobe
posterior segment of left hemithorax (white arrow) cavities, pneumatoceles, cavitary nodules and air-fluid levels
in some of the cavities can be seen. Diseases causing cavitary nodules and pneumatoceles like staphylococcal
pneumonia, septic emboli or Wegeners granulomatosis should be considered in the differential diagnosis.

Table 1. Laboratory data at first

admission, discharge and second
admission

Variable

1st
admission

1st
discharge

2nd
admission

Hemoglobin, g/dl
White cells, /mm3
Differential count, %
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelets, /mm3
ESR, mm/1 h
Echinococcus-specific IgE
Echinococcus indirect hemagglutination
c-ANCA
Anti-HIV
Sputum Gram stain

13.2
29,600

13.1
12,900

14.3
29,300

88.7
6.4
3.2
1.0
0.7
757,000
86
negative
1/20 negative
negative
negative
gram-positive
diplococci
negative

75.4
13.2
5.8
5.3
0.3
537,000
17

86.3
5.9
3.3
4.3
0.2
548,000
52

Sputum and blood culture

ESR = Erythrocyte sedimentation rate.

What is your diagnosis?

An Unusual Lung Abscess

Respiration 2007;74:706709

707

Diagnosis: Classical Hodgkins Lymphoma, Complicated Secondary by an Infection and

Mimicking a Lung Abscess Both Clinically and Radiologically

For definitive diagnosis an anterior mini-thoracotomy

was performed and specimens from the right upper lung
lobe were sent to the pathologist (fig. 4). Pathologic evaluation revealed a diagnosis of Hodgkins lymphoma.

Discussion

Intrathoracic involvement is most commonly seen in

the nodular sclerosis subtype of Hodgkins lymphoma.
Approximately 75% of the Hodgkins lymphoma patients
have mediastinal and/or hilar lymphadenopathy with or
without lung parenchymal lesions. A study reported 22%
pulmonary involvement in adult patients with Hodgkins
lymphoma at some stage of their disease [1]. The term
primary pulmonary Hodgkins lymphoma is used to describe the rare cases when pulmonary involvement is the
only manifestation of the disease [24]. This is an entity
distinct from the secondary involvement of lung parenchyma arising from mediastinal or hilar lymph nodes.
Primary pulmonary lymphoma is thought as an extension of the disease from lymphoid follicles or peribronchial lymph nodes to the lung parenchyma, and is predominant in middle-aged to elderly women [5]. Hodgkins lymphoma usually presents as a mass or multiple
nodules with upper lobe predominance [3]. Cavitation of
the nodules occurs occasionally [1, 2, 6, 7]. Peripheral or
generalized lymphadenopathies are not found, however
coexistent mediastinal lymphadenopaties are reported in
most cases [24, 6, 8]. Our case had a radiologic lesion
consistent with lung abscess and a few mediastinal lymphadenopathies which were considered as reactive secondary to the lung infection. With progression of the disease,
mediastinal lymph nodes became larger and new parenchymal cavitary nodules occurred. Even with progression, the disease did not expand outside the thorax and
no peripheral palpable lymph node or organomegaly was
detected.
Pulmonary cavitation can suggest a wide range of disorders like granulomatous diseases (tuberculosis, Wegeners granulomatosis), acute and chronic infections
(staphylococcal, anaerobic, fungal), neoplastic diseases
(primary bronchial carcinoma, Hodgkins disease, pulmonary metastases), developmental etiologies (intralobar bronchopulmonary sequestration, bronchial cyst),
inhalational diseases [silicosis (progressive massive fi708

Respiration 2007;74:706709

Fig. 4. Histologic preparations of lung biopsy specimens. A mul-

tinuclear Reed-Sternberg cell (arrow) surrounded by neutrophils,

eosinophils, atypical histiocytes and a few lymphocytes is shown.
HE staining. !400.

brosis), coal workers pneumoconiosis], septic emboli

and complicated hydatid cyst [9, 10]. The most considered diagnoses in the current case were hydatid disease,
suppurative lung abscess and chronic infectious process
like actinomycosis.
Systemic symptoms, such as fever, are common features of Hodgkins lymphoma and thus the fever and a
cavitary mass with which our case presented could be attributed to Hodgkins lymphoma. However, as our case
responded clinically and radiologically to antibiotic treatment and the Gram stain of sputum and fine needle aspirate from the cavity wall showed gram-positive diplococci, the possibility of a secondary infection contributing to his symptoms must be considered. Recently, two
case reports demonstrated improvement or clearance of
pulmonary nodules after antibiotic (ciprofloxacin, clarithromycin, imipenem-cilastatin) therapy in patients
with pulmonary Hodgkins lymphoma [8, 11]. BAL of one
of these cases demonstrated two different pathogens
(Streptococcus milleri and Streptococcus mitis) [8]. Such
cases suggest that bacterial infection may be causatively
associated with the disease as mentioned by Sauter and
Blum [11].

Bakan/Camsari/Gur/Ozkan/Bayram/
Gorgulu/Urer

Despite several noninvasive and invasive diagnostic

procedures, diagnosis of this case was a challenge, since
the patients improvement with antibiotic treatment
caused a delay in biopsy procedures. However, upon a review of the literature, we concluded that similar diagnostic difficulties were encountered with other reports of
pulmonary Hodgkins lymphoma, and in those cases, the
diagnosis was confirmed also with specimens via open
lung biopsy [12], some of them requiring lobar resection
[2, 4, 68]. Thus, we conclude that in order to obtain a

sample for a histologic demonstration of Reed-Sternberg

cells in lung tissue, thoracoscopic or open lung biopsy is
virtually inevitable in the diagnosis of pulmonary Hodgkins lymphoma.

Key Words

Lung abscess  Lung modules  Hodgkins disease 

Diagnosis  Antibiotic treatment

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An Unusual Lung Abscess

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