A 35-year-old man with no significant past medical history suffered from relapsing infections of the upper respiratory tract and episodes of nasal bleeding for five months. Chest radiography, which was perfomed in a local hospital, showed a big infiltrate in the right upper pulmonary field. Fiberoptic bronchoscopy was performed twice and a Staphylococcus aureus strain and a Klebsiella pneumoniae strain grew from bronchial samples. The patient had no clinical improvement despite the anti-bacterial and anti-tuberculous treatment that he received for a month.
The patient refused to be operated on for the postulated diagnosis of a pulmonary abscess. He was admitted in an infectious diseases department of another hospital for the management of a persisting pulmonary abscess despite the antimicrobial treatment that he received. Physical examination on admission in our hospital showed fever up to 38.80 C. There were small blood clots in the nose. The examination of the chest showed ronchi in the upper right lung field.
Laboratory tests on admission revealed white blood cell count (WBC) of 13,230/cubic mm (neutrophils = 77.9%, lymphocytes = 12.9%), hematocrit (Ht) =36.3%, platelets =588,000/cubic mm, C-reactive protein = 21.74 mg/dl (normal values < 0.50 mg/dl), and erythrocyte sedimentation rate (ESR) = 105 mm/first hour (normal values 0-20 mm). Laboratory tests for cancer indices and renal function, including urinalysis, did not show abnormal findings. Chest radiography and computed tomography of the thorax showed a big infiltrate with a central cavitation in the right upper pulmonary field (figure 1 and 2). Craniofacial computed tomography revealed ethmoid sinusitis.