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Introduction: Pulmonary Streptococcus anginosus infections in children are rare; however, lung parenchymal and pleural abscesses caused by Strep. anginosus have been described in adults with aspiration pneumonia or Lemierre’s syndrome. Case summary: A 12-year-old previously healthy female presented with hemoptysis, 10 days of fever, cough, left-sided chest pain, and fatigue. Initial chest radiograph showed peripheral pulmonary opacities and chest CT demonstrated numerous sub-pleural pulmonary nodules, some of which demonstrated cavitation. Laboratory studies were notable for a WBC count of 25,000 cells/µL, hemoglobin of 9.6 g/dL, C-reactive protein of 21.6 mg/dL, and erythrocyte sedimentation rate of 55 mm/hr. Flexible bronchoscopy revealed an endobronchial mass in the distal left mainstem bronchus that spontaneously ruptured, yielding bloody purulent fluid. Post-procedurally, she developed complete left lung opacification and hypoxemia requiring mechanical ventilation. Broad-spectrum antibiotics were initiated. Differential diagnosis included infectious (Actinomyces, Nocardia, tuberculosis, endemic fungi or invasive Aspergillus) versus autoimmune (lupus, granulomatosis with polyangiitis, or sarcoidosis) etiologies. Blood cultures, screening tests for tuberculosis and endemic fungi, and ANCA panel were negative. Bronchoalveolar lavage fluid from the contralateral lung was negative for bacterial, mycobacterial, and fungal organisms. Lung biopsy of a pleural-based nodule was obtained. Histology was consistent with a necrotizing broncho-centric granulomatosis without visible organisms or evidence of vasculitis. Tissue culture yielded a single organism, Streptococcus anginosus. Given concern for an embolic etiology of nodules, echocardiogram, and neck ultrasound were obtained and were negative for thrombus or cardiac vegetation. Immunologic evaluation including immunoglobulins, neutrophil oxidative burst, lymphocyte panel, and tetanus/diphtheria titers was normal. She completed 6 weeks of outpatient treatment with oral amoxicillin-clavulanate with normalization of inflammatory markers and return to good health. Repeat chest CT after 1 month showed improved nodules with one persistent area of cavitation in the right lateral lower lung. Discussion: Streptococcus anginosus in chilren typically causes head and neck infections, including sinusitis and lymphadenitis. As normal oral cavity flora, pulmonary infection from this organism is most commonly caused by aspiration but can also occur through direct or hematogenous spread. In this patient, we suspect that the multifocal nodules developed secondary to hematogenous seeding, although the primary site was not identified. Strep. anginosus has several unique virulence factors that makes it a particularly aggressive and invasive pathogen that can cross tissue planes and cause severe disease. This organism should be considered in cases of pediatric pulmonary nodules and hemorrhage.
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