Pan et al. Journal of Medical Case Reports 2011, 5:377 http://www.jmedicalcasereports.com/content/5/1/377 Case presentation A sixty-five-year old Han Chinese man presented with cough, expectoration, chest pain and fever lasting twenty days to the emergency room. His medical history was notable for hypertension over the previous ten years, and a forty-year smoking history (20 cigarettes per day). He did not have previous exposure to respiratory ther- apy solutions and had not taken any antimicrobial agents in the past five years. Pleuritic chest pain was the most prominent symptom. The cough was dry initially, but about five days later became productive. He had a sudden onset of a high fever to 39°C, which resulted in rigors. Upon initial presentation, he received antibiotic therapy of intravenous penicillin sodium for seven days, lavo-ofloxacin for five days and cefotaxime sodium for seven days in turn, but his symptoms did not improve, resulting in admission to our hospital. His initial physical examination upon admission revealed a temperature of 38.8°C; blood pressure, 120/85 mmHg; respiratory rate, 23 breaths per minute; and pulse, 90 beats per minute. Evaluation for a source of the fever demonstrated a right-sided lobar pneumonia on chest X-ray. A thoracic computed tomography (CT) scan supported the diagnosis of right-sided lobar pneu- monia (Figure 1). Subsequently, a CT-guided lung biopsy was done, which confirmed it to be lobar pneu- monia in the period of gray hepatization (Figure 2). Two biopsy specimens from separate sites grew R. pickettii in pure cultures, which was identified by the API 20NE system (bioMérieux France, No.0041445). He received an antibiotic course of intravenous cefepime for six days. A repeat thoracic CT scan revealed the presence of a right-sided abscess (Figure 3). A centesis was Page 2 of 4 Figure 2 Lung biopsy appearance of lobar pneumonia-like changes of the gray phase of liver. It is showing that alveolar space is clearly visible, a large number of cellulose can be seen seeping into cavity to form a network and through Trichoderma Kong mutual links with the neighboring alveolar space. (hematoxylin and eosin, magnification ×40). performed and the purulent fluid grew R. pickettii. The chest tube placed for drainage remained in the cavity of the abscess for rinsing with sterile sodium chloride solu- tion. Because the pathogen had not responded to two antibiotic treatments, its antimicrobial susceptibilities were studied by the disk diffusion method of the Clini- cal and Laboratory Standards Institute (CLSI) (9). The breakpoints used to determine resistance and Figure 1 Computed tomography scan (GE Medical System. lightspeed 16) of the thorax showing features of lobar pneumonia. In this image right lung lower lobe soft tissue density shadow can be seen. Figure 3 Computed tomography scan of the thorax. The scan shows features typical of pulmonary abscesses, consolidation with a single cavity containing an air-fluid level in the right lung after six days of intravenous cefepime treatment.