Purple Haze: An unusual cause of cavitating pneumonia

Abstract

A 40-year-old man, recently recalled to prison, was referred to hospital after presenting to the prison infirmary with right sided chest pain, fever, weight loss and haemoptysis.The initial presentation raised suspicion of Tuberculosis prompting referral to the infection service. Radiological investigations revealed bilateral cavities in the upper apices of both lobes with enlarged hilar.The patient had a previous hospitalisation with Staph aureus bacteraemia predicated by an infected groin injection site and during this admission he revealed he had recently self-lanced a dental abscess causing pus to pour from his nose. He was treated with Clindamycin, but this failed to reduce his CRP or his chest symptoms.Purpureocillium lilacinum was isolated from BAL samples after extended incubation and voriconazole therapy was initiated.Within a week of starting voriconazole, the patient clinically improved and after two weeks his CRP normalised and CXR improved.The isolation of a rare fungal pathogen prompted an extensive investigation into the patients practices and exposures, he revealed he smoked heavily and relied upon sniping to support his addiction. Sniping is a slang term for scavenging discarded cigarette oddments to either smoke or to manufacture “new” cigarettes, it is proposed that this practice may connect Purpureocillium lilacinum, a soil associated filamentous fungus, with our patients’ pathology as no other risk factors have been identified. High-risk smoking practices are not often revealed by proponents due to the associated social stigma which may lead to under-reporting of this practice as a risk factor for fungal lung infection.Abstract without diagnosisA 40-year-old man, recently recalled to prison, was referred to hospital after presenting to the prison infirmary with right sided chest pain, fever, weight loss and haemoptysis.