A rare cause of multiple cavitary lung lesions

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We report on a 32-year-old woman with multiple, progressive cavitary lung lesions. Lung cavities may occur in the context of various diseases and, thus, represent a huge diagnostic challenge. The spectrum of diseases comprises infections, systemic autoimmune rheumatic diseases, and malignancies. Several microorganisms may cause lung cavities such as common bacteria (e.g. Haemophilus influenzae, Klebsiella pneumoniae), Mycobacterium tuberculosis, non-tuberculous mycobacteria, uncommon bacteria such as Nocardia species, fungi (e.g. Aspergillus species), and parasites such as Echinococcus species. In respect of systemic autoimmune rheumatic diseases, granulomatosis with polyangiitis is frequently associated with cavitary lung lesions. Malignancies such as lung carcinomas and pulmonary metastasis may also manifest with cavern formation. In our case, we primarily assumed infection as the cause of the cavitary lung lesions - in fact, an infection with Actinomyces species. However, despite antibiotic therapy according to the resistance test results and the removal of the supposed focus of infection (tonsillectomy with proof of Actinomyces colonization of the tonsils), there was clear progression of lung cavities. Therefore, diagnostics were expanded and enhanced including FDG-PET-CT, bone marrow puncture, VATS pulmonary wedge resection, as well as EBUS- and CT-guided lymph node puncture. Finally, a rare clinical manifestation of Hodgkin lymphoma was diagnosed as the underlying cause of the multiple cavitary lung lesions.