Capnocytophaga species are known commensals of the oral cavity of humans and animals (mainly dogs and cats) and are a rare cause of respiratory tract infections. We report a case of cavitary lung abscess caused by a Capnocytophaga species in a patient with a metastatic neuroendocrine tumor. CASE REPORTA 39-year-old man with a metastatic, well-differentiated neuroendocrine tumor presented with fever and productive cough for 2 weeks. The patient's primary tumor was a large right infrahilar lung mass causing obstruction of the bronchus intermedius and extended to the right-middle-lobe (RML) and rightlower-lobe (RLL) bronchi. He also had multiple bilobar liver metastases. He had been treated with monthly octreotide injections for symptom control of carcinoid syndrome (hormone hypersecretion), which often occurs in metastatic neuroendocrine tumors. He had also recently been on chemotherapy with oral capecitabine and temozolomide.Two weeks after planned right hepatic artery embolization for liver metastasis and symptom control, he experienced lowgrade fevers with cough productive of foul-smelling melanoptysis, night sweats, malaise, and weight loss. The symptoms did not respond to a brief course of azithromycin. A computed tomograph (CT) of the chest revealed a new 8.7-by 6.4-cm cavitary abscess in the right lung. He was empirically treated with oral clindamycin for presumed aspiration pneumonia and anaerobic coverage but was admitted 2 days later for progressive symptoms.His medical history included three episodes of pneumonia that predated the cancer diagnosis, heavy marijuana use for 20 years (he had quit 1 month prior to his current admission), and occasional alcohol use; he denied cigarette smoking. He had four cats at home and denied recent travel, sick contacts, exposure to tuberculosis, or prior incarceration; he worked as a salesman for a waste transfer facility.On admission, he was febrile (38.4°C) and tachycardic without acute distress. Physical examination revealed an illappearing young man with normal dentition; a chest exam was remarkable for decreased breath sounds at the right base, egophony, and dullness to percussion on the right. Laboratory values showed an elevated white blood cell (WBC) count of 24,800/l (neutrophils, 87%), thrombocytosis of 878,000/l (normal, 160,000 to 400,000), mild hyponatremia (132 meq of sodium/liter; normal, 136 to 144), a low albumin level of 2.9 g/dl, and a high international normalized ratio (INR) of 1.83 (normal, 0.85 to 1.17). A chest radiograph obtained at admission and a repeat chest CT revealed an increase in the size of the right lung abscess to 10.2 by 8.3 cm (Fig. 1A and B). The patient was started on intravenous antibiotics, including piperacillintazobactam and vancomycin. A purified protein derivative (PPD) was placed and was negative; sputum samples were also negative for acid-fast bacilli (AFB) on smears, and mycobacterial culture remained negative after 42 days. Blood cultures were negative after 5 days of incubation. Serum Aspergillus galactomannan antigen,...

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