A 63-year-old man with bronchiectasis suffered from respiratory failure status post tracheostomy. He experienced sudden massive hemoptysis requiring an emergent bronchoscopy during admission. After removing a bronchial cast formed by coagulated blood (Fig. 1) in bronchi, no active bleeder was found, and vital signs became stable. However, multiple endobronchial necrotic-like masses containing sulfur granules were found in bilateral sub-branches in the lower bronchi (Fig. 2). The pathological report revealed bacterial colonies with Gram-positive filamentous bacilli and cocci (Fig. 3), suggesting a diagnosis of actinomycosis. Surgical intervention was not recommended after multidisciplinary expert discussion due to poor pulmonary function. The patient received prolonged antibiotic treatment and was successfully weaned from the ventilator.

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