92-year-old woman, with no known drug allergies, with a personal history of arterial hypertension, type 2 diabetes mellitus, chronic atrial fibrillation and Alzheimer's disease. She was admitted for vomiting in coffee grounds, epigastralgia and weight loss in the last month. Physical examination was irrelevant.
Laboratory tests showed: haemoglobin 7.1 g/dl, haematocrit 23.8%, MCV 77, leukocytes 11,940, ESR 40 mm. Glucose 206 mg/dl. Iron 28 ug/dl.
An oral endoscopy showed a large hiatal hernia and a deep ulcer of approximately 2 cm in diameter in the distal third of the oesophagus with abundant whitish exudate in the crater. A biopsy and cytology of the lesion was performed. Histology showed esophageal squamous esophageal mucosa and numerous sulphide granules containing abundant hyphae consistent with actinomycosis.

Treatment was started with intravenous penicillin G for a few days and subsequently discharged with oral penicillin. The patient was lost to follow-up.