The method of obtaining a bronchial sample is important. The sample should be procured anaerobically with a protected specimen brush and ordinary BAL culture may be falsely negative if exposed to air for > 20 min. Fine-needle aspiration, transbronchial biopsy, and CT scan or ultrasound-guided biopsies lead to accurate diagnoses. The presence of sulfur granules in a biopsy sample is highly suggestive of actinomycosis but is not diagnostic because they are also seen in nocardiosis, chromomycosis, eumycetoma, and botryomycosis. The name “sulfur granule” has its origin in the small nodules that are round or oval basophilic masses with a radiating arrangement of eosinophilic clubs on the surface that resemble elemental sulfur. In most studies, the diagnosis of actinomycosis was confirmed by histologic visualization of actinomyces colonies surrounded by necrotic mass, suppuration, and inflammatory cells. The cornerstone therapy for actinomycosis is high-dose penicillin administered over a prolonged period (6 months to 1 year) with a minimal recommended duration of 45 days. Short-course antibiotic therapy of 1 month after removal of the foreign body (aspirated buttons/bone) led to a good outcome in some reported cases. Lack of clinical response to penicillin usually indicates a resistant copathogen because penicillin-resistant actinomyces is rare. Treatment success with fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) has been cited in few case reports. Drug choices in penicillin-allergic patients are lincosamides, tetracyclines, macrolides, and cephalosporin. Treating the copathogens associated with actinomyces is still a debatable topic, although some advocate designing initial antibiotic regimens to target these organisms as well. Interestingly, although most of these organisms are not sensitive to penicillin in vitro, they are usually eradicated (clinical cure) when the antibiotic is administered. Early antibiotic treatment can prevent disease progression. The disease can spread to involve the blood vessels, causing massive hemoptysis, lung parenchyma with abscess formation, or bronchoesopageal fistula. These complications will need a surgical intervention such as lobectomy, segmentectomy, or bronchial artery embolization as indicated. Actinomycosis has little regard for anatomic barriers and in later stages can destroy the lung parenchyma and extend across fissures to a neighboring pulmonary lobe (transfissural extension), the pleura, or chest wall, with abscess formation in these areas.