February 2020 Imaging Case of the Month: An Emerging Cause for Infiltrative Lung Abnormalities

Prasad M. Panse MD*, Fiona F. Feller MD^†, Yasmeen M. Butt MD^‡, Michael B. Gotway MD*

Departments of *Radiology, ^†Medicine, and ^‡Laboratory Medicine

Mayo Clinic, Arizona

Phoenix, Arizona

Clinical History: A 25-year-old man with no previous medical history presented to the Emergency Room with complaints of worsening non-productive cough and fever to 102°F over the previous 7 days. The patient also complained of some nausea, vomiting, and generalized muscle aches. The patient denies rhinorrhea, sore throat, congestion, and diarrhea. The patient also illicit drug use, and drinks alcohol only occasionally. He said he previously smoked 1-2 packs-per day, having quit 6 months earlier.

The patient’s physical examination showed normal vital signs, although his respiration rate was approximately 18/minute. The physical examination showed some mild basilar crackles bilaterally, but was otherwise entirely within normal limits.

Basic laboratory data showed a white blood cell count near the upper of normal= 10.3 x 10⁹ / L (normal, 4–10.8 x 10⁹/L) with a normal platelet count and no evidence of anemia, normal serum chemistries and renal function parameters, and normal liver function tests. The patient was referred for chest radiography (Figure 1).

Figure 1. Frontal (A) and lateral (B) chest radiography at presentation.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to be directed to the second of fourteen pages)

1. The chest radiograph shows bilateral consolidation
2. The chest radiograph shows findings suggesting increased pressure pulmonary edema
3. The chest radiograph shows mediastinal and peribronchial lymph node enlargement
4. The chest radiograph shows mild perihilar infiltration
5. The chest radiograph shows normal findings

Cite as: Panse PM, Feller FF, Butt YM, Gotway MB. February 2020 imaging case of the month: an emerging cause for infiltrative lung abnormalities. Southwest J Pulm Crit Care. 2020;20(2):43-58. doi: https://doi.org/10.13175/swjpcc004-20 PDF 

Medical Image of the Month: Penicillium Pneumonia Presenting as a Lung Mass

Figure 1. Representative image from thoracic CT scan in lung windows.

Figure 2. Panel A: Culture plate showing growth on culture plate. Panel B: Photomicrograph showing the dimorphic fungus taken from the culture plate.

A 72-year-old woman who is a non-smoker was referred for evaluation of a suspected lung cancer. She had progressive shortness of breath at rest for 5 months associated with right-sided chest pain, cough and yellowish sputum. She failed multiple courses of antibiotics.

Her past medical history was significant for hypertension, dyslipidemia, hypothyroidism and poorly controlled diabetes mellitus type 2. She also had mild coronary artery disease for which she was on dual antiplatelet therapy. On physical examination, her oxygen saturation was 94% on room air her other vital signs also being unremarkable. Her physical exam revealed decreased breath sounds on the right associated with dullness to percussion.

Her chest radiograph demonstrated right middle lobe opacities. Her chest CT showed a right hilar mass surrounded by multiple nodules along with interlobular septal thickening, a right middle lobe consolidation with air bronchograms, and multiple mediastinal lymph nodes – all suggestive of malignancy (Figure1).

The patient underwent bronchoalveolar lavage and multiple transbronchial biopsies from the right upper and right middle lobes. The lung biopsy showed nonspecific lymphocytic inflammatory infiltrates. Her bronchoalveolar lavage was positive for fungus on PAS stain. The BAL culture showed germ tube negative yeast, which were identified to be Penicillium species (Figure 2).

Fungi are uncommon causes of pneumonia in the general population, but they are more prevalent in immunocompromised hosts with HIV infection, bone marrow transplant, patients on steroids, or patients with neutropenia (1). Penicillium are thermally dimorphic fungi, widely spread in the environment (2). They found especially in soil or where decaying organic material is present. They are saprophytic and capable of causing food spoilage. Patients usually inhale the spores of penicillium present in soil, and so lungs are the primary site of infection. However, disseminated Penicilliosis with lymphadenopathy and organomegaly (especially in immunocompromised patients) can be seen. There was no evidence of disseminated Penicilliosis in our patient. She was not immunocompromised, and her only risk factor was poorly-controlled diabetes mellitus. If not recognized early, Penicillium pneumonia can be fatal. The diagnosis depends on obtaining tissue, sputum and/or BAL samples for fungal cultures. Use of a serum galactomannan antigen assay may facilitate earlier diagnosis of Penicillium infections, however it is not specific for this pathogen as it is a polysaccharide cell wall component of most Aspergillus species as well (3).

There is no consensus about the treatment of Penicillium pneumonia, however standard therapy consists of intravenous amphotericin B, followed by oral itraconazole for several weeks. The optimal duration of treatment is unknown as several cases of relapse have been reported in the literature.

The patient received two weeks of intravenous amphotericin B deoxycholate followed by 12 months of oral itraconazole. The patient improved significantly with resolution of the consolidation seen on her previous chest radiography.

Hasan S. Yamin MD¹, Amro Alastal MD², Abbas Iter MD¹, Murad Azamttah¹

¹Pulmonary and Critical Care, An-Najah University Hospital, Nablus, Palestine

²Pulmonary and Critical Care, Marshall University, WV, USA

References

1. Kang Y, Feitelson M, de Hoog S, Liao W. Penicillium marneffei and its pulmonary Involvements. Current Respiratory Medicine Reviews. 2012;8(5):356-64. [CrossRef]
2. Visagie CM, Houbraken J, Frisvad JC, Hong SB, Klaassen CH, Perrone G, Seifert KA, Varga J, Yaguchi T, Samson RA. Identification and nomenclature of the genus Penicillium. Stud Mycol. 2014 Jun;78:343-71. [CrossRef] [PubMed]
3. Hung CC, Chang SY, Sun HY, Hsueh PR. Cavitary pneumonia due to Penicillium marneffei in an HIV-infected patient. Am J Respir Crit Care Med. 2013 Jan 15;187(2):e3-4. [CrossRef][PubMed]

Cite as: Yamin HS, Alastal A, Iter A, Azamttah M. Medical image of the month: Penicillium pneumonia presenting as a lung mass. Southwest J Pulm Crit Care. 2019;19:164-6. doi: https://doi.org/10.13175/swjpcc033-19 PDF 

Medical Image of the Week: Pulmonary Mycetoma

Figure 1. Thoracic CT scan showing mycetoma (arrow) in cavitary lesion in right upper lobe.

A 59 year-old woman presented with right sided chest pain and worsening shortness of breath. On CT of the chest she was found to have cavitary lesions in her right lung with one of them having a distinct opacity within the lesion concerning for a pulmonary mycetoma (Figure 1, arrow). Most literature describes pulmonary mycetomas occurring due to Aspergillus species. However, in our patient, neither the bronchoscopy with bronchoalveolar lavage (BAL) nor serological studies tested positive for Aspergillus. Cultures did however grow Candida albicans in 2 of the samples from the BAL. Mycetoma due to Candida has been described in the urinary tract in immunocompromised patients and, uncommonly, in the lung (1-3). Our patient had been treated for Stage III ovarian cancer with chemotherapy and at presentation her absolute neutrophil count was reduced at 860. In the hospital, she was treated for her shortness of breath with albuterol-ipratropium nebulizations to which she responded well. She was discharged once stable to follow up as outpatient for further treatment of her Candida albicans mycetoma.

Saud Khan, MD and Huzaifa A. Jaliawala, MD

Internal Medicine

University of Oklahoma Health Sciences Center

Oklahoma City, OK USA

References

1. Praz V, Burruni R, Meid F, Wisard M, Jichlinski P, Tawadros T. Fungus ball in the urinary tract: A rare entity. Can Urol Assoc J. 2014 Jan-Feb;8(1-2):E118-20. [CrossRef] [PubMed]
2. Song Z, Papanicolaou N, Dean S, Bing Z. Localized candidiasis in kidney presented as a mass mimicking renal cell carcinoma. Case Rep Infect Dis. 2012;2012:953590. [CrossRef] [PubMed]
3. Bachh AA, Haq I, Gupta R, Varudkar H, Ram MB. Pulmonary candidiasis presenting as mycetoma. Lung India. 2008 Oct;25(4):165-7. [CrossRef] [PubMed]

Cite as: Khan S, Jaliawala HA. Medical image of the week: pulmonary mycetoma. Southwest J Pulm Crit Care. 2017;15(4):169-70. doi: https://doi.org/10.13175/swjpcc123-17 PDF

August 2017 Imaging Case of the Month

Brandon T. Larsen, MD, PhD¹

Michael B. Gotway, MD²

Departments of Pathology¹ and Radiology²

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 67-year-old man with a 23 pack-year history of smoking, stopping 6 years earlier, presented with a year-long history of intermittent hemoptysis consisting of small specs of blood particularly in the morning after he awoke. No sputum discoloration was reported and the patient denied shortness of breath, fever, shortness of breath, and chills. The patient also denied rash, joint pain, and night sweats. His past surgical history was remarkable only for an appendectomy, tonsillectomy, and repair of an ankle fracture, all as a young man. The patient did report some asbestos exposure in the past. He takes a multivitamin and occasional over-the counter pain relievers, but was not taking prescription medications.

Physical examination: unremarkable and the patient’s oxygen saturation was 98% on room air.

Laboratory evaluation: largely unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative. An outside otolaryngology examination was reported to show no abnormalities. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of nine pages)

1. The chest radiograph shows a mediastinal mass
2. The chest radiograph shows multifocal consolidation and pleural effusion
3. The chest radiograph shows multifocal smooth interlobular septal thickening
4. The chest radiograph shows a possible focal air space opacity
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Larsen BT, Gotway MB. August 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(2):69-79. doi: https://doi.org/10.13175/swjpcc098-17 PDF

December 2015 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: An 80-year-old woman with a history of polycythemia vera (12 years), migraines, hypertension, and gastroesophageal reflux disease presented with complaints of declining functional status due to worsening shortness of breath over 3-4 weeks’ duration. She also complained of occasional palpitations. No history of fever, cough, chest pain, or hemoptysis was elicited. A frontal chest radiograph (Figure 1) was performed.

Figure 1.  Panel A: Frontal chest radiograph obtained at presentation, when the patient complained of worsening shortness of breath. Panel B: 3 years earlier.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of five panels)

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows fairly diffuse, bilateral, increased opacity
3. The frontal chest radiograph shows layering pleural effusions bilaterally
4. The frontal chest radiograph shows multifocal consolidation
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. December 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(6):254-9. doi: http://dx.doi.org/10.13175/swjpcc150-15 PDF 

Medical Image of the Week: CMV Cytopathic Effect

Figure 1. Cluster of 3 large cells, most likely infected type II pneumocytes, with a single prominent red stained nuclear inclusion surrounded by a clear halo. This appearance is the “cytopathic effect” needed to definitively diagnose active CMV infection.

Figure 2. Electron microscopy (8800x) of an infected cell showing  cytomegalovirus (CMV) virions within the nuclear inclusion (small black dots encircled).

Bronchoalveolar lavage (BAL) was performed on a 45-year old man with a history of treated mycosis fungoides and Sézary syndrome, who presented with fever and pulmonary infiltrates. BAL Papanicolaou stain (Figure 1, 400x) showed single cells (lymphocytes, arrows and alveolar macrophages, stars) and a small cluster of 3 large cells, most likely infected type II pneumocytes, with a single prominent red stained nuclear inclusion surrounded by a clear halo. Nuclear chromatin was marginated on the nuclear membrane creating this “owl’s eye” appearance. In vitro, infected cells show cytomegalovirus (CMV) virions within the nuclear inclusion (Figure 2, small black dots encircled, 8,800x)

The "owl's eye" appearance (Figure 1) is the “cytopathic effect” needed to definitively diagnose active CMV infection. While cells infected with adenovirus or herpesvirus may have nuclear inclusions, the cells typically are much smaller. CMV was cultured from the BAL, and no other pathogen was identified by cytology or culture. Quantitative PCR on blood for CMV was 144359 IU/ml.

Afshin Sam, MD; Felicia Goodrum, PhD; Robert Ricciotti, MD; Ken Knox, MD and Richard Sobonya, MD

Departments of Medicine, Immunobiology, and Pathology

University of Arizona Health Sciences Center

Tucson, AZ

Reference as: Sam A, Goodrum F, Ricciotti R, Knox KS, Sobonya R. Medical image of the week: CMV cytopathic effect. Southwest J Pulm Crit Care. 2014;9(6):341-2. doi: http://dx.doi.org/10.13175/swjpcc161-14 PDF

Medical Image Of The Week: Secondary Pneumonia Presenting as Hemoptysis

Figure 1. A-C: Axial images of the chest demonstrating bilateral consolidation of the lung with air bronchograms. D: Chest radiograph on presentation. E: BAL findings. F: Bronchoscopic images of diffuse airway sloughing; this is the main carina.

A 44 year-old man with a history of asthma presented to the hospital with encephalopathy, severe hypoxia and what was reported to be hematemesis. The patient was intubated in the Emergency Department and mechanical ventilation was instituted. Upper endoscopy was performed but source of bleeding could not be identified. Imaging of the chest showed pulmonary consolidation on both plain radiograph (D) and computed tomography (A-C). Bronchoscopy revealed a very friable mucosa with sloughing of the respiratory epithelium from the main carina (F) to at least the subsegmental level. Bronchoalveolar lavage (BAL) returned bloody fluid (E) but without any increase in blood with subsequent aliquots of fluid. The patient had progressively worsening hypoxia consistent with the acute respiratory distress syndrome (ARDS) requiring rescue maneuvers including paralysis, airway pressure release ventilation, and inhaled nitric oxide but we were unable to implement proning or transfer for extracorporeal life support due to profound cardiovascular collapse refractory to treatment. Ultimately, he succumbed from multiorgan failure. On laboratory evaluation of the BAL both Staphylococcus aureus and Influenza B virus were detected.

Bacterial pneumonia is a common complication of influenza infection. Historically, patients at the extremes of age have been most susceptible to secondary pneumonia. However, during the recent 2009 influenza pandemic an unusually high rate of secondary pneumonia among young adults was observed (1). The most common bacterial pathogens isolated following influenza infection include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus mitis, Streptococcus pyogenes and Haemophilus influenzae (2). A number of pathogenic mechanisms for synergies between influenza and bacteria have been proposed including disruption of the respiratory epithelium leading to enhanced bacterial adhesion (3).

Cameron Hypes MD MPH^1,2, Christian Bime MD MSc¹, Kevin Sun MD³, and Elizabeth Ulliman MD³

¹ Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona Medical Center; Tucson, AZ

² Department of Emergency Medicine, University of Arizona Medical Center; Tucson, AZ

³ Department of Medicine, University of Arizona Medical Center; Tucson, AZ

References

1. Chowell G, Bertozzi SM, Colchero MA, Lopez-Gatell H, Alpuche-Aranda C, Hernandez M, et al. Severe respiratory disease concurrent with the circulation of H1N1 influenza. New Engl J Med. 2009;361(7):674-9. [CrossRef] [PubMed]
2. Centers for Disease Control and Prevention (CDC). Bacterial coinfections in lung tissue specimens from fatal cases of 2009 pandemic influenza A (H1N1) - United States, May-August 2009. MMWR Morb Mortal Wkly Rep. 2009;58(38):1071-4. [PubMed]
3. Metersky ML, Masterton RG, Lode H, File Jr TM, Babinchak T. Epidemiology, microbiology, and treatment considerations for bacterial pneumonia complicating influenza. Int J Infect Dis. 2012;16(5):e321-e31. [CrossRef] [PubMed]

Reference as: Hypes C, Bime C, Sun K, Ulliman E. Medical image of the week: secondary pneumonia presenting as hemoptysis. Southwest J Pulm Crit Care. 2014;9(3):177-8. doi: http://dx.doi.org/10.13175/swjpcc116-14 PDF

Medical Image of the Week: Fat Embolism Syndrome

A 33-year-old man presented to the emergency department with shortness of breath and hemoptysis. He was discharged two days prior after hospitalization for a motor vehicle accident, in which he suffered a fracture of the shaft of the right femur. He had undergone open reduction and internal fixation of the fracture four days prior to this admission. He had diffuse parenchymal disease on his admission chest x-ray. A CT scan of the chest demonstrated multilobar ground glass opacities (Figure 1).

Figure 1. Thoracic CT scan showing ground glass opacities.

Bronchoscopy demonstrated progressively bloody BAL aliquots in two different lobes, consistent with diffuse alveolar hemorrhage (DAH). His workup for other etiologies was negative, and he was given a diagnosis of DAH secondary to fat embolism syndrome.

Joshua Malo, MD and Kenneth S. Knox, MD

Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Arizona, Tucson, AZ

Reference as: Malo J, Knox KS. Medical image of the week: fat embolism syndrome. Southwest J Pulm Crit Care. 2014;8(4):246. doi: http://dx.doi.org/10.13175/swjpcc041-14 PDF

February 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man presented with a history of weight loss and dysphagia for about 2 weeks duration. There was a possible history of asthma accompanied by ongoing shortness of breath first noticed nearly 2 years ago. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Choose the correct answer to move to the next panel)

1. The chest radiograph shows a mass
2. The chest radiograph shows hilar and mediastinal lymph node enlargement
3. The chest radiograph shows multifocal consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities suggesting fibrosis
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. February 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(2):88-95. doi: http://dx.doi.org/10.13175/swjpcc010-14 PDF

August 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 60-year-old man presented with gradually worsening shortness of breath and dry cough over the previous six months, unresponsive to presumptive antibiotic therapy with levofloxacin first, followed by azithromycin. Frontal chest radiography (Figure 1) was performed. 

Figure 1. Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows basal predominant fibrotic lung disease
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multifocal bronchiectasis
4. The chest radiograph shows multiple nodules
5. The chest radiograph shows upper lobe peripheral consolidation and reticulation

Reference as: Gotway MB. August 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(2):75-83. doi: http://dx.doi.org/10.13175/swjpcc102-13  PDF

March 2013 Imaging Case of the Month

Michael B. Gotway, MD*

Sudheer Penupolu, MD^‡

Jasminder Mand, MD^†

*Department of Radiology, Mayo Clinic, Arizona

^‡Fellow, Pulmonary Medicine, Mayo Clinic Arizona

^†Pulmonary and Critical Care Medicine, Maricopa Medical Center

Clinical History: A 54-year old Hispanic woman with no significant past medical history presented with complaints of cough and worsening dyspnea. She was in her usual state of health until 4-5 weeks prior to presentation when she started noticing gradually worsening dyspnea on exertion. She reported a dry cough initially which subsequently became productive of whitish, mucoid sputum. The patient denied chest pain, sore throat, sick contacts, or recent travel history. A chest x-ray was performed (Figure 1).

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows bilateral linear and reticular abnormalities
2. The chest radiograph shows nodular interstitial thickening
3. The chest radiograph shows multiple, bilateral circumscribed nodules
4. The chest radiograph shows mediastinal and hilar lymph node enlargement
5. The chest radiograph shows mediastinal widening

Reference as: Gotway MB, Penupolu S, Mand J. March 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(3):112-24. PDF

Medical Image of the Week: BAL Findings in Lipoid Pneumonia

 

Figure 1: Oil red O stain shows red-stained cytoplasm of several lipid-laden alveolar macrophages

A 66 year old woman presented with a two year history of recurrent pneumonias requiring multiple hospitalizations for treatment. A chest CT revealed bilateral multifocal opacities. The patient admitted regular use of a petroleum based product in her nose at night and severe gastroesophageal reflux disease. A bronchoalveolar lavage (BAL) was performed in the right lower lobe.  The BAL revealed significant Oil red O staining of alveolar macrophages (approximately 20% in Figure 1) consistent with exogenous lipid, suggesting recurrent microaspiration.

Aarthi Ganesh, MD; Rebecca Millius, MD and Linda Snyder, MD

Departments of Medicine and Pathology

University of Arizona

Tucson, Arizona

Reference as: Ganesh A, Millius R, Snyder L. Medical image of the week: findings in lipoid pneumonia. Southwest J Pulm Crit Care 2013;6(2):82. PDF

April 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 31-year-old previously healthy, immunocompetent, non-smoking female developed cough and was initially treated with broad spectrum antibiotics without improvement. Approximately 48 hours later, the patient presented to her physician with progressive shortness of breath and fever to 103°F. A chest radiograph was performed (Figure 1).

Figure 1: Frontal chest radiograph shows extensive bilateral pulmonary opacities predominantly in the lower lobes with preserved lung volumes, normal mediastinal width, and no definite pleural effusion.

The differential diagnostic considerations for the appearance on the chest radiograph include which of the following?

1. Hydrostatic pulmonary edema
2. Acute hypersensitivity pneumonitis
3. Community-acquired pneumonia
4. Opportunistic pulmonary infection
5. All of the above

Reference as: Gotway MB. April 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:102-10. (Click here for a PDF version)