Medical Image of the Week: Valley Fever Cavity with Fungus Ball

Figure 1. Chest x-ray taken in 2004 showing pulmonary nodule (arrows).

Figure 2. A: Thoracic CT scan in lung windows from 2004 showing the pulmonary nodule with cavitation. B: CT scan from 2007 showing thin-walled cavity. C: CT scan from 2008 showing fungus ball inside the cavity.  D: CT scan from 2010 showing the continued presence of the fungus ball inside the cavity.

A 72-year-old man was seen in 2010 because of hemoptysis. In 2004 a routine chest x-ray discovered a new pulmonary nodule (Figure 1, Figure 2A). Coccioidomycosis by complement fixation and IgM were negative but IgG was elevated at 0.203 (upper limit of normal 0.150).  A transthoracic needle biopsy revealed a granuloma without malignancy and no growth of any organisms. He was followed because he was asymptomatic. He remained asymptomatic but developed a thin-walled cavity (Figure 2B). However, beginning in 2008 he developed a cough with occasional hemoptysis. His thoracic CT scan was repeated and was interpreted as showing findings consistent with a fungus ball (Figure 2C). He was treated with fluconazole for about 6 months but his hemoptysis persisted and therapy was switched to itraconazole. His hemoptysis persisted although it was somewhat improved. A repeat CT scan performed in 2010 (Figure 2D) continued to show the fungus ball. He was referred to pulmonary and bronchoscopy revealed no other source of the hemoptysis; stains and cultures were negative; and he was referred to thoracic surgery for resection.

Hemoptysis from coccioidomycosis is unusual and should prompt a search for other causes (1). These could include bronchitis, malignancy, or rarely, a fungus ball as in our case. When hemoptysis is present with a fungus ball, treatment with fluconazole, itraconazole or amphotericin B is often advised although descriptions are limited to case reports. When hemoptysis persists despite drug therapy, resection of the cavity has been performed (2).

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Reference

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):238-49. [CrossRef]
2. Thadepalli H, Salem FA, Mandal AK, Rambhatla K, Einstein HE.Pulmonary mycetoma due to Coccidioides immitis. Chest. 1977 Mar;71(3):429-30. [PubMed]

Cite as: Robbins RA. Medical image of the week: valley fever cavity with fungus ball. Southwest J Pulm Crit Care. 2018;16(5):281-2. doi: https://doi.org/10.13175/swjpcc064-18 PDF 

Medical Image of the Week: Granulomatous Amoebic Encephalitis

Figure 1. Progressively worsened encephalitis with increasing T2/FLAIR hyperintensity, with restricted diffusion and increasing cortical enhancement in the left anterior/medial temporal lobe and inferior frontal lobe, multifocal areas of hemorrhage, mass effect and interval development of multiple progressive areas of rim enhancement with small areas of restricted diffusion suggested new abscess formation.

Figure 2. Necrotizing granulomas with acute inflammation and microorganisms with the morphologic features of amoeba (H & E stained slides: 500X and 1000X).

A 64-year-old woman with history of deceased donor kidney transplantation presented with altered mental status. MRI of the brain showed new region of T2/FLAIR hyperintensity with restricted diffusion and slight cortical enhancement in the left middle temporal lobe (Figure 1, Panel A). Her neurological exam was notable for expressive aphasia and right-sided weakness. Initial diagnosis of ischemic stroke was further evaluated due to immunosuppressive status. Her CSF showed a WBC of 12 cells/microL with 80% lymphocytes, glucose 61 mg/dL, and protein 53 mg/dL. Follow up MRI showed progression of T2/FLAIR hyperintensity, intraparenchymal hemorrhage, and peripheral patchy enhancement in the left anterior/medial temporal lobe and inferior frontal lobe suspicious for encephalitis (Figure 1, Panel B). Left temporal lobe biopsy revealed granulomatous encephalitis with microorganisms morphologically consistent with amoeba (Figure 2), and tissue cultures grew MRSA. Acanthamoeba species was confirmed by the Centers for Disease Control and Prevention (CDC) with antibody testing. Immunosuppression was tapered. She was treated with vancomycin and a CDC approved regimen of pentamidine, sulfadiazine, flucytosine, fluconazole, azithromycin, and miltefosine. Repeat MRI revealed continued progression of encephalitis with increased T2/FLAIR hyperintensity, mass effect, multifocal hemorrhage and new abscess formation (Figure 1, Panel C). Despite aggressive medical management, her neurologic status continued to deteriorate. Given her grim prognosis and failure to show clinical improvement, her family decided to pursue hospice care.

Granulomatous amebic encephalitis is a life-threatening central nervous system infection caused by the free-living amoebae Acanthamoeba spp., Balamuthia mandrillaris and Sappinia pedata. Onset is subacute to chronic affecting predominantly the immunocompromised population. The diagnosis requires high index of suspicion, and early diagnosis is crucial to survival. Radiological findings are nonspecific and can be seen in CNS tuberculosis, neurocysticercosis, disseminated encephalomyelitis, viral encephalitis etc. Multiple antibiotics targeting various proteins or receptors are required for successful treatment. A combination of surgical and medical interventions may be required to prevent morbidity and mortality.

Ateefa Chaudhury MD¹, Christopher Geffre MD², and Tauseef Afaq Siddiqi MD³

¹ Department of Medicine

² Department of Pathology

³ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona, Tucson, AZ

Reference

1. Parija SC, Dinoop K, Venugopal H. Management of granulomatous amebic encephalitis: Laboratory diagnosis and treatment. Trop Parasitol. 2015;5(1):23-8. [CrossRef] [PubMed]

Reference as: Chaudhury A, Geffre C, Siddiqi TA. Medical image of the week: granulomatous amoebic encephalitis. Southwest J Pulm Crit Care. 2015;10(6):330-1. doi: http://dx.doi.org/10.13175/swjpcc051-15 PDF