Medical Image of the Week: Intracavitary View of Mycetoma

Figure 1. Thoracic CT scan shows Monod’s sign, a mycetoma within an existing cavity, in the left upper lobe.

Figure 2. A: Current thoracic CT scan. B: thoracic CT scan 8 months earlier.

Figure 3. Bronchoscopic views of the cavity with intracavitary mycetoma in the left upper lobe.

A 46-year-old Hispanic man with no medical history presents to the pulmonary service for a second opinion regarding his unresolved pneumonia that initially presented as fever and cough; he did not have hemoptysis. He was found to have left upper lobe cavitary lesion and had been diagnosed with Aspergillus multiple times, with the initial diagnosis one year prior to presentation. He was seen by an outside pulmonologist and was placed on voriconazole 200 mg/day. Since being on the voriconazole he has not been feeling better. He continued to note symptoms of productive cough, fatigue, and weakness. Monod’s sign (Figure 1) is appreciated on CT imaging during initial encounter at an outside facility. Comparison of parenchymal damage is seen in Figure 2 comparing CT scans 8 months apart. Patient’s fungal cavity was appreciated on bronchoscopic exam (Figure 3). Ultimately, he was evaluated by cardiothoracic surgery and underwent a left upper lobectomy which he tolerated well.

Aspergillomas present as a mycetoma within an existing cavity. Monod’s sign is the radiographic finding of a mycetoma within the existing cavity as evidenced in the CT scan. This is not to be confused with the air-crescent sign which is seen more often with invasive aspergillosis, a separate clinical entity. This case is unique given its unique radiographic sign along with the visualization of fungal cavity from within through the bronchoscope.

Steve Tseng, DO and Raed Alalawi, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

References

1. Pesle GD, Monod O. Bronchiectasis due to aspergilloma. Dis Chest. 1954;25(2):172-183. [PubMed]
2. Thompson BH, Stanford W, Galvin JR, Kurihara Y. Varied radiologic appearances of pulmonary aspergillosis. Radiographics. 1995 Nov;15(6):1273-84. [CrossRef] [PubMed]

Cite as: Tseng S, Alalawi R. Medical image of the week: Intracavitary view of mycetoma. Southwest J Pulm Crit Care. 2018;16(6):360-1. doi: https://doi.org/10.13175/swjpcc082-18 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

Medical Image of the Week: Fungus Ball

Figure 1. Panel A: Coronal view of thoracic CT scan shows a fungus ball (mycetoma) within a 4.7cm thin walled cavity, Panel B: Axial image of fungus ball and thin walled cavity.

Figure 2 Panel A. Prominent eosinophilic infiltration with epithelial-lined cavity containing fungus ball (orange arrow). Panel B: Higher magnification.

A 69 year-old Asian woman living in Arizona with a past medical history of nephrotic syndrome on high-dose steroids had worsening pulmonary symptoms. A computed tomography (CT) of the chest (Figure 1) showed a 4.7 cm thin walled cavitary lesion in the right middle lobe compatible with mycetoma. She underwent thoracotomy for mycetoma resection. Surgical pathology confirmed an epithelial-lined cavity containing dense mycelia (Figure 2). Given the patient lived in an endemic area; the cavity was thought to be likely due to coccidioidomycosis. However, the mycetoma was of unclear etiology. No spherules were noted on GMS stain and tissue culture was negative. While of unclear clinical significance which fungus colonizes a pre-existing cavity, a Coccidioides PCR was performed and no Coccidioides genes were amplified making a Coccidioides mycetoma very unlikely.

Pulmonary mycetoma or “fungus ball” consists of dense fungal elements and amorphous cellular material within a pre-existing pulmonary cavity. Classically presenting as an aspergilloma, other fungi can cause similar lesions. Patients with mycetoma rarely develop symptoms. When present, symptoms can include chest pain, cough, hemoptysis, fatigue, fever, or unintentional weight loss. If asymptomatic, no treatment is required. Surgical resection and/or embolization may be required in cases of severe symptoms including hemoptysis.

Scott Rosen MD, Bridget Barker PhD, Branden Larsen MD PhD, and Ishna Poojary MD

Department of Medicine and Pathology

University of Arizona Medical Center

Tucson, AZ

and

Tgen North

Flagstaff, AZ

References

1. Winn RE, Johnson R, Galgiani JN, Butler C, Pluss J. Cavitary coccidioidomycosis with fungus ball formation. Diagnosis by fiberoptic bronchoscopy with coexistence of hyphae and spherules. Chest. 1994;105(2):412-6. [CrossRef] [PubMed]
2. Sobonya RE, Yanes J, Klotz SA. Cavitary pulmonary coccidioidomycosis: pathologic and clinical correlates of disease. Hum Pathol. 2014;45(1):153-9. [CrossRef] [PubMed]
3. Sheff KW, York ER, Driebe EM, Barker BM, Rounsley SD, Waddell VG, Beckstrom-Sternberg SM, Beckstrom-Sternberg JS, Keim PS, Engelthaler DM. Development of a rapid, cost-effective TaqMan Real-Time PCR Assay for identification and differentiation of Coccidioides immitis and Coccidioides posadasii. Med Mycol. 2010;48(3):466-9. [CrossRef] [PubMed]

Reference as: Rosen S, Barker B, Larsen B, Poojary I. Medical image of the week: fungus ball. Southwest J Pulm Crit Care. 2015;10(4):182-3. doi: http://dx.doi.org/10.13175/swjpcc025-15 PDF

November 2011 Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Reference as: Gotway MB. November 2011 Case of the month. Southwest J Pulm Crit Care 2011;3: 154-8. (Click here for PDF version of manuscript)

Clinical History

A 47-year-old woman presents with complaints of hemoptysis. The hemoptysis was witnessed and was massive, resulting in anemia. A frontal and lateral chest radiograph (Figures 1A and B) was performed.

Figure 1: Frontal and lateral chest radiograph

What is the main finding on the chest radiograph? How would you describe the finding?

1. A solitary pulmonary nodule
2. An anterior mediastinal mass
3. Basal predominant linear and reticular abnormalities suggesting fibrotic lung disease
4. An intracavitary mass superimposed on a background of interstitial abnormality
5. Bilateral pleural effusions and thickening