Correct!
4. The histopathologic specimen shows pauciseptate fungal hyphae suggesting angio-invasive fungal infection

The H&E (hematoxylin and eosin) stains shows areas of fibrinous injury and scattered hemosiderin-laden macrophages. There is no evidence of necrotic lymphoproliferative tumor or obliterative arteritis. In addition small collections of eosinophils and rare neutrophils are identified. Hypervacuolated macrophages are also present. The biopsy is negative is negative for HSV1, HSV2, and cytomegalovirus. The Grocott-Gomori's (or Gömöri) methenamine silver stain and acid-fast bacilli stains shows the cells walls of the organisms that are present to be stained brown-black, but no acid-fast organisms (including weakly acid-fast organisms) are present, nor are the spherules of coccidioidomycosis evident. The morphology of the organisms show a pauciseptate hyphal appearance, suggestive of Mucorales fungi (Rhizopus species, Mucor species, Rhizomucor species, among others, and are consistent with angio-invasive fungal infection. However, other invasive fungi, such as Aspergillus, Fusarium, Scedosporium, and Penicillium species, can appear somewhat similarly on tissue sections and culture is required for proper species identification.

Within a few days, Rhizopus spp. was identified in culture. The patient was started on isovuconazole and improved over the next few weeks.

Diagnosis: Angio-invasive fungal infection due to Rhizopus (zygomycosis / mucormycosis.

References

  1. Chung JH, Godwin JD, Chien JW, Pipavath SJ. Case 160: Pulmonary mucormycosis. Radiology. 2010 Aug;256(2):667-70. [CrossRef] [PubMed]
  2. Georgiadou SP, Sipsas NV, Marom EM, Kontoyiannis DP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. Clin Infect Dis. 2011 May;52(9):1144-55. [CrossRef] [PubMed]
  3. Marom EM, Kontoyiannis DP. Imaging studies for diagnosing invasive fungal pneumonia in immunocompromised patients. Curr Opin Infect Dis. 2011 Aug;24(4):309-14. [CrossRef] [PubMed]
  4. Georgiadou SP, Pongas G, Fitzgerald NE, Lewis RE, Rytting M, Marom EM, Kontoyiannis DP. Invasive mold infections in pediatric cancer patients reflect heterogeneity in etiology, presentation, and outcome: a 10-year, single-institution, retrospective study. J Pediatric Infect Dis Soc. 2012 Jun;1(2):125-35. [CrossRef] [PubMed]
  5. Marchiori E, Marom EM, Zanetti G, Hochhegger B, Irion KL, Godoy MC. Reversed halo sign in invasive fungal infections: criteria for differentiation from organizing pneumonia. Chest. 2012 Dec;142(6):1469-73. [CrossRef] [PubMed]
  6. Wahba H, Truong MT, Lei X, Kontoyiannis DP, Marom EM. Reversed halo sign in invasive pulmonary fungal infections. Clin Infect Dis. 2008 Jun 1;46(11):1733-7. [CrossRef] [PubMed]
  7. Godoy MC, Marom EM. Reversed halo sign in pulmonary zygomycosis. Thorax. 2011 Jun;66(6):544. [CrossRef] [PubMed]
  8. Algın O, Gökalp G, Topal U. Signs in chest imaging. Diagn Interv Radiol. 2011 Mar;17(1):18-29. [CrossRef] [PubMed]
  9. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008 Mar;246(3):697-722. [CrossRef] [PubMed]

Home/Imaging