Medical Image of the Week: Coccidioidomycosis

Figure 1. Preoperative x-ray (Panel A) demonstrating a right upper lobe cavitary lesion. X-ray (Panel B) status post lobectomy.

Figure 2. Coronal (Panel A) and axial (Panel B) images from a chest CT further demonstrating a right upper lobe cavitary lesion.

Figure 3. The 200x magnification H&E image (Panel A) demonstrates one of the numerous granulomas seen in the lung specimen. A low magnification (40x) (Panel B) H&E image showing the granulomatous infection, prominent at the left, surrounded by a wall made up of collagen.

Figure 4. Two images, both at 400x magnification, are of GMS stained tissue.  Panel A shows the numerous branching hyphae of the lesion.  Panel B shows a granuloma with a central Coccidioides spherule, marked by the red arrow.

A 41-year-old Hispanic man with a history of uncontrolled type 2 diabetes and coccidioidomycosis, presented to the emergency department with a two year history of hemoptysis and recent onset lower chest pain. Patient was found to have a right upper lobe cavitary lesion on x-ray (Figure 1). Due to concern for pulmonary and pericardial tuberculosis the patient was placed on isolation, and QuantiFERON Gold testing, Coccidioides antibodies and computed tomography of the chest were ordered. At this time the patient revealed that he had taken only 30 days of treatment for his coccidioidomycosis 2 years ago due to his understanding this was the complete course. The CT (Figure 2) demonstrated an irregular, spiculated, and thin-walled right apical cavitary lesion with satellite nodules. QuantiFERON Gold testing and Coccidioides testing were both positive. Surgical resection was performed due to ongoing hemoptysis. The surgical specimen demonstrated hyphae (Figure 4A), a rare spherule (Figure 4B) and caseating granulomas (Figure 3) consistent with coccidioidomycosis. Acid-fast stains were negative. Indications for surgery in coccidioidomycosis are continued or progressing symptoms following 3 months of treatment, complications (such as rupture, pneumothorax or effusion), and large size of abscess (1,2).

Kareem Hassan BA, Spencer Paulson MD, Carlos Tafich Rios MD

Departments of Medicine and Pathology

University of Arizona 

Tucson, AZ

References

1. Jaroszewski DE, Halabi WJ, Blair JE, et al. Surgery for pulmonary coccidioidomycosis: a 10-year experience. Ann Thorac Surg. 2009; 88:1765-72. [CrossRef] [PubMed]
2. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis. 2005;41: 1217-23. [CrossRef] [PubMed]

Reference as: Hassan K, Paulson S, Rios CT. Medical image of the week: coccidioidomycosis. Southwest J Pulm Crit Care. 2014;9(2):128-9 . doi: http://dx.doi.org/10.13175/swjpcc106-14 PDF

Medical Image of the Week: Pneumatocele

Figure 1. Portable AP film showing a large cystic lesion in the left lower lobe in addition to small bilateral pleural effusions and adjacent consolidation.

Figure 2. Axial enhanced CT scan section showing a large cystic space with an air-fluid level with adjacent consolidated atelectasis. No perceptible wall is seen.

A 50-year-old man presented with polymicrobial pneumonia which included Proteus mirabilis, Enterobacter cloacea and MRSA pathogens. A large cystic lesion with an air-fluid level was found on chest imaging in a region of pneumonia (Figure 1). There was associated mass effect onto the adjacent lung. No perceptible wall was noted which would be more associated with a cyst rather than a cavity or abscess. Directed aspiration of this lesion resulted in decompression without further complication. Minimal sterile fluid was recovered. Therefore the proposed diagnosis was a pneumatocele within the setting of infection. Pneumatoceles may be challenging at times to distinguish from a cavity particularly when surrounded by airspace disease however merit consideration in the differential diagnosis particularly in the absence of findings of a thick irregular wall.

The exact mechanism causing development of a pneumatocele is not known, but believed to develop due to a check valve type bronchiole or bronchiolar obstruction (1). Pneumatoceles most commonly undergo spontaneous remission within weeks to months without any known long term implications. Complications occur rarely and include pneumothorax, tension pneumatocele, and secondary infection of a pneumatocele. Usual treatment is directed towards the underlying pneumonia with appropriate antibiotics. In rare cases percutaneous drainage may be necessary and is ideally performed with a small bore catheter to minimize trauma. The role of positive pressure ventilation in development of a pneumatocele is unclear.

Bhupinder Natt, MD and Veronica Arteaga, MD

Divisions of Pulmonary and Thoracic Imaging

University of Arizona College of Medicine

Tucson, AZ

Reference

1. Lysy J, Werczberger A, Globus M, Chowers I. Pneumatocele formation in a patient with Proteus mirabilis pneumonia. Postgrad Med J. 1985;61(713):255-7. [CrossRef] [PubMed]

Reference as: Natt B, Arteaga V. Medical image of the week: pneumatocele. Southwest J Pulm Crit Care. 2014;9(2):126-7. doi: http://dx.doi.org/10.13175/swjpcc102-14 PDF