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: Recurrent Sarcoidosis Resembling Malignancy

Figure 1. CT scan showing multiple splenic masses.

The patient is a 64-year-old, non-smoking, woman who presented with a dry cough for a year and had a history of sarcoidosis. Five years ago, she presented with cough, bilateral pulmonary nodules and mediastinal adenopathy. At that time by a fine needle aspiration (FNA) under endobronchial ultrasound biopsy (EBUS), revealing non caseating granulomatous inflammation. She had complete remission after she was treated with a course of steroids. Follow up chest CT showed remission of her disease. On this presentation, she was found to have incidental multiple splenic masses on a CT scan of the chest (Figure 1). Physical examination was normal, CBC and chemistry were normal, and she had negative tests for tuberculosis, rheumatologic disease, systemic sclerosis, and mixed connective tissue disease. 

Pulmonary function tests were consistent with restrictive impairment and mild decrease in diffusion capacity for carbon monoxide. Positron Emission Tomography (PET scan) showed increased uptake corresponding to these lesions with no other areas of abnormal uptake in the body. CT-guided biopsy of splenic lesion showed non-caseating granulomas consistent with sarcoidosis. She was retreated with a course of steroids and a follow up CT scan of the abdomen showed resolution of the splenic masses.

Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by non-caseating granulomas. It is thought to result from an exaggerated host cellular immune response to an unknown antigen. Although the lungs are involved in 90 % of patients, other organs can be affected with the lungs or in isolation. Visceral involvement is usually asymptomatic and presents as hepatosplenomegaly on physical exam, or less often as isolated nodular splenic lesions suspicious of lymphoma. Rarely patients can have elevated liver enzymes from liver involvement or cytopenias from splenic enlargement (1).

Other differential diagnoses include infectious, neoplastic or benign conditions that may have similar morphology, such as tuberculosis, histoplasmosis, and lymphomas, hemangiomas and hamartomas. Diagnosis is usually confirmed by a biopsy and the disease responds to steroid treatment in over 70% of patients (2). Splenectomy is a therapeutic option in cases of steroids failure, severe hypersplenism, inability to exclude malignancy, or if risk of splenic rupture is high (3).

Isolated splenic sarcoidosis is a rare condition that can be the first presentation of sarcoidosis or a site of disease recurrence. It can mimic a variety of infectious, benign or malignant conditions especially when it presents with cytopenias due to hypersplenism, making biopsy necessary. Fortunately, splenic sarcoidosis responds to steroid treatment in most patients. Splenectomy can be considered in refractory cases.

Fuad Zeid MD¹, Hasan S. Yamin MD¹, Ahmed Amro MD², Fadi Alkhankan MD³, and Hani Alkhankan MD⁴

¹Pulmonary and Critical Care and ²Internal Medicine

Marshall University

Huntington, WV USA

³Pulmonary and Critical Care

Mercy hospital/ St. Louis University

St. Louis, MO USA

⁴McLaren Oakland Pulmonary/Critical Care,

Pontiac, MI USA

References

1. Vakil A, MD, Upadhyay H, Sherani K, Cervellione K, Fein A. A case of splenic sarcoidosis: initial diagnosis and one-year symptom follow-up. Chest. 2014;145(3):210A [Abstract].
2. Calik M, Aygun M, Yesildag M, et al. Nodular splenic sarcoidosis: a rare case report and review of the literature. Chest. 2014;146(4):399A [Abstract].
3. Sharma OP, Vucinic V, James DG. Splenectomy in sarcoidosis: indications, complications, and long-term follow-up. Sarcoidosis Vasc Diffuse Lung Dis. 2002 Mar;19(1):66-70. [PubMed]

Cite as: Zeid F, Yamin HS, Amro A, Alkhankan F, Alkhankan H. Medical image of the week: recurrent sarcoidosis resembling malignancy. Southwest J Pulm Crit Care. 2018;18(5):279-80. doi: https://doi.org/10.13175/swjpcc057-18 PDF