Pulmonary artery aneurysms are a very rare vascular anomaly. Here we report a case in which cavitary lung disease due to coccidioidomycosis led to a pulmonary arterial aneurysm.CASE PRESENATION: A 52-year-old man with a past medical history of coronary artery disease, hyperlipidemia was admitted in hospital for massive hemoptysis. He reported one similar episode of hemoptysis in 1990. At that time, he was found to have a left upper lobe cavity and mediastinal lymphadenopathy.In general, the patient appeared athletic and well nourished. Auscultatory exam revealed crackles in the left base, and diminished breath sounds posteriorly over the left upper lobe. The physical examination was otherwise unremarkable. Initial laboratory tests revealed a white blood count of 10,500 /uL with 82% neutrophils, 12% lymphocytes, and 5% lymphocytes. The hemoglobin was 12 g/Dl, and the platelet count was 274, 000 per mm3. Electrolytes and creatinine levels were normal. Blood cultures were negative. Three consecutive sputum smears were negative for AFB. Chest radiography demonstrated a thin walled cavity in the left upper lobe. Computed tomography (CT) of the chest with contrast revealed a pseudo aneurysm within the left upper lobe cavity.Fiberoptic bronchoscopy found scanty blood without a source of active bleeding. Blood was noted prominently in the posterior segment of the left upper lobe. Initially all culture were unrevealing. The patient continued to bleed, and therefore a repeat CT-scan of the chest was performed. This time 3-dimensional chest pulmonary artery angiography was utilized, revealing a (4-5 mm) pulmonary artery aneurysm within the cavity. Thoracic surgery was consulted given the possibility of exsanguination. Subsequently, an immediate left upper lobe lobectomy was performed, and the procedure was tolerated well. Pathologic examination revealed multiple necrotizing granulomas identified within the lung parenchyma. In addition, a medium sized artery exhibited necrotizing granulomatous inflammation, disrupting the wall of the vessel. After approximately 4 weeks, Bronchoalveolar lavage (BAL) cultures revealed coccidioidomycosis. The patient was treated for 3 months with fluconazole 400 mg a day, and had no recurrent episodes of hemoptysis.DISCUSSION: We report a patient with cavitary lung disease and hemoptysis caused by coccidioidomycosis. It is estimated that 60% of the infections with coccidiidomycosis are asymptomatic. Symptomatic patients may experience symptoms ranging from a mild respiratory illness to acute pneumonia(1). In a small number of cases symptoms persist for more than 6 weeks. Coccidioidomycosis may disseminate and present as multisystemic disorder. Persistent pulmonary coccidiidomycosis is characterized with residual pulmonary nodules, cavities, fibrosis and bronchiectasis (23). Serology, skin testing, culture and smear and pathologic evaluation may play an important role in diagnosis of this disorder. The vast majority of symptomatic patients do not require specific therapy, however patients with severe or prolonged disease should be treated(1). Amphotericin, fluconazole and itroconazole are used for treatment for coccidioidomycosis. Surgery may also play an important role in treatment of this disorder. Here we were using novel radiographic technique (3D CT pulmonary artery angiography) to better describe pulmonary vascular anatomy.Three-dimensional computed tomographic angiography can easily and quickly be obtained and provide very useful visual information in various diseases.CONCLUSIONS: We demonstrated that coccidioidomycosis may cause necrotizing granulomatous inflammation of vascular structures in association with destruction of pulmonary parenchyma and also forming of vascular anomaly. Finally, it is important to recognize the role of 3D CT pulmonary artery angiography in diagnosing abnormalities of pulmonary vasculature.
R. Tomic, None.