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Chest Infections |

Cavitary Lung Lesion in a Patient With Granulomatosis With Polyangiitis

Aarthi Ganesh, MD; Mohammed Alzoubaidi, MD; Linda Snyder, MD; Veronica Arteaga, MD; Richard Sobonya, MD
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University of Arizona, Tucson, AZ


Chest. 2013;144(4_MeetingAbstracts):186A. doi:10.1378/chest.1678011
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Abstract

SESSION TITLE: Infectious Disease Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Zygomycosis is a severe and rare angio-invasive fungal infection that develops in patients with immunosuppression and diabetes mellitus. This infection causes significant morbidity and has a high mortality rate.

CASE PRESENTATION: A 46 year-old male with a history of granulomatosis polyangiitis (GPA) presented with acute onset of right upper quadrant pain, pleuritic chest pain and a dry cough. He had received four doses of cyclophosphamide in the past and his current treatment for GPA was rituximab and corticosteroids. Physical examination revealed normal vital signs, mild tenderness in the right upper quadrant and right lower lobe inspiratory crackles. A chest radiograph revealed bibasilar opacities more prominent in the right lung base. A computed chest tomography (CT) scan showed a 4.8 cm right lower lobe mass with central ground-glass and a peripheral rim of consolidation suggesting the reversed halo sign (RHS). Bronchoscopy with bronchoalveolar lavage (BAL) was performed and cultures revealed Stenotrophomonas maltophilia and herpes simplex virus, however fungal, mycobacterial and cytologic studies were negative. Serum anti-neutrophil cytoplasmic antibodies, aspergillus galactomannan antigen, cryptococcocal antigen and Coccidioides immitis serologies were negative. He was treated with broad-spectrum antibiotics, clinically improved and was discharged with close clinical follow-up. A follow-up chest CT showed a large right lower lobe thin walled cavity. The patient was asymptomatic. A repeat BAL grew Influenza B and penicillium species. In order to secure a diagnosis, the patient underwent a right lower lobectomy. Histopathology of the lung tissue showed large non-septate hyphae with cavitary granulamatous inflammation due to Zygomycetes and caseating granulomas adjacent to the cavity containing Zygomycetes. No evidence of vasculitis suggesting GPA was noted. Posaconazole treatment was recommended.

DISCUSSION: Our patient presented a challenging differential diagnosis given his history of GPA and immunosuppression as the RHS can be seen in both fungal infections and GPA. Histopathology examination of the resected lung cavity revealed granulomatous inflammation due to zygomycetes and no evidence of vasculitis.

CONCLUSIONS: Pulmonary zygomycosis causes severe morbidity and mortality in patients with immunosuppression, diabetes mellitus and iron overload states. There are reports of patients cured after surgical resection and our patient is clinically doing well.

Reference #1: . Hamilos G, et al. Pulmonary Mucormycosis; Semin Respir Crit Care Med. 2011; 32(6): 693-702

Reference #2: Marchiori E, et al. Reversed Halo Sign: High-resolution CT scan findings in 79 patients; Chest. 2012; 141(5): 1260-1266

DISCLOSURE: The following authors have nothing to disclose: Aarthi Ganesh, Mohammed Alzoubaidi, Linda Snyder, Veronica Arteaga, Richard Sobonya

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