PMC9692072_01
(A) Selected axial image of the soft-tissue window on contrast-enhanced chest CT before treatment, showing a mass in middle mediastinum (orange arrows) with compression of lower trachea (red arrow) and superior vena cava (blue arrow), it is heterogeneous in density. (B) Selected axial image of the soft-tissue window on contrast-enhanced chest CT after 2-week therapy of nebulized AmBd, suggesting the middle mediastinal mass shrinks (orange arrows) and the compression of lower trachea (red arrow) and superior vena cava (blue arrow) is partially relieved. (C) Selected axial image of the soft-tissue window on chest CT scan at 3-month follow-up, demonstrating the significant mass shrinkage in the middle mediastinum (orange arrows). The compression of lower trachea (red arrow) and superior vena cava (blue arrow) is almost completely relieved. (D) Selected axial image of the pulmonary window on chest CT before treatment, showing patchy infiltrates in the right middle lobe (orange arrows). (E) Selected axial image of the pulmonary window on chest CT after 2-week therapy of nebulized AmBd, suggesting the infiltrates in the right middle lobe are partially absorbed (orange arrows). (F) Selected axial image of the pulmonary window on chest CT at 3-month follow-up, demonstrating further absorption in the right middle lobar lesion (orange arrows).
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F1
The contrasted chest CT demonstrated a 4.0 x 3.6 cm non-uniformly enhanced middle mediastinal mass with compression of lower trachea and superior vena cava (Figure 1A). Enlarged intramediastinal lymph nodes were appreciated, as well as right middle lobar infiltration (Figure 1D). AmBd. At 3-month follow-up, the patient was still stable with subsequent therapy of oral itraconazole (dose: 400 mg/d) and CT scan uncovered significant improvement (Figures 1C,F).
(A) Bronchoscopic view of the lower trachea, revealing severe compression stenosis caused by an extratracheal neoplasm (blue arrows). (B) Ultrasonogram of the extratracheal neoplasm reveals an enlarged para-aortic hypoechoic zone (blue arrows), with blood flow signals inside (orange arrow). (C) Micrograph of imprint smear obtained from cultured samples of needle aspirates at 25 C, suggesting conidiophores of T. marneffei bearing phialides and chains of conidia on the background of lactophenol cotton blue staining. Scale = 10 mum. (D) 5-day culture of needle aspirates of mediastinal mass at 25 C, demonstrating red-pigmented fungus colonies on Sabouraud dextrose agar plate.
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F2
Bronchoscopy revealed severe trachea compression stenosis caused by an extratracheal neoplasm anterior to the lower trachea (Figure 2A), along with bronchial inflammation and airway secretion. Whereas, with the technology of EBUS-TBNA, we were able to observe the ultrasonogram of the extratracheal neoplasm (Figure 2B) and obtain the needle aspirates of the mass. On the 9th day of admission, culturing on Sabouraud dextrose agar medium at 25 C confirmed T. marneffei in the biopsied mass with colonies showing characteristic red-pigmented fungal colonies from the needle aspirates (Figure 2D). Under the microscope, the mold form of T. marneffei was also observed in imprint smear obtained from cultured samples of needle aspirates at 25 C on the background of lactophenol cotton blue staining (Figure 2C).
(A) Photomicrograph of TBLB. Infiltrations of massive neutrophils and lymphocytes are demonstrated by hematoxylin-eosin staining, which indicates acute inflammation (HEx200). Scale = 40 mum. (B) Photomicrograph of needle-aspirated material obtained by EBUS-TBNA with hematoxylin and eosin staining. Yeast cells of T. marneffei with transverse septa are difficult to observe on the background of acute inflammatory infiltration (HEx800). Scale = 10 mum. (C) Photomicrograph of needle-aspirated material obtained by EBUS-TBNA with PAS staining. The characteristic transverse septum within the sausage-shaped yeast cell (orange arrow) can be identified (PASx800). Scale = 10 mum. (D) Photomicrograph of needle-aspirated material obtained by EBUS-TBNA with GMS staining. Ovoid, elliptic and sausage-shaped yeast cells with characteristic transverse septa (orange arrows) are more distinguishable compared with PAS staining (GMSx800). Scale = 10 mum.
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F3
T. marneffei with 15 sequence reads identified out of 84 total reads. TBLB showed acute inflammation, negative for Acid-fast, PAS and GMS stains, and no tumor cells were seen (Figure 3A). On the same day, histopathologic picture of needle aspirates demonstrated acute exudative inflammation and focal necrosis, where yeast cells with characteristic transverse septa were identified through PAS and GMS staining (Figures 3C,D).