PMC10201002_01
Chest x-ray showing a magnified cardiac silhouette due to anteroposterior projection, prominent aortic arch with elongation of the descendent aorta. Unremarkable pulmonary hila, central trachea, and in the right pulmonary base a cystic lesion, with thick walls, air-fluid level inside (blue arrows), alongside alveolar opacities without consolidation. Obliteration of right costophrenic angle due to pleural effusion.
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A chest x-ray showed pulmonary congestion and a rounded, thick-walled image at the right pulmonary base (Figure 1).
Chest CT scan. (A-D) Sequence of images in the mediastinal window. (E-H) Sequence of images in lung window. There is a loss of the normal architecture of the middle and inferior right lobes, with consolidation in the posterior basal segment of the inferior right lobe, alongside varicose bronchiectasis (blue arrows). There is ipsilateral pleural effusion (red arrow), with air bubbles and anterior laminar pneumothorax (yellow arrow). The lateral segment of the middle lobe is replaced by thick-walled cavitation (green arrows).. Abbreviation: CT, computerized tomography.
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A chest computerized tomography (CT) scan showed a cavitated image in the lateral segment of the middle lobe with a nodule inside, in addition to varicose bronchiectasis and centrilobular nodules in the lower lobe (Figures 2 and 3).
Chest CT scan, sagittal reconstruction. (A, B) A thick-walled cavitated lesion is observed, alongside varicose bronchiectasis (red arrows) and right pleural effusion.. Abbreviation: CT, computerized tomography.
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A chest computerized tomography (CT) scan showed a cavitated image in the lateral segment of the middle lobe with a nodule inside, in addition to varicose bronchiectasis and centrilobular nodules in the lower lobe (Figures 2 and 3).
Transbronchial biopsy. (A) H&E staining showing a fragment of the respiratory epithelium with a dense subepithelial chronic inflammation (blue arrow). (B) Collagenous stroma (green arrow) with dense subepithelial chronic inflammation.
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Aspergillus (Figures 4-6). A diagnosis of IPA was made and management with liposomal amphotericin B was initiated.
Transbronchial biopsy with Gomori Methenamine-Silver staining, where hyaline hypha is observed within the stroma, at a 45-degree angle (blue arrow).
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Aspergillus (Figures 4-6). A diagnosis of IPA was made and management with liposomal amphotericin B was initiated.
(A) Macroscopic aspect of the Aspergillus fumigatus colony in Sabouraud agar, showing a fast-growing colony, flat, velvety, initially green, which then turned into a grayish color with a white halo (blue arrow). (B, C) Microscopic characteristics, were typic columnar heads are seen, with short conidiophores, smooth walls, and cone-shaped terminal vesicles supporting a single row of phialides in the upper two-thirds of the vesicle. The conidia have a globose shape, with rough walls and a greenish color (red arrows).
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Aspergillus (Figures 4-6). A diagnosis of IPA was made and management with liposomal amphotericin B was initiated.
Cerebral nuclear magnetic resonance. (A-D) Multiple lesions with an increased signal intensity are observed, of rounded morphology, compromising the white batter of both cerebral hemispheres (yellow arrows). The knee of the corpus callosum and right cerebellar hemisphere are visualized. There is vasogenic edema, especially around the lesion located adjacent to the frontal horn of the left lateral ventricle. After the administration of contrast medium, enhancement of these lesions is shown, compared to the adjacent parenchyma.
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One week later, the patient presented with a left inferior monoparesis and nominal aphasia, so he was followed with a nuclear magnetic resonance of the brain finding multiple lesions along the corpus callosum, right cerebellar hemisphere, diffuse leptomeningeal enhancement and changes due to volume loss of the parenchyma (Figure 7).
(A) Echocardiographic image, showing 2, 8-mm lesions in the crista terminalis (red arrows), which have decreased in size compared to the initial echocardiography. (B) 3D image of the tricuspid valve, showing 2, 9-mm masses (black arrows), also smaller than seen in the initial exam.
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The patient received 8 weeks of in-hospital management and despite the poor prognosis, clinical stability and regression of pulmonary, cardiac, and CNS lesions were achieved (Figures 8 and 9).
Chest CT scan, lung window. (A, B) The cavitated lesion of the middle lobe has decreased in size, as well as the consolidation in the inferior right pulmonary lobe (blue arrows).. Abbreviation: CT, computerized tomography.
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The patient received 8 weeks of in-hospital management and despite the poor prognosis, clinical stability and regression of pulmonary, cardiac, and CNS lesions were achieved (Figures 8 and 9).