PMC6010647_01
a) Coronal chest CT: bilateral airspace opacities with predominant right sided involvement. Air bronchograms can be appreciated in right superior and right middle lobe (arrows). b) Transverse plane chest CT: predominant right middle lobe airspace disease. A small air bronchogram can be appreciated in the posterior portion of the middle lobe. There is bronchiectasis in the right inferior lobe (arrow). Trace right pleural effusion can also be appreciated. c) Last known Xray from 3 years prior to presentation.
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Given his respiratory picture, chest imaging was obtained and demonstrated bilateral multifocal airspace disease right greater than left involvement (Fig. 1).
a) Coronal chest CT showing worsening bilateral pleural effusions and worsening right sided pulmonary consolidation. b) Transverse plane chest CT demonstrating moderate sized bilateral pleural effusions. Bilateral parenchymal involvement can be appreciated with air bronchograms on the right side.
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After starting voriconazole, his laboratory parameters initially improved; however, his respiratory status deteriorated due to worsening parapneumonic effusions and parenchymal infiltrates (Fig. 2).
a and b: HE stains of a lung parenchymal biopsy demonstrating organized necrotizing granulomas surrounding fungal forms. A multicellular infiltrate can be appreciated.
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Pathology results were consistent with pulmonary parenchyma and invasion with Aspergillus hyphae within necrotizing granulomas (Fig. 3), and pleural fluid analysis was consistent with exudative effusion without empyema.
a and b: Coronal and sagittal views of chest computed tomography done after 12 weeks of treatment. Complete resolution of parenchymal infiltrates representing resolution of airspace disease can be observed. There is lung scarring present as well as right diaphragmatic tenting seen in the coronal view. Some residual effusion can be see in the right side on the coronal view in the interlobar fissure. On the sagittal view a bulla can be appreciated in the anterior right side.
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Repeat chest imaging showed marked improvement, albeit with residual scarring (Fig. 4).