PMC4681960_01
A-B, Successive frontal chest radiographs showing progression of a diffuse nodular infiltrate. C, CT scan of the chest showing numerous ill-defined nodules in a centrilobular distribution (arrows).
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Serial chest radiography revealed a rapidly progressive diffusely nodular infiltrate (Fig. 1A and B). Computed tomography (CT) of the chest confirmed the presence of innumerable nodules (Fig. 1C).
A, Surgical lung biopsy specimen showing extensive necrotizing granulomatous inflammation (arrows) (H&E, original magnification x100). B, Methenamine silver stain highlighting numerous budding fungal organisms morphologically consistent with H. capsulatum (arrows) (original magnification x100). Inset: Closer look at the characteristic narrow-based budding of H. capsulatum (arrows).
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She likewise informed her clinicians that her children, who had accompanied her on that trip, were now ill in Mexico with "nodules in their lungs." Liposomal amphotericin B (L-AmB) was started empirically for histoplasmosis, and the patient was referred for surgical lung biopsy, which revealed necrotizing granulomatous inflammation with fungal forms consistent with H. capsulatum (Fig. 2A and B).
PMC4681960_02
A, Frontal chest radiograph showing subtle reticulonodular densities bilaterally. B, Chest CT with innumerable tiny nodules in a miliary pattern. C, Subsequent frontal chest radiograph showing dramatic worsening of the previously subtle reticulonodular densities.
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CXR revealed subtle diffuse reticulonodular densities (Fig. 3A). Chest CT demonstrated a miliary pattern of involvement superimposed on chronic changes (Fig. 3B). Despite the initiation of empiric anti-tuberculous therapy, she became progressively more hypoxemic and somnolent with a worsening CXR (Fig. 3C).
Bone marrow aspirate showing a loose aggregate of histiocytes. In one area they have conglomerated into a multinucleated giant cell (arrow).
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Continued deterioration and pancytopenia prompted a bone marrow biopsy, which revealed rare aggregates of histiocytes (Fig. 4).
PMC4681960_03
A, Frontal chest radiograph showing bilateral lower lobe streaky densities and a left mid-lung field opacity with central radiolucency suggestive of cavitation (arrow). B, Chest CT confirms the presence of a cavitary consolidation in the superior segment of the left lower lobe. C, Abdominal CT showing hepatosplenomegaly with a peripheral hypodense area in the spleen likely representing infarct (arrow).
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CXR showed bilateral lower lobe streaky densities with probable cavitation on the left (Fig. 5A). Subsequent CT of the chest demonstrated a cavitary left lower lobe consolidation with an associated small pleural effusion (Fig. 5B). Abdominal CT revealed hepatosplenomegaly with an area of wedge-shaped hypoenhancement in the lateral aspect of the spleen compatible with infarct (Fig. 5C).