PMC5996088_01
Timeline. Abbreviations: 18FDG, 18-fluordeoxyglucose; CT, computed tomography; VATS, video assisted thoracic surgery; 18FDG-PET-CT, 18-fluordeoxyglucose positron emission tomography-computed tomography; EBUS-TBNA, endobronchial ultrasound with transbronchial needle aspiration; MRI, magnetic resonance imaging.
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F1
A clear overview of the medical disease history is demonstrated in a timeline (Figure 1).
Evolution of thoracic lesions. Top: Follow-up chest computed tomography (CT) in 2011 showing a right-sided lobulated pulmonary mass at the right lower lobe (3.0-cm diameter). Middle: CT (left) and fusion 18-fluordeoxyglucose positron emission tomography-computed tomography (18FDG-PET-CT) (right) in August 2013 shows an increase at the medial side of the mass and right hilar lymphadenopathy, with intense 18-fluordeoxyglucose (18FDG) uptake. Bottom: CT (left) and fusion 18FDG-PET-CT (right) in January 2014 showing further growth of the 18FDG-avid mass in the right lower lobe with hilar invasion and a mild 18FDG-avid subcarinal lymph node.
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F2
There was no fever nor night sweats. 18FDG-PET-CT revealed an intense 18FDG-avid mass in the right lower lobe, just next to the old pulmonary lesion, with intense hilar lymphadenopathy (Figure 2). A new 18FDG-PET-CT showed progression of the 18FDG-avid lesion with extension into the mediastinum and lymph node station 4R, with also mass effect on the right pulmonary artery and invasion of the left superior pulmonary vein (Figure 2).
Brain magnestic resonance imaging in March 2014. T1-weighted image after gadolinium of the brain shows a small right frontal enhancing cerebral lesion.
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F3
Additional brain imaging with magnetic resonance imaging (MRI) revealed multiple brain lesions in the cortex and watershed region, in the left corpus callosum, the left thalamus and partially in the right semioval center, which were considered brain metastases by the referring hospital (Figure 3).
Brain magnetic resonance imaging in May 2014. There is an increase in size of the right frontal lesion with surrounding perilesional edema. T2-weighted image (left) demonstrates a hypo-intense rim with ring-enhancement after gadolinium (contrast-enhanced T1-weighted middle). At diffusion imaging (right panels) there is restricted diffusion in a part of the central area.
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F4
On this MRI (May 2014), two lesions had enlarged significantly with marked perilesional edema but other lesions showed shrinkage (Figure 4).
Skin biopsy with presence of fungal hyphae. Periodic Acid Schiff stain on skin biopsy with fungal hyphae stained purple. Two fungal hyphae with dichotomous branching (diagnostic of Aspergillus) are depicted (arrows).
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F5
Because of her worse clinical condition, she was hospitalized in our tertiary hospital and cerebral and skin biopsies were performed: both showed marked inflammation and fungal hyphae with dichotomous branching, suggestive for Aspergillus, there was no evidence for malignancy (Table 1; Figures 5 and 6).
Cerebral biopsy with presence of fungal hyphae. Hematoxylin and eosin stain on cerebral biopsy showing nectrotic tissue with moderate numbers of septate fungal hyphae with parallel walls. Two fungal hyphae with dichotomous branching (diagnostic of Aspergillus) are depicted (arrows).
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F6
Because of her worse clinical condition, she was hospitalized in our tertiary hospital and cerebral and skin biopsies were performed: both showed marked inflammation and fungal hyphae with dichotomous branching, suggestive for Aspergillus, there was no evidence for malignancy (Table 1; Figures 5 and 6).