PMC7248623_01
Computed tomography of the (A) pre-contrast and (B) post-contrast neck. The curved arrow highlights the esophagus. Hypoattenuating, contrast-enhancing tissue obscures the mucosal tissue extending through the esophageal wall into the surrounding tissue (white chevrons). The abnormal tissue effaces the left thyroid lobe (white arrow); compare to the normal right thyroid lobe (white caret).
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F1
There was abnormal pre-contrast hypoattenuating tissue that was heterogeneously contrast-enhancing associated with the left aspect of the esophagus (Figures 1A,B).
Computed tomography of hyperattenuating soft tissue (white chevrons) representing the fistulous tract that is contiguous with the esophagus (white asterisk). Within the fistulous tract there are small gas bubbles (white arrows).
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F2
The tissue that extended from the esophagus was hyperattenuating on the pre-contrast series with small gas bubbles within the hyperattenuating tissue (Figure 2).
Computed tomography of the (A) pre-contrast and (B) post-contrast cranial neck. There are multiple enlarged, contrast enhancing lymphocenters that are primarily left-sided (black asterisks). Central portions of the lymphocenters are heterogeneous and contrast-enhancing with hypoattenuating regions. Soft tissue striations surround the enlarged lymphocenters causing disruption of the fat fascial planes between structures (white arrow).
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F3
The lymph nodes of the left side of the head and neck were enlarged with heterogeneous contrast enhancement of the central portion of the lymph nodes and strong peripheral contrast enhancement giving a rim-enhancing appearance; affected lymph nodes included left medial retropharyngeal lymph node, left lateral retropharyngeal lymph node, and left mandibular lymph nodes (Figures 3A,B).
(A) Left lateral neck, (B) right lateral thorax, and (C) ventrodorsal thorax radiographs. There is gas within the cervical and thoracic esophagus (white arrows). The remaining tissues of the neck and thorax are unremarkable.
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F4
Radiographs revealed a mild amount of gas within the cervical and intrathoracic portions of the esophagus (Figure 4).
Esophagoscopic images demonstrating a (A) chronic-appearing, erythematous fistulous tract (white asterisk) ~3cm distal to the upper esophageal sphincter (white triangle; distal esophagus) and (B) visualization within the fistula and distal extension of the tract (white arrow).
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F5
Esophagoscopy revealed a small hole opening in the esophagus surrounded by proliferative tissue (Figure 5).
(A) Neck mass. Thyroid gland is disrupted and replaced by multifocal to coalescing pyogranulomatous and lymphoplasmacytic inflammation with peripheral fibroplasia (*). Hematoxylin and eosin (H&E), 2X objective. (B) Neck mass. Centrally, pyogranulomas occasionally have fungal spherules (arrow). H&E, 20X objective. (C) Neck mass. Intralesional fungal spherules are circular, measure up to 21 mum, and have a 1 mum refractile capsule with central vacuolated basophilic granular material (arrow). H&E, 60X objective.
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F6
Microscopically, thyroid gland and peripheral adipose tissue, skeletal muscle, and connective tissue were infiltrated and disrupted by multifocal to coalescing mixed inflammation often organized as pyogranulomas rimmed by lymphocytes, plasma cells, and surrounded by dense fibroplasia transitioning to peripheral edematous granulation tissue (Figure 6). Centrally, often admixed with cell debris and neutrophils, there were occasional circular up to 21 mum diameter fungal structures with a 1 mum refractile capsule and central vacuolated basophilic granular material (Coccidioides spp. spherules) (Figure 6).