PMC8276918_01
Chest x-ray showing right lower lung and left lower lobe opacities along with a small left pleural effusion
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A chest x-ray (Fig. 1) showed ill-defined airspace opacity projecting over the right lower lung, unchanged ill-defined lingular and left lower lobe opacities, and a persistent small left pleural effusion.
C.T scan of the chest showing right upper lobe patchy ground glass opacities and centrilobular micronodules, and a tiny right pleural effusion
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A chest CT scan (Fig. 2) revealed patchy ground glass opacities in the right upper lobe (RUL) and right lower lobe (RLL), centrilobular micronodules and tree-in-bud opacities in the RUL, calcified granuloma in the left upper lobe, a parenchymal scar in the left lower lobe and a tiny right pleural effusion.
Irregularly branched conidiophores, swollen phialides, and ellipsoid conidia of Paecilomyces (400x)
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A bronchoscopy was performed and the bronchoalveolar lavage fluid culture isolated Paecilomyces (Fig. 3).
CT of the chest showing cavitary nodules in the right lower lobe
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A repeat CT of the chest (Fig. 4) a week later showed a small 19 mm broncho-centric cavitary nodule in the RLL (unchanged) with a new 9 mm cavitary nodule in the RLL, improved but persistent ground glass opacities and unchanged small pleural effusions.
CT of the chest showing progression in bilateral broncho-centric nodular opacities and consolidations
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CRP (11.6 mg/dl) suggesting failure of amphotericin therapy. CT of the chest (Fig. 5) showed progression in bilateral bronchocentric nodular opacities and consolidations throughout the right and left upper and lower lobes as well as a slight increase in size and a cavitary lesion in the RLL.