PMC6478981_01
The computed tomography findings at two years before presentation (a-d), and at presentation (e-h). Multiple well-defined nodules of soft tissue attenuation were seen (e-h). A nodule in the left upper lobe (f) was resected thoracoscopically five months after presentation.
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Two years previously, a chest computed tomography (CT) scan demonstrated emphysema without nodular lesions (Fig. 1a-d). Chest CT also revealed multiple nodules in both lungs including fifteen nodules of 0.4 to 1.3 cm in diameter in the right upper lobe, two nodules of 0.4 cm in diameter in the right middle lobe, one subpleural cavitary nodule of 2.3 cm in diameter in the right lower lobe, eight nodules of 0.4 to 0.9 cm in diameter in the left upper lobe, and one subpleural nodule of 1.7 cm in diameter in the left lower lobe (Fig. 1e-h). As a CT scan two months after this dose tapering revealed no improvement in his nodular lesions, one of the nodules in the left upper lobe was resected thoracoscopically so that a more definite, histopathological diagnosis could be obtained (Fig. 1f).
At low magnification, a necrotic nodule was seen adjacent to the respiratory bronchiole (RB) and pulmonary artery (A) [Hematoxylin and Eosin (H&E) staining]. Interlobular septa (arrows) and a pulmonary vein (V) were identified near the nodular lesion (a). At 40x magnification, no parenchymal invasion was seen around the fibrous capsule (H&E staining) (b). Grocott staining at 200x magnification revealed branching septate hyphae compatible with Aspergillus spp. inside the necrotic nodule (c).
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A histological examination during surgery revealed a nodular lesion of 5 mm in size with central necrosis and a dense fibrous capsule adjacent to a respiratory bronchiole and pulmonary artery (Fig. 2).
The computed tomography findings at the patient's first visit (a, c) and six months after the initiation of antifungal therapy (b, d). One of the patient's nodules decreased in size from 13 to 10 mm in diameter (a, b). The cavity wall of the right lower lobe lesion showed thinning (c, d).
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He was consequently started on voriconazole antifungal therapy and CT performed an additional six months later revealed that some nodules had decreased in size, and that the cavity wall of his right lower lobe lesion had thinned (Fig. 3, 4).
The clinical course. Voriconazole was administered intravenously for two weeks, then orally. Alb: albumin, CRP: C-reactive protein, CT: computed tomography, i.v.: intravenous, m: months, p.o.: oral, yr: year(s)
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He was consequently started on voriconazole antifungal therapy and CT performed an additional six months later revealed that some nodules had decreased in size, and that the cavity wall of his right lower lobe lesion had thinned (Fig. 3, 4).