Bilateral Areas Of Consolidation Research Articles

Pulmonary Granuloma Associated with Pneumocystis Jirovecii in a Patient with Peripheral T-Cell Lymphoma: Presentation of a Rare Case with Review of the Literature

Abstract Casestudy: Although Pneumocystis jirovecii (PJ) is a known opportunistic pulmonary infection among immunocompromised patients, it is a rare (<5%) cause of pneumonia in this cohort. Majority of cases are observed in patients with HIV or solid organ transplant recipients. Granuloma formation in patients infected with PJ is even rarer. We present a case of multiple pulmonary granulomas associated with PJ in a non-HIV patient. A 49-year-old female with a history of asthma presented with worsening dyspnea. Initial imaging revealed multifocal bilateral areas of consolidation and a diagnostic bronchoalveolar lavage (BAL) demonstrated PJ organisms. Additional investigation was pursued to determine the etiology of this infection in a seemingly immunocompetent patient. New findings noted during hospitalization included a new maculopapular skin rash, significant weight loss, and lymphopenia. A bone marrow biopsy revealed a clonal proliferation of plasma cells. Subsequent imaging revealed mediastinal adenopathy. There was no improvement in symptoms despite treatment for pneumonia and a month later, a lung wedge biopsy revealed organizing acute lung injury and multiple non-caseating granulomas without lymphoid rimming, asteroid, or Schaumann bodies. Silver stain highlighted numerous PJ organisms within and outside of the granulomas. An inguinal lymph node and skin biopsies eventually revealed involvement by peripheral T-cell lymphoma (PTCL). Repeat BAL revealed clearance of organisms after additional therapy; however, the PTCL was refractory to chemotherapy and palliative care was pursued. To date, we could only find <30 cases of pulmonary PJ granulomas in patients with hematologic malignancies. Most are in patients with B cell lymphomas and just 1 report in a patient with adult T-cell leukemia/lymphoma. In summary, this case highlights that PJ associated pulmonary granulomas are uncommon, can be a harbinger of an underlying immunocompromised state, such as a lymphoma, and are even rarer to be associated with PTCL.

Neumonía eosinofílica crónica

La neumonía eosinofílica crónica es una entidad poco frecuente y estudiada en nuestro medio, cuyo diagnóstico se basa inicialmente en la sospecha clínica y los antecedentes comunmente asociados como atopia o asma; sin embargo, no todos los casos se presentan como lo describe la literatura científica. Se expone el caso de un paciente previamente sano, con un cuadro crónico de tres meses de tos y síntomas constitucionales que no mejoraron a pesar de múltiples esquemas antibióticos de forma empírica y con persistencia de múltiples opacidades de compromiso alveolar con broncograma aéreo y áreas de consolidación de predominio basal bilateral. Se realizó fibrobroncoscopia y lavado broncoalveolar con evidencia de eosinofilia pulmonar, hallazgo que determinó el diagnóstico de neumonía eosinofílica crónica, sin realización de biopsia. Una de las pruebas para confirmar el diagnóstico es la respuesta a la terapia esteroidea, dejando como última opción las medidas invasivas.Un alto índice de sospecha clínica, la documentación de eosinofilia periférica y/o pulmonar y la respuesta al tratamiento con corticoides deberían ser suficientes para el diagnóstico definitivo de neumonía eosinofílica crónica, en los casos en los que no es posible realizar biopsia pulmonar.

Computed tomographic features of pregnant women with pandemic H1N1 virus infection

ObjectiveThe aim of this study was to review the chest CT findings at presentation and on follow-up in pregnant women with confirmed S-OIV. Materials and methodsWe reviewed the CT findings at presentation (n = 16) and after hospital admission (n = 10) of 18 pregnant women diagnosed with Influenza A (H1N1) in our hospital between Nov 5, 2009 to Dec 12, 2009. CT manifestations were reviewed independently by 3 observers who reached a consensus decision. Chest CT findings were analyzed with regard to the patterns and distributions of pulmonary abnormalities. ResultsThe predominant CT findings at presentation consisted of unilateral (n = 6) or bilateral (n = 10) ground-glass opacities or focal unilateral (n = 3) or bilateral (n = 9) areas of consolidation. 4 of the 16 patients had associated mild thickening of the interlobular septa. The predominant follow-up abnormalities consisted of unilateral (n = 3) or bilateral (n = 7) ground-glass opacities or unilateral (n = 1) or bilateral (n = 1) consolidation. 8 of the 10 patients had interstitial opacity findings, including smooth thickening of the interlobular septa (n = 5), reticulation (n = 2) and honeycombing (n = 1). 3 patients had irregular lines (n = 3) and traction bronchiectasis (n = 1). ConclusionThe most common CT manifestations of pregnant women with confirmed S-OIV are unilateral or bilateral ground-glass opacities or focal unilateral or bilateral areas of consolidation. In pregnant women, the abnormalities seem to more extensive than general patients. Some pregnant women patients may develop interstitial opacity and traction bronchiectasis due to fibrosis.

High-resolution computed tomographic findings of Aspergillus infection in lung transplant patients

ObjectiveThe aim of this study was to assess high-resolution computed tomographic (HRCT) findings at presentation in lung transplant patients diagnosed with pulmonary Aspergillus infection. Materials and methodsWe retrospectively reviewed HRCT findings from 23 patients diagnosed with pulmonary aspergillosis. Imaging studies were performed 2–5 days after the onset of symptoms. The patient sample comprised 12 men and 11 women aged 22–59 years (mean age, 43.6 years). All patients had dyspnea, tachypnea, and cough. Diagnoses were established with Platelia Aspergillus enzyme immunoassays for galactomannan antigen detection in bronchoalveolar lavage and recovery of symptoms, and HRCT findings after voriconazole treatment. The HRCT scans were reviewed independently by two observers who reached a consensus decision. ResultsThe main HRCT pattern, found in 65% (n=15) of patients, was centrilobular tree-in-bud nodules associated with bronchial thickening. This pattern was described in association with areas of consolidation and ground-glass opacities in 13% (n=3) of patients. Consolidation and ground-glass opacities were the main pattern in 22% (n=5) of patients. The pattern of large nodules with and without the halo sign was observed in 13% (n=3) of patients, and were associated with consolidation and ground-glass opacities in one case. ConclusionThe predominant HRCT findings in lung transplant patients with pulmonary aspergillosis were bilateral bronchial wall thickening and centrilobular opacities with the tree-in-bud pattern. Ground-glass opacities and/or bilateral areas of consolidation were also common findings. Pulmonary nodules with the halo sign were found in only 13% of patients.

Do Not Play with Fire

We report a case of exogenous lipoid pneumonia caused by inhalation of liquid paraffin in a fire eater young man. The patient was admitted to the Emergency Department because of acute retrosternal pain, dry cough and dyspnea. Chest radiograph showed multiple bilateral basal alveolar opacities associated to left pleural effusion; CT chest scan showed multiple bilateral areas of consolidation with cavity areas. BAL cytologic examination revealed abundant lipid-laden macrophages. Clinical symptoms resolved after corticosteroid treatment. Lipoid pneumonia is a rare and often underdiagnosed entity. The presence of lipid-laden macrophages in sputum or BAL fluid helps to confirm the diagnosis.

Follow-up Aspects of Influenza A (H1N1) Virus-Associated Pneumonia: the Role of High-Resolution Computed Tomography in the Evaluation of the Recovery Phase

We read with great interest the manuscript written by Lee et al. (1), who described the imaging findings of pulmonary complications in two patients with influenza A (H1N1) infection. The first patient showed ill-defined ground-glass opacity nodules and patchy areas of groundglass attenuation. The second, with secondary bacterial pneumonia, showed bilateral areas of lobar consolidation and ground-glass opacities. In addition, some other reports describing the imaging features, especially on high-resolution computed tomography (HRCT), have been published in the last months (2). The predominant HRCT findings reported bilateral, peripheral, ground-glass opacities and/or bilateral areas of consolidation. The patients who presented with consolidations had a more severe clinical course (2). Limited data are available, however, on the tomographic or pathological aspects observed during the recovery phase after H1N1 infection. However, the information available on pneumonias caused by other strains of the Influenza A virus allow us to presume similarities with the behavior of H1N1. In the early stages, features of diffuse alveolar damage are predominant. Later stages may show typical changes of organization and fibrosis, including interstitial fibrosis, and bronchiolitis obliterans with or without evidence of organizing pneumonia (3). Recently, Gill et al. (4) described the pulmonary pathologic findings of 34 people who died following confirmed H1N1 infection. Twentyfive patients showed focal to extensive diffuse alveolar damage (DAD). Of these, 16 cases showed only acute DAD, seven showed acute and organizing DAD, and two had fibrosing and organizing DAD (average hospitalization time: 31.5 days). During the treatment and recovery phases, persistent opacities on radiographs may not be informative enough to distinguish disease progression from healing. HRCT may play a role in the detection and characterization of the disease, in monitoring the disease progress and response to treatment, as well as in the identification of complications. We have recently followed a patient treated for H1N1 virus-associated pneumonia, whose condition improved. The initial HRCT showed consolidations and ground-glass opacities. A follow-up examination conducted at one month, during convalescence, showed marked improvement in cough; however, dyspnea on exertion persisted. A follow-up scan performed in this phase revealed an almost complete remission of the lesions, as well as the development of linear opacities in the same location. These opacities probably represent the stage of organizing pneumonia. The patient was then treated with corticosteroids and became asymptomatic. An additional follow-up HRCT performed three months after the onset of the symptoms was normal. In conclusion, although pulmonary opacities secondary to H1N1 infection usually regress during convalescence, the consolidations may occasionally progress to linear opacities (parenchymal bands). These linear opacities probably represent organizing pneumonia.

High-resolution computed tomography findings from adult patients with Influenza A (H1N1) virus-associated pneumonia

Objective The aim of this study was to assess the high-resolution computed tomography (HRCT) findings at presentation in patients diagnosed with Influenza A (H1N1) virus-associated pneumonia. Materials and methods We reviewed the HRCT findings from 20 patients diagnosed with Influenza A (H1N1) and compared their HRCT scans with chest radiographs, obtained on the same day. The imaging studies were obtained 4–9 days after the onset of symptoms. The patients included 11 men and 9 women (ages 24–62 years; mean 42.7 years). All patients had a body temperature greater than 100.4 °F (>38 °C), tachypnea, and cough. Other common symptoms included diarrhea (60%) and sore throat (30%). The radiographs and HRCT scans were reviewed independently by two observers who reached a consensus decision. Results The predominant HRCT findings consisted of bilateral ground-glass opacities ( n = 12), bilateral areas of consolidation ( n = 2), or a mixed bilateral pattern of ground-glass opacities and areas of consolidation ( n = 6). The abnormalities were bilateral in all of the 20 patients, had a predominantly sub-pleural distribution in 13 patients, and had a random distribution in the remaining 7 patients. The predominant radiographic findings were consolidations. Normal radiographs were found in 4 out of the 20 patients. Conclusion HRCT may reveal parenchymal abnormalities in patients with Influenza A (H1N1) infection who have normal findings on radiographs. The predominant HRCT findings were bilateral, peripheral, ground-glass opacities and/or bilateral areas of consolidation. The patients who presented consolidations had more severe clinical course.