Multiple Cavitary Lung Lesions Research Articles

Pulmonary and Liver Toxocariasis Mimicking Metastatic Tumors in a Patient with Colon Cancer.

Toxocariasis is an uncommon cause of multiple cavitary lung lesions and an ill-defined liver lesion. We herein report a patient with lung and liver toxocariasis, which mimicked metastatic lesions of colon cancer on 18F-FDG PET-CT and chest and abdominal CT performed for cancer staging after diagnosis of colon cancer. The patient was diagnosed with lung and liver toxocariasis by a positive enzyme-linked immunosorbent assay. Lung toxocariasis may occur as multiple cavitary lung lesions, and liver toxocariasis may appear as a solitary ill-defined nodule, which may be misdiagnosed as metastatic tumors. Clinicians should consider toxocariasis when multiple cavitary lung lesions and a solitary ill-defined focal liver lesion are detected, especially in a patient with cancer.

Pulmonary Actinomycosis and Multiple Cavitary Lung Lesions in a Patient Previously Reported with Pulmonary Candidiasis: A Case Report

This paper presents the case of a 43 years old patient admitted three times to the Pneumology Department with productive cough, asthenia,
 important weight loss, and fever. His chest CT showed multiple pulmonary cavities growing over time, ground-glass opacities, and pleural effusion. Clinical symptoms and radiological signs were highly suggestive of tuberculosis, but he tested negative multiple times. Candida spp. was diagnosed through bronchial washing and treated. After a few months, the patient comes back with worsened symptoms and is diagnosed with pulmonary actinomycosis.

Hodgkin’s Lymphoma Presenting as Multiple Cavitary Lung Lesions

Hodgkin Lymphoma (HL) typically presents similarly to an infectious etiology, thus awareness of its atypical presentations is essential. We present a case of an adult woman who was found to have HL after presenting with a dry, non-productive cough and showing cavitary lesions on chest computed tomography (CT). We also describe the clinical, laboratory, and radiological workup done leading to the diagnosis and management of HL in a critical care setting.

Hodgkin's Lymphoma Presenting as Multiple Cavitary Lung Lesions.

Hodgkin Lymphoma (HL) typically presents similarly to an infectious etiology, thus awareness of its atypical presentations is essential. We present a case of an adult woman who was found to have HL after presenting with a dry, non-productive cough and showing cavitary lesions on chest computed tomography (CT). We also describe the clinical, laboratory, and radiological workup done leading to the diagnosis and management of HL in a critical care setting.LEARNING POINTSCavitary lung lesions, particularly multiloculated, are often caused by mycobacterium tuberculosis (TB), aspergillosis, granulomatosis with polyangiitis, sarcoidosis, and rheumatic nodules.Pulmonary infiltration is a rare disorder of an extra-nodal site in Hodgkin’s Lymphoma. The mediastinum and head and neck regions remain the most common sites affected by HL.Radiologically, primary pulmonary HL may mimic pneumonia, carcinoma making the diagnosis unclear.

Multiple cavitary lung lesions on CT: imaging findings to differentiate between malignant and benign etiologies.

ABSTRACTObjective:To determine the CT findings of multiple cavitary lung lesions that allow the differentiation between benign and malignant etiologies. Methods:We reviewed CT scans, including patients with two or more cavitary lung lesions. We evaluated the number of cavitary lesions, their location, cavity wall thickness, and additional findings, correlating the variables with the diagnosis of a benign or malignant lesion. Results:We reviewed the chest CT scans of 102 patients, 58 (56.9%) of whom were male. The average age was 50.5 ± 18.0 years. Benign and malignant lesions were diagnosed in 74 (72.6%) and 28 (27.4%) of the patients, respectively. On the CT scans, the mean number of cavities was 3, the mean wall thickness of the largest lesions was 6.0 mm, and the mean diameter of the largest lesions was 27.0 mm. The lesions were predominantly in the upper lobes, especially on the right (in 43.1%). In our comparison of the variables studied, a diagnosis of malignancy was not found to correlate significantly with the wall thickness of the largest cavity, lymph node enlargement, emphysema, consolidation, bronchiectasis, or bronchial obstruction. The presence of centrilobular nodules correlated significantly with the absence of malignant disease (p < 0.05). In contrast, a greater number of cavities correlated significantly with malignancy (p < 0.026). Conclusions:A larger number of cavitary lung lesions and the absence of centrilobular nodules may be characteristic of a malignant etiology. However, on the basis of our evaluation of the lesions in our sample, we cannot state that wall thickness is a good indicator of a benign or malignant etiology.

METASTATIC CAVITARY ADENOCARCINOMA OF THE LUNG IN A PATIENT WITH RECENT AGGRESSIVE SQUAMOUS CELL CARCINOMA OF THE CHEST WALL

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Simultaneous existence of two histologically different primary malignancies, although rare, has been reported in literature1. This represents a diagnostic dilemma especially when the first detected primary malignancy is aggressive, therefore, the second primary is often deemed to be a metastatic lesion, until proven otherwise on biopsy. We present a case of a 62 year old male, with a recent aggressive squamous cell carcinoma (SCC) of the chest wall, who developed metastatic cavitary adenocarcinoma of the lungs. CASE PRESENTATION: A 62-year old gentleman, with past medical history significant for basal cell carcinoma of the nose and a recent aggressive SCC of the chest wall, status post Mohs surgery, was referred to the outpatient pulmonology clinic after a CT scan of the chest showed persistent dense consolidation of the left upper lobe, multiple bilateral lung nodules with central necrosis and cavitation, and left sided hilar and mediastinal lymphadenopathy. He presented with low-grade fever and a productive cough, unresponsive to antibiotics, for the past three weeks prompting the CT scan of the chest. Diagnostic work-up, for infection (including fungal studies), vasculitis or any other autoimmune disorder, was started and urgent bronchoscopy was arranged. PET/CT scan showed a hyper-metabolic left upper lung mass, multiple hypermetabolic cavitary lung lesions. Bronchoscopy with endobronchial ultrasound revealed a reversible external compression of the right middle lobe bronchus with mediastinal lymphadenopathy. Bronchoalveolar lavage from the left upper lobe showed atypical cells, suspicious for malignancy while negative for fungal organisms. Fine needle aspiration of lymph nodes, station 7 and 4L, revealed non-small cell carcinoma with tumor cells being positive for CK-7 and TTF-1 and negative for CK20, CDX-2 and NKX3.1. With the recent aggressive SCC history and multiple cavitary lung lesions, biopsy of one of the cavitary lesions was recommended by the tumor board, to determine if they were SCC vs adenocarcinoma. Results of the biopsy were consistent with an invasive lung adenocarcinoma. DISCUSSION: Cavitary lesions shown on chest imaging can have several etiologies. Although various radiological features of these cavitations, including wall thickness, have been studied to differentiate benign from non-benign etiologies2, the final diagnosis in many instances is made on serological investigations or biopsy. 22% of primary lung cancers can cause cavitation with squamous cell carcinoma being the most common type of lung cancer associated with cavitary lesions followed by adenocarcinoma and large cell carcinoma3. CONCLUSIONS: Our case emphasizes that cavitary lesions on imaging, in patients with a prior history of malignancy, should prompt investigation for possible malignancy. Early biopsy, in such cases, becomes crucial for a timely and accurate diagnosis, and appropriate management. Reference #1: Jena A, Patnayak R, Lakshmi AY, Manilal B, Reddy MK. Multiple primary cancers: An enigma. South Asian J Cancer. 2016;5(1):29-32. Reference #2: Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions. Journal of the Belgian Society of Radiology. 2016;100(1):100. DOI: http://doi.org/10.5334/jbr-btr.1202. Reference #3: Gill, R. R., Matsusoka, S. & Hatabu, H. Cavities in the lung in oncology patients: imaging overview and differential diagnoses. Applied Radiology 39, 10 (2010). DISCLOSURES: No relevant relationships by Huthayfa Ateeli, source=Web Response No relevant relationships by Mahum Shahid, source=Web Response

SUN-606 Thyroid Cancer Presenting As Acute Limb Ischemia

INTRODUCTION: Cardiac metastases are present in up to 20% of patients with extra-cardiac malignancies and are 40 times more common than primary cardiac tumors. However, thyroid cancer metastatic to the heart is rare. We report a case of mixed follicular and papillary thyroid carcinoma with the presence of anaplastic features presenting with cardiac metastasis. CASE: A 52-year old female non-smoker was admitted with right arm ischemia. Two years earlier, she had been diagnosed with thyroid cancer and underwent total thyroidectomy. Surgical pathology at the time revealed multifocal follicular and papillary thyroid cancer with focal anaplastic changes and positive central lymph nodes. She was treated with 150mCi RAI for remnant ablation, with the post treatment whole-body scan revealing radiotracer activity in the neck but no scintigraphic evidence of distant metastases. She was subsequently lost to follow-up. At the time of admission, she was found to have acute limb ischemia due to axillary artery thrombosis and underwent fasciotomy and embolectomy. Chest CT revealed multiple cavitary lung lesions and a left ventricular mass with adherent thrombus. Biopsy of the lung lesions confirmed metastatic poorly differentiated thyroid cancer (immunohistochemical staining positive for Pax8, TTF-1 and P40, but negative for thyroglobulin). PET scan showed multiple hypermetabolic lesions, including bilateral pulmonary nodules, right hilar adenopathy, a left ventricular mass, and right hepatic lobe lesion. Mutational analysis showed BRAF V600E mutation. The patient is receiving salvage chemotherapy with dabrafenib/ trametinib. DISCUSSION: While rare, follicular carcinoma is the most common thyroid cancer with cardiac metastasis, mostly involving the central veins and right atrium. Papillary thyroid cancer tends to metastasize through the lymphatic system and involve the right side of the heart. The aggressive behavior of our patient’s tumor, with involvement of the left heart suggestive of vascular metastasis, is likely due to the concurrent presence of anaplastic de-differentiation. Anaplastic carcinomas are highly aggressive neoplasms and 71% are said to occur simultaneously with a well-differentiated thyroid cancer. About 50% of patients diagnosed with anaplastic thyroid cancer have metastatic disease at the time of diagnosis and another 25% develop metastasis during the course of disease. The prognosis is very poor with median survival ranging from 4-12 months.

DIAMETER, THICKNESS AND DISCORDANCE DEGREE OF SOLITARY PULMONARY CAVITARY LESION TO DIFFERENTIATE BENIGN FROM MALIGNANT LESIONS, A MUTLISLICE CT STUDY.

DIAMETER, THICKNESS AND DISCORDANCE DEGREE OF SOLITARY PULMONARY CAVITARY LESION TO DIFFERENTIATE BENIGN FROM MALIGNANT LESIONS, A MUTLISLICE CT STUDY. Ammar Mosa Jawad *, Mohammed Abd kadhim# & Husham Jubran Mousa@ *MB,ChB, Radiologist in The Medical Collage, Al-Nahrain University. #MB,ChB, FIBMS, Radiologist, Professor in The Medical Collage, Al-Nahrain University, Consultant Radiologist in Al-Imamain AlKadhimain Medical City, Baghdad Iraq. @MB,ChB, FIBMS, Specialist Radiologist in Al-Sader Teaching hospital, Basrah, IRAQ. Absctract Cavities are frequent image findings in a variety of pulmonary diseases including both lung cancer and pulmonary tuberculosis, Computed Tomography (CT) is accepted as the modality of choice for detection of possible cavitating pulmonary nodules. The aim of this study is to assess the role of diameter, thickness and discordance degree of solitary pulmonary cavitary lesion to differentiate benign from malignant lesions in multislice CT. This cross sectional study was done in the Computed Tomography Unit of Al-Imamain Al Kadhimain Medical City, Baghdad, Iraq and Al-Sader Teaching Hospital, Basrah, Iraq between October 2016 and June 2017. All patients are with solitary pulmonary cavitary lesions detected by chest x-ray referred for different reasons. Exclusion criteria included: multiple cavitary lung lesions, patients with known lung carcinoma or pulmonary tuberculosis on treatment, and patients receiving chest radiotherapy for different reasons. CT examination of the chest was performed by multi-detector CT (Somatom definition edge, SIEMENS (256 slices)) with 2 sets of CT examination one before and another after giving IV nonionic iodinated contrast medium (Ultravist 370 mg /ml), 1.5 ml/kg Body weight. The final diagnosis was obtained depending on the sputum culture for AFB, bronchoscopy and biopsy, bronchoscopy and brush cytology and true cut biopsy. Eighty percent of the patients were diagnosed as having benign lesions and 20% were diagnosed as having malignant lesions, the most frequent diagnosis was TB (60%), followed by squamous cell carcinoma (14%), lung abscess (10%), hydatid cyst (10%), adenocarcinoma (4%), and metastasis (2%). The discordance of CT scan (FDCW3) show highly significant association with malignant solitary cavitary lesions, while CT concordance (FCCW1 and FCCW2) were significantly associated with benign solitary cavitary lesions (p

Non Infectious Cavitary Lung Lesions in a Patient with Adult Onset Still’s Disease: A Case Report

Acute Onset Still’s Disease (AOSD) is a disease of immunologic and hematologic dysfunction, whereby a percentage of cases develop further into Macrophage Activating Syndrome (MAS). This patient is a 35 year old Caucasian male with Acute Onset Still’s Disease without MAS was hospitalized for multiple cavitary lung lesions. Lesions included a larger estimated 2.5 cm x 2.5 cm cavitary lesion in the Right Middle Lobe and smaller estimated 1.3 x 1.4 cm and 1.8 x 1.2 cm lesions in the Left Lower Lobe of the lungs. The larger lesion was seen on chest X-ray a further detailed on a chest CT scan, which revealed the remaining two smaller pulmonary lesions. The patient experienced undulating fevers as high as 101°F. The patient was put on isolation and received serial blood cultures, sputum cultures, acid fast stains of sputum, urine cultures, viral film array serology all resulting in negative results. Over seven acid fast bacilli stains of sputum were negative in the setting of multiple cavitary lung lesions with high suspicion of active Tuberculosis. The patient received immediate broad spectrum antibiotic and antifungal intravenous antibiotics without relief in fever or symptoms. The patient received a full body Indium scan and MRI of the brain looking for a source of possible infection and further classification of his disease; both of which were negative. The blood and sputum fungal and bacterial cultures were negative. Serial chest CT and chest X-ray demonstrated slightly smaller cavitary lung lesions with thinner walls. The suspicion of Tuberculosis remained high and a lung biopsy was obtained of the large cavitary lesion in the Left Middle Lobe, which did not demonstrate acid fast staining on three separate samples. This patient was concluded to have noninfectious cavitary lung lesions and discharged home with close follow up. He is the first patient reported with AOSD Disease without MAS hospitalized for undulating fevers and multiple cavitary lung lesions without evidence of Tuberculosis of active infection.

Postpartum Tuberculosis: A Diagnostic and Therapeutic Challenge.

Tuberculosis (TB) infection in pregnant women and newborn babies is always challenging. Appropriate treatment is pivotal to curtail morbidity and mortality. TB diagnosis or exposure to active TB can be emotionally distressing to the mother. Circumstances can become more challenging for the physician if the mother's TB status is unclear. Effective management of TB during pregnancy and the postpartum period requires a multidisciplinary approach including pulmonologist, obstetrician, neonatologist, infectious disease specialist, and TB public health department. Current guidelines recommend primary Isoniazid prophylaxis in TB exposed pregnant women who are immune-suppressed and have chronic medical conditions or obstetric risk factors and close and sustained contact with a patient with infectious TB. Treatment during pregnancy is the same as for the general adult population. Infants born to mothers with active TB at delivery should undergo a complete diagnostic evaluation. Primary Isoniazid prophylaxis for at least twelve weeks is recommended for those with negative diagnostic tests and no evidence of disease. Repeated negative diagnostic tests are mandatory before interrupting prophylaxis. Separation of mother and infant is only necessary when the mother has received treatment for less than 2 weeks, is sputum smear-positive, or has drug-resistant TB. This case highlights important aspects for management of TB during the postpartum period which has a higher morbidity. We present a case of a young mother migrating from a developing nation to the USA, who was found to have a positive quantiFERON test associated with multiple cavitary lung lesions and gave birth to a healthy baby.

Diffuse interstitial and multiple cavitary lung lesions due to Talaromyces marneffei infection in a non-HIV patient.

A 57-year-old man presented with unproductive cough and dyspnea for 6 months in Fujian Province, China. His misuse of a large amount of steroids (accumulated dose equivalent to 3530 mg prednisolone) resulted in Talaromyces marneffei infection. Chest computed tomographic scan revealed diffuse interstitial and multiple cavitary lung lesions. Treatment with amphotericin B combined with itraconazole resulted in total recovery, with marked regression of lung lesions.

Reversed halo sign caused by huge tricuspid native valve infective endocarditis associated with community-acquired methicillin-resistant Staphylococcus aureus

Introduction: A reversed halo sign (RHS) has diverse differential diagnoses such as cryptogenic organizing pneumonia, fungal, bacterial and mycobacterial infections, and systemic and neoplastic diseases. However, no report has been described regarding an RHS associated with infective endocarditis (IE). Case presentation: A 43‐year‐old man was transferred to our hospital because of persistent pyrexia, chest pain with multiple cavitary lung lesions for a month. He was diagnosed with tricuspid native valve IE caused by massive vegetations in the context of CA‐MRSA (staphylococcal cassette chromosome mec type II, sequence type 91, clonal complex 509) infection with multiple pulmonary septic emboli, manifesting as an atypical RHS. Conclusion: The present case showed huge tricuspid native valve IE associated with community‐acquired meticillin‐resistant Staphylococcus aureus (CA‐MRSA), which was analysed successfully by multilocus sequence typing.

Diffuse cavitary lung lesions: reply to Marchiori et al.

Sir, We appreciate the comments of Marchiori et al. [1] and their recommendation for inclusion of benign neoplasm in the differential diagnosis of multiple cavitary lung lesions. Our case illustrates that coming to a correct diagnosis in this situation can be difficult [2]. Considering all diagnostic possibilities, including malignancy, early in the process it is important to allow steps to be taken to make a specific diagnosis and avoid delays in the initiation of the appropriate therapy. In the case we presented, PET/CT played an important role in guiding our choice of location to biopsy to obtain a definitive diagnosis. Earlier use of PET/CT may have led to a more rapid diagnosis. We agree that PET/CT, while it may provide clues, is not a specific diagnostic test and does not distinguish malignancy from alternative benign conditions.

Diffuse cavitary lung lesions

An 11-year-old girl presented with a 2-month history of progressively worsening cough, daily fevers, and weight loss. A chest radiograph revealed multiple cystic cavitary lung lesions. An extensive infectious work-up was negative. Chest CT verified multiple cavitary lung lesions bilaterally, and [F-18]2-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography with CT (PET/CT) showed increased uptake in the lung lesions as well as regional lymph nodes. Subsequent biopsy of an involved lymph node confirmed classical Hodgkin lymphoma, nodular sclerosis type. This case represents an unusual presentation for a child with Hodgkin lymphoma and demonstrates a role for (18)F-FDG PET/CT in evaluating a child with cavitary lung lesions.

Candida albicans lung abscess sensitive to fluconazole and responding only to amphotericin B in a non-immunocompromised critically ill patient

To the Editor: We would like to present an uncommon case of candida lung abscess in a non-immunocompromised patient who developed disseminated candidiasis and candida albicans lung abscess responding only to amphotericin B despite sensitivity to fluconazole. A 53-yr-old male was transferred to our intensive care unit (ICU) from the floor after developing high fever, respiratory failure requiring mechanical ventilation, bilateral basal infiltrates on his chest x-ray and blood cultures growing Candida Albicans sensitive to fluconazole. The patient had undergone a meningioma excision 53 days previously. Postoperative course was complicated by ventilator-associated pneumonia and herpetic meningoencephalitis which were treated with cefuroxime, ceftazidime, vancomycin and acyclovir. No steroids were administered and the patient received total parenteral nutrition for 11 days. On the floor and subsequently in the ICU the patient was placed on iv high-dose fluconazole (800 mg daily) and on empiric broad spectrum antibiotic coverage due to known colonization with methicillin-resistant staphylococcus aureus and acinetobacter baumanii. In the following nine days the blood cultures continued growing C. albicans and the patient remained febrile despite therapy with fluconazole. No candida was grown from intravascular catheters. A thoraco-abdominal computerized tomography revealed multiple cavitary lung lesions consistent with lung abscesses (Figure). Fundoscopy revealed findings consistent with C. albicans endophthalmitis and C. albicans was isolated from the bronchoalveolar lavage fluid. Both staining for acid-fast bacteria and cultures were negative for M. tuberculosis. The patient was switched to amphotericin B on the ninth day of his ICU stay (60 mg daily) and became afebrile two days later. Blood cultures became negative the next day after amphotericin B was administered and remained negative until the patient was discharged in good condition with significant improvement of the lung legions. This course contrasts recent studies in which high-dose fluconazole appeared equivalent to standard dose amphotericin B.1 The persistence of our patient's lesions during therapy with broad-spectrum antibiotic therapy and their resolution after appropriate antifungal therapy points towards the diagnosis of candida lung abscess, a very rare clinical entity.2,3 The negative cultures of the intravascular catheters argue against septic candida lung emboli. Additionally, poor tissue penetration of a candida lung abscess and the predominantly fungistatic activity of fluconazole against C. albicans in vitro may explain the poor response to fluconazole.4 Clinicians taking care of critically ill patients with documented C. albicans infection sensitive to fluconazole should consider switching to amphotericin B if high-dose fluconazole therapy is not effective and especially if there is a suspicion of a developing lung abscess.