Multiple Cavitary Pulmonary Nodules Research Articles

Suspected nocardiosis in an immunosuppressed patient: a case report highlighting diagnostic challenges and management strategies

Nocardiosis is a rare but potentially fatal opportunistic infection caused by Nocardia species, predominantly affecting immunocompromised individuals. This case report details the clinical course, diagnostic workup, and management of a 63-year-old female with a history of renal transplantation. Initial investigations, including imaging studies, revealed multiple cavitary pulmonary nodules and a solitary brain lesion, raising concerns for disseminated infection. The diagnostic challenge was compounded by the broad differential diagnosis in this patient population, including fungal, mycobacterial, and other opportunistic infections. Empirical antimicrobial therapy was initiated, and subsequent microbiological confirmation of Nocardia asteroides from bronchoalveolar lavage specimens established the diagnosis. Despite initial therapeutic response, the patient developed worsening neurological symptoms indicative of CNS involvement, necessitating prolonged treatment with a combination of trimethoprim-sulfamethoxazole and imipenem. This report underscores the importance of early recognition, comprehensive diagnostic evaluation, and individualized therapeutic approaches in managing suspected nocardiosis in immunocompromised patients. Furthermore, it discusses the diagnostic pitfalls, highlights the need for a high index of suspicion, and reviews current therapeutic recommendations for both pulmonary and disseminated nocardiosis, providing a valuable reference for clinicians managing similar cases.

Cavitating pulmonary metastases from a renal cell carcinoma.

Cavitary lung lesions are quite common findings on chest imaging and often pose a diagnostic challenge to the clinicians. We describe a case of a 75-year-old male who presented to the emergency room with hemoptysis. Computed tomography of the chest demonstrated multiple cavitary pulmonary nodules with peripheral groundglass opacities. Bronchoscopy did not reveal any active bleeding source, and washings were negative for malignancy and infectious cause. Computed Tomography guided biopsy of the left lung nodule showed metastatic carcinoma consistent with papillary renal cell carcinoma. This case highlights the unusual presentation of metastatic renal cell carcinoma.

Pancreatic Head Mass: A Rare Manifestation of Granulomatosis With Polyangiitis

A solid pancreatic mass is found to be malignant 95% of the time, while inflammation accounts for the remaining cases. We report a case of granulomatosis with polyangiitis (GPA) presenting as an inflammatory mass initially suspected to be metastatic pancreatic cancer. This is a 73-year-old male who presented to the ED with weakness, fevers, night sweats, and weight loss. His medical history was significant for severe chronic sinusitis and nasal polyps. On physical examination, he was noted to have bilateral lower extremity nodular purple plaques with necrotic centers. Laboratory studies were significant for leukocytosis, mildly elevated alkaline phosphatase, normal kidney function, transaminases and bilirubin. CT imaging demonstrated a low-attenuation mass in the pancreatic head along with multiple cavitary pulmonary nodules without hepatic lesions. Our differential diagnoses included metastatic pancreatic cancer versus an autoimmune process. CA 19-9 and CEA were within normal limits. An autoimmune work-up showed negative ANA, positive RF, elevated WSR, elevated IgE, and an elevated C-ANCA. Skin biopsy yielded leukocytoclastic vasculitis with granular fluorescence of C3 and IgG. Biopsy of lung nodules revealed extensive necrosis with acute neutrophilic infiltrates, fibrin thrombi, multinucleated giant cells, consistent with GPA. He was started on high dose steroids. He was discharged with plans for repeat imaging and biopsy of the pancreatic mass. A pancreatic mass in an elderly patient is highly concerning for cancer, which was our primary differential diagnosis. The absence of hepatic involvement and normal tumor markers decreased the likelihood of a primary pancreatic cancer with lung metastases. Due to his history of recurrent sinusitis, nasal polyps, and skin lesions, an autoimmune etiology was explored. A positive C-ANCA coupled with the lung biopsy findings established the diagnosis of GPA, a very rare cause of pancreatic masses. Most cases detailing GI manifestations of GPA present with pancreatitis or painless jaundice, but few have reported pancreatic masses. Necrotizing vasculidities can mimic pancreatic carcinoma and should be considered in the differential diagnosis of atypical cases. It is important to distinguish a pancreatic mass caused by GPA from pancreatic cancer due to the significant differences in treatment and prognosis. More studies are needed to determine whether these pancreatic masses should be biopsied or followed with imaging.1406_A.tif Figure 1: ßLungßonstrating extensive necrosis with acute neutrophilic infiltrates, fibrin thrombi, and multinucleated giant cells.1406_B.tif Figure 2: Low attenuation mass anteriorly in the pancreatic head measuring approximately 2.0 cm. The margins of the mass are inseparable from posterior wall of the duodenal bulb.1406_C.tif Figure 3: Bilateral lower extremity lesions described as nodular purple plaques with necrotic centers.

Multiple Cavitary Pulmonary Nodules Caused by Mycobacterium intracellulare.

Nontuberculous mycobacteria (NTM) have been increasingly recognized as an important cause of chronic pulmonary infections. The Mycobacterium avium complex (MAC), which is composed of two species, Mycobacterium avium and Mycobacterium intracelluare, is the most commonly encountered pathogen associated with NTM lung disease. MAC pulmonary infection typically presents in a fibrocavitary form or a nodular bronchiectatic form. However, there have been atypical presentations of MAC pulmonary infections, including solitary pulmonary nodules (SPN). There have been several previous reports of SPN due to MAC infection in the United States, Japan, and Korea. In 2009, Sekine and colleagues reported a case of MAC pulmonary infection presenting with multiple nodules. To date, however, there have been no cases of NTM lung infection with multiple cavitary pulmonary nodules, and neither a fibrotic change nor nodular bronchiectasis. The present case showed a multiple cavitating nodular lung infection due to MAC, which is very rare and different from the typical presentation of MAC pulmonary infections. We also showed that percutaneous transthoracic needle aspiration can be a useful diagnostic tool to evaluate a case of multiple cavitary nodules.

Benign Metastasizing Leiomyoma: A Rare Type of Lung Metastases—Two Case Reports and Review of the Literature

Benign metastasizing leiomyoma (BML) is a rare disease that usually occurs in women of reproductive age. They typically have history of uterine leiomyoma treated with hysterectomy. BML can metastasize to distant organs, with the lung being the most common organ. We report two patients who presented with benign metastasizing leiomyoma to the lung. Our first case was a fifty-two-year-old female who presented with multiple lung masses, with a past medical history of uterine leiomyoma who underwent hysterectomy 17 years ago. A CT-guided biopsy showed benign appearing spindle cells and pathology confirmed her diagnosis with additional positive estrogen/progesterone receptor stains. Our second case was a fifty-six-year-old female who presented with multiple cavitary pulmonary nodules. She subsequently underwent a video-assisted thoracoscopic surgery (VATS) with wedge resection of one of the nodules. Pathology confirmed the diagnosis based on morphology and immunohistochemical staining strongly positive for estrogen/progesterone receptors. Benign metastasizing leiomyoma is a rare condition which may affect women of reproductive age. This should be considered in the differential in patients who present with multiple pulmonary nodules, especially with a history of uterine leiomyoma. Additional stains, such as estrogen/progesterone receptors, may need to be done to confirm the diagnosis.

Heterogeneous 18F-FDG Uptake in Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) describes an infection of the upper aerodigestive tract by the human papilloma virus most commonly affecting the larynx with rare lung involvement in 1%-2% of affected patients. We describe an unusual case of a 28-year-old male patient with a longstanding history of RRP where a whole-body PET/CT obtained for disease staging revealed multiple cavitary pulmonary nodules in addition to the more typical tracheobronchial papillomas. In the case described herein, we report heterogeneous uptake of 18F-FDG among these RRP lesions, suggesting significant unexpected variability in the underlying metabolic behavior of these lesions.

Multiple cavitary pulmonary nodules in association with pyoderma gangrenosum: case report

Pyoderma gangrenosum is a rare neutrophilic disease of unknown origin that is associated with systemic diseases in 50% of cases. It is characterized by erythematous-violaceous nodular lesions that quickly progress to painful ulcers, with undermined edges, necrotic-hemorrhagic, varying in size and depth, located mainly in the lower limbs. Extracutaneous locations of pyoderma gangrenosum are rare, usually involving the lungs; the main differential diagnosis in these cases is Wegener granulomatosis. We report a case of pyoderma gangrenosum, which showed multiple cavitary lung nodules, with good response to high doses of steroids. Once excluded the possibility of Wegener granulomatosis, the authors concluded that it was the manifestation of systemic pyoderma gangrenosum with pulmonary involvement.

Hodgkin Lymphoma Presenting as Multiple Cavitary Pulmonary Nodules With Associated Mediastinal Adenopathy and Neck Mass

Hodgkin lymphoma involving the lung may present in a variety of radiographic and clinical patterns including solid or necrotizing lesions, with or without associated mediastinal adenopathy. Cavitary pulmonary lesions are exceedingly rare, occurring in less than 1% of cases, and are typically solitary. We report a case of an 18-year-old male presenting with multiple cavitating pulmonary nodules and a palpable mass in the neck. Imaging revealed associated mediastinal and cervical adenopathy. Biopsy of the neck mass and lung nodule initially revealed necrosis and granulomata, suggesting infection. Treatment for a presumed infectious etiology was without resolution. Subsequent open lung biopsy revealed marked granulomatous inflammation with diagnostic Reed-Sternberg cells. Hodgkin lymphoma should always be considered in the differential diagnosis of cavitary pulmonary lesions, especially those refractory to treatment.

Accelerated Pulmonary Nodulosis and Sterile Pleural Effusion in a Patient With Psoriatic Arthropathy During Methotrexate Therapy

Pulmonary nodulosis and sterile pleural exudates are well-known extra-articular manifestations in rheumatoid arthritis patients with a positive rheumatoid factor. In some patients, treatment with methotrexate has been postulated as the trigger of these complications. We report a patient with psoriatic arthropathy, negative RF, negative anticyclic citrulinated peptide antibodies but positive antibodies to cardiolipin who developed massive sterile pleural empyema and multiple cavitary pulmonary nodules during methotrexate treatment. We suggest that awareness of methotrexate-induced lung and pleural complications should be extended to other than rheumatoid arthritis diseases, not necessarily accompanied by rheumatoid factor or anticyclic citrulinated peptide antibodies.

Lemierre Syndrome: An All-But-Forgotten Disease

DOI:10.2214/AJR.06.0096 WEB—This is a Web exclusive article. Lemierre Syndrome: An All-But-Forgotten Disease An otherwise healthy 21-year-old man presented to the emergency department with a 1week history of progressively worsening fever, chills, sore throat, nausea, vomiting, and cough. He was toxic-appearing, tachycardic, tachypneic, and hypotensive on arrival. Physical examination findings were significant for erythematous, swollen tonsils without exudate and diffuse bilateral crackles on lung auscultation. Laboratory values revealed an elevated WBC with a left shift and findings compatible with acute kidney failure. A portable chest radiograph showed diffuse parenchymal opacities and bilateral pleural effusions. The patient was admitted to the ICU with the diagnosis of sepsis and was given broad-spectrum antibiotics pending culture results. Despite intensive monitoring and broadspectrum antibiotic therapy, the patient continued to decompensate, requiring endotracheal intubation. Contrast-enhanced CT of the neck and chest was performed, revealing right internal jugular vein thrombosis (Fig. 3A), multiple cavitary pulmonary nodules, and bilateral pleural effusions (Fig. 3B). Thoracentesis confirmed the suspicion of bilateral exudative effusions. On the basis of the clinical history of a recent oropharyngeal infection and the presence of internal jugular vein thrombosis with multiple pulmonary septic emboli, the diagnosis of Lemierre syndrome was suspected and later confirmed with blood cultures positive for Fusobacterium necrophorum. After prolonged treatment with tailored antibiotic therapy and percutaneous drainage of the bilateral exudative effusions, the patient achieved a remarkably full recovery with restoration of baseline renal and pulmonary functions. Lemierre syndrome is a rare clinical entity, with fewer than 160 cases reported since it was first described in the early 1900s [1]. This syndrome consists of internal jugular vein thrombosis after a primary oropharyngeal infection with the development of distant septic emboli [2]. The lungs are most often affected; however, almost any organ may be involved. Classically, Lemierre syndrome occurs in otherwise healthy adolescents and young adults. Appropriate diagnosis is often delayed because of the initial indolent course of the infection and the relative obscurity of the disease. The diagnosis is made with positive blood cultures, usually F. necrophorum, and appropriate imaging findings. Often, imaging findings precede blood culture results; therefore, radiologists play a crucial role in the early recognition of this syndrome [3]. Prompt diagnosis and treatment are necessary to prevent sepsis and subsequent death. O’Brien WT Sr, Kattin GE Jr, Thompson AK William T. O’Brien, Sr. Grant E. Lattin, Jr. Adrianne K. Thompson David Grant U.S. Air Force Medical Center Travis AFB, CA 94535 Note—The views expressed in this material are those of the authors and do not reflect the official policy or position of the U.S. government, the Department of Defense, or the Department of the Air Force.