A case of intermittent hemoptysis and cavitary lung masses in a 62 year old Iranian woman.

A. Grigoriyan, MD MRCP, A. Vaid, MD

Author address: 

Houston, TX/US

Abstract: 

Introduction. A lung mass is always a concerning radiological finding. The diagnostic work-up should be based on a thorough history and take into account the epidemiology of pulmonary diseases in various geographical regions. We present a case of intermittent hemoptysis in a 62 year old Iraninan non-smoker with cavitary lung lesions. Description. A 62 year old Iranian woman was referred to our clinic with recurrent hemoptysis and fever. She had traveled to the US three months prior and was in good health until six months prior to her visit when she presented with fever and hemoptysis. Medical records from her hospitalization overseas were not available. According to the patient her radiograph at that time showed "œtwo shadows on the lungs". She underwent a bronchoscopy with biopsy and was diagnosed with Wegener's granulomatosis. She was started on cyclophosphamide and prednisone with relief of symptoms. Cyclophosphamide was later changed to azathioprine as the patient developed microscopic hematuria suggestive of hemorrhagic cystitis. Prednisone was tapered off. However, three months later she developed a recurrence of hemoptysis and CT of the chest showed increasing size of the lung lesions. The patient initially refused a surgical biopsy and instead underwent a bronchoscopy with endobronchial biopsies which showed lymphocytic infiltration but no evidence of vasculitis. A CT-guided biopsy was non-diagnostic. The diagnosis of Wegener’s disease was questioned. She continued to cough and repeat imaging demonstrated lung masses with features of cavitation suspicious for a neoplasm. An open-lung biopsy was eventually performed. Histology revealed a thin-walled cyst with a lamellated membrane infiltrated by fungal hyphae. There were chronic inflammatory changes in the surrounding lung parenchyma with numerous Charcot-Leyden crystals and eosinophils. No evidence of vascular invasion or vasculitis was seen. Final diagnosis: aspergilloma in an echinococcal cyst. Discussion and conclusion. Aspergilloma represents saprophytic colonization of a pre-existing lung cavity. It is seen worldwide and most often in patients with healed tuberculosis. Rarely, aspergillus spp. may grow in hydatid cysts, mainly in the immunocompromized host. Echinococcal cysts in the lungs are usually asymptomatic. Blood eosinophilia may not be present. The diagnosis is histological and tissue is best obtained by surgical excision. Biopsy of these lesions is notoriously dangerous and may result in anaphylaxis. A high index of suspicion is therefore needed, especially in endemic areas, before making this decision. A lack of prior imaging studies and relevant clinical data may present significant challenges as illustrated in our case. Am J Respir Crit Care Med 181;2010:A4731
2010

abstract No: 

Poster Board # C21

Full conference title: 

American Thoracic Society International Conference
    • ATS 2010