This 54 year old man developed right upper lobe shadowing after development of cough, chest pain and shortness of breath. He suffered from emphysema. Investigations, including a PET scan suggested carcinoma of the lung. He underwent an apical resection and histology showed bullae in the lung with one containing necrotic material and conidial heads consistent with Aspergillus.
Two wedges of lung tissue were examined. The larger 90 x 35 x 35mm with adherent parietal pleura 100 x 45mm. Sectioning reveals irregular scarring and bullae in the lung tissue. No definite tumour is identified. A focus of possible necrosis up to 10mm in diameter is present, 10mm from the pleura and 20mm from the nearest staple line. Lung and adherent parietal pleura show dense fibrosis around a cavity (see fig A) arrow, lined by granulation tissue and fibrin. This is filled with necrotic material (Fig B) and branching septate fungal hyphae with conidial heads, consistent with Aspergillus and a fungal ball.(Fig C at higher power). A few scattered granulomata are seen away from the cavity. No invasion of lung parenchyma was seen. There is congestion of the lung parenchyma and collections of pigmented macrophages are seen within air spaces.
A- Section of lung showing a fungal ball within a cavity (x25). B- Showing branching septate hyphae with conidial heads (x250) C- Higher power magnification (x 500) showing the conidial heads more clearly. D - Edge of cavity showing from left to right - necrosis, granulaomatous reaction, fibrosis, chronic inflammation (x100). E- CT scan (July 08) showing a speculated nodular lesion in the right apex. F - Chest X-ray (May 08) - showing right upper lobe shadowing. G.PET scan (July 08)