Date: 26 November 2013
Transverse sections through the thorax of a patient with AIDS, hepatitis C and a left tempero-parietal cerebral lymphoma. His CD4 cell count was 45 x 106 / l. The lymphoma was proven by biopsy after a poor response to anti-toxoplasma therapy. He was given dexamethasone to cover the surgery and then developed diabetes mellitus. He did not receive chemotherapy for his lymphoma but did have 2 cerebral radiotherapy treatments (1.8 Gy each). Three weeks after the biopsy he developed dyspnoea and fever. Shortly after this he developed a right-sided hemiparesis, became comatose and died 2 days later.Autopsy showed a cerebral lymphoma and pulmonary and renal aspergillosis. Aspergillus nidulans was recovered from cultures of lungs and kidney.
Copyright:
Images submitted by Dr. Cornelia Lass-Floerl, University of Innsbruck – Institute of Hygiene; the case team includes: Dr. Mario Sarcletti, Dr. Alfons Stöger and Prof. Hans Maier all at the University of Innsbruck.
Notes: n/a
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Yamik catheter for rinsing nasal and paranasal cavities. Image A
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Diagnosis: Aspergilloma with invasive aspergillosis evidence of invasion found in the lumbar spine and brain, in addition to heart.
Fungal endocarditis with NO evidence of bacterial endocarditismia.Additional image details:
A. Normal chest X ray:
This (normal) chest X-ray was taken about 6 weeks before endocarditis was diagnosed, and 3 months before death due to disseminated aspergillosis. No CT scan was done (a chest radiograph has a 10% false negative rate in leukaemic patients, compared with CT).B. Aspergillus niger Fungal ball:
Gross section of lung at autopsy showing a discrete, well-demarcated dark/black mass surrounded by a fibrotic capsule. There was no evidence of local invasion, or infarction. The patient had had acute myeloid leukaemia (M1) and responded poorly to chemotherapy. He developed A.niger endocarditis and disseminated disease to the kidneys, lumbar disc and heart, probably arisiong from this lesion. It is unclear whether this lung lesion was a partially cured ‘mycotic lung sequestrum’ following antifungal therapy, or originated as an aspergilloma. The confirmation of genus and species was obtained by PCR on blood and vegetations.C. Endocarditis:
Macroscopic view of the heart at autopsy, showing an infracted lesion on the papillary muscle of the mitral valve in the left ventricle. In addition the patient had large vegetations, which are not shown here. The confirmation of genus and species was obtained by PCR on blood and vegetations; the pericarditis was a manifestation of disseminated aspergillosis.D. Pericarditis due to Aspergillus niger:
Macroscopic view of the pericardium at autopsy, showing gross chronic haemorrhagic pericarditis. The confirmation of genus and species was obtained by PCR on blood and vegetations; the pericarditis was a manifestation of disseminated aspergillosis.E. Lumbar discitis:
Macroscopic lesion of a lumbar intervertebral vertebral at autopsy, showing haemorrhagic necrosis, caused by hyphal invasion and infarction. The confirmation of genus and species was obtained by PCR on blood and vegetations; the discitis was a manifestation of disseminated aspergillosis.
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