Fernando Gazzoni

Fungal diseases mimicking primary lung cancer: radiologic-pathologic correlation.

A variety of fungal pulmonary infections can produce radiologic findings that mimic lung cancers. Distinguishing these infectious lesions from lung cancer remains challenging for radiologists and clinicians. In such cases, radiographic findings and clinical manifestations can be highly suggestive of lung cancer, and misdiagnosis can significantly delay the initiation of appropriate treatment. Likewise, the findings of imaging studies cannot replace the detection of a species as the aetiological agent. A biopsy is usually required to diagnose the infectious nature of the lesions. In this article, we review the clinical, histologic and radiologic features of the most common fungal infections that can mimic primary lung cancers, including paracoccidioidomycosis, histoplasmosis, cryptococcosis, coccidioidomycosis, aspergillosis, mucormycosis and blastomycosis.

High-resolution computed tomographic findings of Aspergillus infection in lung transplant patients

OBJECTIVE The aim of this study was to assess high-resolution computed tomographic (HRCT) findings at presentation in lung transplant patients diagnosed with pulmonary Aspergillus infection. MATERIALS AND METHODS We retrospectively reviewed HRCT findings from 23 patients diagnosed with pulmonary aspergillosis. Imaging studies were performed 2-5 days after the onset of symptoms. The patient sample comprised 12 men and 11 women aged 22-59 years (mean age, 43.6 years). All patients had dyspnea, tachypnea, and cough. Diagnoses were established with Platelia Aspergillus enzyme immunoassays for galactomannan antigen detection in bronchoalveolar lavage and recovery of symptoms, and HRCT findings after voriconazole treatment. The HRCT scans were reviewed independently by two observers who reached a consensus decision. RESULTS The main HRCT pattern, found in 65% (n=15) of patients, was centrilobular tree-in-bud nodules associated with bronchial thickening. This pattern was described in association with areas of consolidation and ground-glass opacities in 13% (n=3) of patients. Consolidation and ground-glass opacities were the main pattern in 22% (n=5) of patients. The pattern of large nodules with and without the halo sign was observed in 13% (n=3) of patients, and were associated with consolidation and ground-glass opacities in one case. CONCLUSION The predominant HRCT findings in lung transplant patients with pulmonary aspergillosis were bilateral bronchial wall thickening and centrilobular opacities with the tree-in-bud pattern. Ground-glass opacities and/or bilateral areas of consolidation were also common findings. Pulmonary nodules with the halo sign were found in only 13% of patients.

Pulmonary diseases with imaging findings mimicking aspergilloma.

Abstract Patients with preexisting lung cavities are at risk of developing intracavitary fungal colonization. Because Aspergillus spp. are the most commonly implicated fungi, these fungal masses are called aspergillomas. Their characteristic “ball-in-hole” appearance, however, may be found in a variety of other conditions that can produce radiologic findings mimicking aspergilloma. In this paper, we review the main diseases that may mimic the radiographic findings of aspergilloma, with brief descriptions of clinical, radiologic, and histopathologic findings.

Aspergillus fumigatus fungus ball in the native lung after single lung transplantation

A 49-year-old woman underwent right lung transplantation due to pulmonary emphysema, with favorable evolution in the early postoperative period. A year later she was readmitted to our department with productive cough. During that admission, the patient was treated for cytomegalovirus pneumonia and received broad-spectrum antibacterial therapy.At outpatient follow-up, cavities appeared in the native lung, which gradually increased in size. Ten months later, she was admitted for the resection of a hyperinflated cavity. Chest X-rays showed an increase in the cavity in the left upper lobe with herniation of the lung and compression of the transplanted lung. Chest HRCT at various positions showed a round mass with soft tissue density within a lung cavity that moved when the patient changed position, thus strengthening the hypothesis of a fungus ball (Figure 1). Bullectomy was performed, and the histopathologic examination showed fungal colonization by Aspergillus fumigatus in emphysematous bullae and bronchiectasis. She was treated with itraconazole and had a satisfactory response.Lung transplantation has become an acceptable treatment option for many end-stage lung diseases and could be single or double.

Intrapulmonary lymph node: a common and underrecognized tomography finding

We read with great interest the well-written manuscript by Melo et al.,(1) who analyzed clinical and radiological findings that influence the pathological diagnosis of solitary pulmonary nodule (SPN). They concluded that advanced age, greater maximum SPN diameter, and spiculated margins were significantly associated with the diagnosis of malignancy. For radiologists and pulmonologists, SPNs continue to represent a major diagnostic challenge. Recent technological advances in imaging techniques and the widespread use of CT have increased the frequency of pulmonary nodule detection.(2) Small nodules (1-2 mm in diameter) are commonly detected on CT images, and their clinical importance appears to differ markedly from that of larger nodules identified on chest X-rays.(2) Thus, this enhanced detection has not affected the basic issue of distinguishing the status of a nodule, whether benign (requiring no specific approach) or indeterminate (potentially malignant),(2) and most nodules are resected for diagnosis and determination of the appropriate treatment.(3) Pulmonary lymph nodes are a common and underrecognized cause of a peripheral SPN. These lymph nodes are usually found at the bifurcation of the bronchi, before the fourth branch, where they are referred to as peribronchial lymph nodes. Lymph nodes are occasionally present within the lung parenchyma, where they are designated intrapulmonary lymph nodes (IPLNs)(3) or perifissural nodules (PFNs). The differentiation of IPLNs from other small pulmonary nodules on CT images is difficult although clinically important. In particular, the misinterpretation of a radiologically detected IPLN as a separate tumor nodule leads to overstaging and possible exclusion from indication for surgical treatment in patients with primary lung cancer. (3) Several tomographic characteristics may aid in the differential diagnosis of an IPLN (Figure 1). These lymph nodes are oval, round, triangular, or trapezoidal, with sharply defined borders; they are almost always located below the level of the carina, predominantly in the subpleural regions of the lower lobes. They are frequently attached to the pleura or separated from the pleural surface by a few millimeters.(3-5) IPLNs have thin linear attachments extending from the nodule to the pleura. These linear densities have been shown to represent ectatic lymphatic channels.(5) De Hoop et al.(6) recently reported that the growth rates of PFNs can reach those of malignant nodules, but no PFN in their study was malignant. In conclusion, IPLNs are benign features that should be taken into consideration in the differential diagnosis of an SPN. Their identification might reduce the number of unnecessary surgeries and follow-up examinations.