roentgenogram of the month Upper Lobe Cystic Lesions and Cough in a Young Woman* Ryland P. Byrd, Jr., M.D ., F.C.C .P.; Cheryl L. Fields, M.D ., F.C.C.P.; Jeffery W Dickerson, M.D ., EC .C .P.; Judah H. Skolnick, M.D., F.C.C.P.; and Tho11UlS M. Roy, M.D., EC.C .P.
(Chest 1992; 102:261-62)
27-year-old white woman was referred for evaluation of a chronic cough productive of a greenish and foul-tasting sputum that was occa sionally blood streaked . She recalled no prodromal symptoms. She denied weight loss, fevers, or chills. The patient did not smoke and had no noxious occupational exposures. She had no pets or livestock . She was an urban dweller without outdoor interests or activities. She had not traveled recently. She had had only the usual childhood illnesses. She had no risk factors for infection with human imunodeficiency virus (HIV). There was no family history of pulmonary disease. The patient was thin but in no acute distress. She was afebrile, and her vital signs were stable. Breath sounds were diminished in the upper lung fields. The remainder of the physical examination findings were unremarkable . The patient's white blood cell count and differential were normal. Her biochemical profile was unremarkable. Her aI-antitrypsin level was normal. Fungal serologic findings by immunodiffusion and complement fixation were within normal limits. Her PPD test was nonreactive. Serum protein immunoelectrophoresis findings were within normal limits . The patient was seronegative for HIV antibody. Multiple biapical thin-walled cavities were apparent on chest roentgenogram (Fig 1). When compared with the appearance on previous chest radiographs, the cavities appeared to be enlarging. Multiple thin-walled cavities were present in both apices on computed tomography of the chest (Fig 2). The patient had undergone two bronchoscopic evaluations, but bacterial, mycobacterial, and fungal cultures of respiratory secretions were negative. Transbronchial biopsy findings were consistent with chronic bronchitis. Due to the progressive nature of the patient's disease, a thoracotomy with lung biopsy was performed .
*Fmm the Division of Respiratory and Environmental Medicin e . Univers itv of Louisville School of Medicine and the Louisville Veterans Admin istration Medical Center. Louisville . Reprint requests : Dr. Byrd. Pulmonaru and Enoironmcutal Medi cine . University of Louisville , Ambulatory Can - Buildinu, Iouisoille 40292 CHEST I 102 I 1 I JULY, 1992
Diagnosis: Pulmonary blastonujcosi» A wanulomatous infiltrate with ~iant cells and broad-based budding yeast forms consistent with Blastomyces dermatitulis were present in the biopsy specimens (Fig 3 and 4). The cavities were cystic and lined with squamous epithelium . Cultures of the biopsy specimens on Sabourauds medium confirmed the diagnosis of pulmonary hlastomycosis. The radiologic presentation of hlastomycosis includes consolidation, fihronodular infiltrates, mass densities, interstitial infiltrates, pleural thickening, and pleural effusion.' Although thick-walled cavitary lesions have been previously reported," thin-walled cavities or cysts have heen described in the literature on only one occasion." This patient was a young male with upper lobe lesions who also had intermittent hemoptysis. The significance of a cystic or cavitary radiographic presentation of hlastomycosis is unclear. The medical literature gives no indication that the nature of the chest radiographic change influences mortality. Patients with cavitary lesions who have been treated with amphotericin B have shown a ~reater tendency to relapse than patients without cavities. ~ This phenomenon has not yet been confirmed with treatment employing the newer imidazoles. The potential morbidity of cavitary lesions includes colonization with opportunistic fun~i or bacteria, with resultant hemorrhage and hemoptysis. The thinwalled lesions increase the possibility of pneumothorax . Finally, their presence may lead to delay in making the correct diagnosis. Other mycotic diseases that are characterized by upper lobe thin-walled cavities include Sporothrix schenckii, Ceotrichum species, and Coccidioides immitis. The thin-walled cavities of blastomycosis were persistent in both reported cases, This feature may he helpful in distinguishing them from the thin-walled cavities that occur as residual lesions from disease caused by C illlmitis or those caused by other fungi . Diabetics and immunocompromised hosts are more likely to develop these transient cavities than irnmunocompetent patients. In the previously reporte-d case, the patient improved with the administration of amphotericin B, and his chest radiograph showed only minimal shrinkage of the cavities. Onr patient is being treated with ketoconazole , 400 mg/d . and has become asymptomatic with continued reduction in the size of the cavities. REFEHENI :E S Brown LH. Swense-n SJ. Van S("oy HE , Prakash tlRS . Coles D1: Colhy Tv. Ho,·ntg("nologi.· f,'alun's of pulmonary hlasltlmy."sis, May Clin PnK' IW1 : 66:29-:1Il
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F":l 'ltt: 4 2 SheRin JR . Camplx-ll JA, Thompson (;P. Pulmonary hlastomycosis : findings on chest radiographs in fla patients. AJH 199(); 1.'54: 1177-110 3 AIlt'rnathy RS. Clinical manifestations of pulmonary blastomyeosis. Ann Intern Med 19.'59; .'>1 :707-27 4 Chapman SW Blastomyces de-rmantidis. In: Mandell GL. Douglas R(; Jr. Bennett JE ...ds. Prtncipk-s and practice of infectious diseases. New ",rk: Churchill Livingstone. 1990, WH!J-20011
Roentgenogram of the Month (Byrd al al)