Radiology/Pathology Correlation

Unknown 1

A 45-year-old man on highly active anti-retroviral therapy for AIDS (CD4 count 12) presents with several months of shortness of breath, cough, and chest pain, not improving on broad-spectrum antibiotics. He has a history of previous opportunistic infections and is currently taking prophylactic therapy for Mycobacterium avium-complex and Pneumocystis carinii.

Radiology

cavitynodulelymphadenopathy

Figure 1

Find and describe the apical lesion in the right lung. Click on the structure in the image to get verification.

In the left lung, find an example of a lung parenchymal nodule.

Find an example of lymphadenopathy in the left lung.

Detail of Figure 1

Compare this image of the thick-walled, cavitary lesion with that of the CT and the picture of the gross specimen below.

Figure 2

The axial CT image reveals a right apical thick-walled cavity with complex internal architecture as well as ill-defined left lung apical nodules. Note the emphysema in the left lung.


Pathology

Autopsy Findings, Right Lung

Outline the central cavitary lesion that is surrounded by a white fibrotic wall. What is the probable nature of the tissue in the upper portion of the lesion? Answer

Find the thickened pleura and adjacent chest wall.

What general term is used to describe the adjacent lung parenchyma that is firmer than normal? Answer

pleura

Etiologic Agent

Organisms similar to those shown in one of the panels were found in the lesion. Name the likely organisms in each panel and indicate which is the most likely cause of the lesion. Gomori methenamine silver stain

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Differential Diagnosis of Thick-walled Cavities on Chest Radiographs and CT Scans: Neoplasms (especially squamous cell carcinoma), bacterial lung abscess, fungal infections, certain parasitic infections, Wegener's granulomatosis, and pulmonary infarction.

Diagnoses: Chronic ("semi-invasive") necrotizing pulmonary aspergillosis (CNPA), right lung. Acute invasive aspergillosis, left lung nodules (probably disseminated from the chronic lesion)

Features suggestive of chronic (semi-invasive) necrotizing aspergillosis on chest radiography and CT [1,2]

Pathologic Features and Differential Diagnosis of Cavitary Types of Aspergillosis: CNPA may show a necrotizing cavitary lesion as seen here, a necrotizing granulomatous pneumonia, or an invasive bronchitic lesion [3]. Cavitary CNPA differs from aspergilloma, which develops in a preformed cavity and contains hyphae and debris rather than necrotic lung tissue. CNPA differs from a lung ball, which appears acutely in persons with severe neutropenia.

References

1. Franquet T, Muller N. L, Gimenez A, Domingo P, Plaza V, Bordes R. Semiinvasive pulmonary aspergillosis in chronic obstructive pulmonary disease: radiologic and pathologic findings in nine patients. Am J Roentgenol AJR 2000; 174: 51-56. abstract

2. Kim S. Y, Lee K. S, Han, J, Kim J, Kim T. S, Choo S. W, Kim S. J. Semiinvasive pulmonary aspergillosis: CT and pathologic findings in six patients. Am J Roentgenol AJR 2000; 174:795-798. abstract

3. Yousem S. A. The histological spectrum of chronic necrotizing forms of pulmonary aspergillosis. Hum Pathol 1997; 28:650-656. abstract

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Cavity containing an irregular density

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Lymphadenopathy. Note the hilar adenopathy in the left lung.

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Thickened pleura and portion of adjacent chest wall

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Consolidation. It contributes to the radiographic thickening of the wall of the cavity.

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Necrotic lung tissue.

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Left: Candida

Middle: Aspergillus

Right: Mucor

The most likely organism is aspergillus.

More information

Give the differential diagnosis of 1. the radiographic findings and 2. the cavitary types of aspergillosis. What is the diagnosis? Answers