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Chest Pain and a Cavitary Lung Mass in a Woman With Diabetes

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 55-year-old woman from the Southeastern US with a history of smoking, poorly controlled type 2 diabetes mellitus (hemoglobin A1c level, 15.5%), and chronic pain from osteoarthritis treated with inhalational medical marijuana presented with 4 months of productive cough, 22.7-kg (50-lb) weight loss, subjective fevers, and 3 days of worsening chest pain.

Chest computed tomography (CT) showed a large right upper lobe cavitary mass. She was treated empirically with intravenous vancomycin and piperacillin-tazobactam. Bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was performed. Lung tissue was sent for bacterial, fungal, mycobacterial, and Nocardia cultures and for histopathology. BAL cultures grew 100 colony-forming units (CFUs)/mL of group B streptococci and 1 CFU/mL of Aspergillus niger. Results of acid-fast bacilli (AFB) smear and GeneXpert MTB/RIF testing were negative. Voriconazole was added to her treatment. Transbronchial biopsy histopathology showed acute and chronic inflammation, granulation tissue and necrosis, and negative fungal and AFB stains.

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Fungal empyema

D. Perform right upper lobe resection

The key to the correct diagnosis was recognizing that the tension pneumothorax after intubation suggested rupture of the right-sided cavitary lesion into the pleural space. The charcoal-colored pleural fluid is characteristic of the melanin-producing Aspergillus niger. A change in antimicrobial therapy would not be sufficient to manage this complication. Voriconazole is favored over amphotericin B for Aspergillus spp. Without malignancy, radiation therapy is not indicated.

The differential diagnosis of a cavitary lung mass includes infection, malignancy, or autoimmune disease. In patients with immunosuppression from diabetes, infection should be considered. Fevers, weight loss, and chronic productive cough are consistent with Mycobacterium tuberculosis or nontuberculous mycobacteria, but negative AFB smears and Xpert MTB/RIF results (for Mycobacterium tuberculosis) from the BAL makes this less likely. Prior residence in the Southeastern US is associated with cavitary histoplasmosis or blastomycosis, showing small intracellular yeast or broad-based budding yeast on histopathology, respectively. The lungs may be the primary site of mold infections (eg, Aspergillus or Mucorales spp), which cause significant morbidity and mortality. Mold in the sputum may be considered a contaminant but should be further evaluated in patients with a cavitary lung lesion or underlying risk factors. Pulmonary cavitation may be caused by a necrotizing bacterial infection (eg, Staphylococcus aureus, Klebsiella pneumoniae, anaerobes) or bacterial superinfection of existing cavities. Noninfectious causes of cavitary lung disease include malignancy (eg, primary lung cancer, metastatic squamous cell carcinoma), granulomatosis with polyangiitis, or thromboembolism with pulmonary infarction.

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Article Information

Corresponding Author: Maricar Malinis, MD, Yale School of Medicine, PO Box 208022, New Haven, CT 06520-8022 (maricar.malinis@yale.edu).

Published Online: May 22, 2020. doi:10.1001/jama.2020.4111

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Santiago Delgado, MD (Department of Pathology and Laboratory Medicine, Yale University) for providing slides and thank the patient for providing permission to share her information. Dr Delgado received no compensation for his contributions.

References
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Nam  HS , Jeon  K , Um  SW ,  et al.  Clinical characteristics and treatment outcomes of chronic necrotizing pulmonary aspergillosis: a review of 43 cases.   Int J Infect Dis. 2010;14(6):e479-e482.PubMedGoogle ScholarCrossref
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Denning  DW , Cadranel  J , Beigelman-Aubry  C ,  et al; European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society.  Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management.   Eur Respir J. 2016;47(1):45-68.PubMedGoogle ScholarCrossref
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Patterson  TF , Thompson  GR  III , Denning  DW ,  et al.  Practice guidelines for the diagnosis and management of aspergillosis.   Clin Infect Dis. 2016;63(4):e1-e60. doi:10.1093/cid/ciw326PubMedGoogle ScholarCrossref
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Endo  S , Sohara  Y , Murayama  F ,  et al.  Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis.   Ann Thorac Surg. 2001;72(3):889-893. doi:10.1016/S0003-4975(01)02884-3PubMedGoogle ScholarCrossref
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