Want to take quizzes and track your credits?
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.
Please finish quiz first before checking answer.
Read the answer below and download your certificate.
Read the discussion below and retake the quiz.
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.
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
Corresponding Author: Maricar Malinis, MD, Yale School of Medicine, PO Box 208022, New Haven, CT 06520-8022 (email@example.com).
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.
You currently have no searches saved.