A 62-year-old woman comes to the emergency department due to 3 days of fever, chest pain, shortness of breath, and cough. The cough has been occasionally productive of small amounts of bright red blood. The patient was diagnosed with giant cell arteritis a month ago after developing new headaches, jaw claudication, and transient vision loss. She was started on high-dose prednisone, which has since been tapered to 40 mg daily. She also has a history of hypertension, which is well controlled with amlodipine. The patient has a 30-pack-year smoking history.
Temperature is 38.4 (101.1 F) , blood pressure is 120/72 mm Hg, pulse is 94/min, and respirations are 18/min; oxygen saturation is 93% on room air. Physical examination shows a frail woman in mild distress with moist mucous membranes and no lymphadenopathy. Lung auscultation reveals occasional crackles in the left lung.
Leukocyte count is 7,400/mm³ with 15% neutrophils, hemoglobin is 13.2 g/dL, and creatinine is 0.8 mg/dL. CT scan of the lungs reveals a 1-cm cavitation and multiple nodules surrounded by ground-glass infiltrates.
The patient is admitted to the hospital and started on empiric broad-spectrum antibiotics.
Further laboratory results are as follows:
What is the most likely diagnosis in this patient?

Question

A 62-year-old woman comes to the emergency department due to 3 days of fever, chest pain, shortness of breath, and cough. The cough has been occasionally productive of small amounts of bright red blood. The patient was diagnosed with giant cell arteritis a month ago after developing new headaches, jaw claudication, and transient vision loss. She was started on high-dose prednisone, which has since been tapered to 40 mg daily. She also has a history of hypertension, which is well controlled with amlodipine. The patient has a 30-pack-year smoking history.
Temperature is 38.4 (101.1 F) , blood pressure is 120/72 mm Hg, pulse is 94/min, and respirations are 18/min; oxygen saturation is 93% on room air. Physical examination shows a frail woman in mild distress with moist mucous membranes and no lymphadenopathy. Lung auscultation reveals occasional crackles in the left lung.
Leukocyte count is 7,400/mm³ with 15% neutrophils, hemoglobin is 13.2 g/dL, and creatinine is 0.8 mg/dL. CT scan of the lungs reveals a 1-cm cavitation and multiple nodules surrounded by ground-glass infiltrates.
The patient is admitted to the hospital and started on empiric broad-spectrum antibiotics.
Further laboratory results are as follows:

What is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_96a4_9a95_853d_6b1e4ce7a4ff_MD0002_00 Invasive pulmonary aspergillosis typically arises in the setting of severe immunosuppression due to prolonged neutropenia, chronic high-dose corticosteroid use, or solid organ or allogeneic stem cell transplantation. Patients classically have the triad of fever, pleuritic chest pain, and hemoptysis. CT scan of the chest usually reveals single or multiple nodules with surrounding ground-glass opacities ("halo sign") and/or cavitations with air-fluid levels ("air crescent sign"). Suspected cases are generally confirmed using noninvasive testing, including: Sputum fungal stain and culture-sensitivity is 25%-50%Serum fungal biomarkers (eg, galactomannan, beta-D-glucan)-serum galactomannan assays are relatively specific (>75%) for Aspergillus, but false positives can occur with Blastomyces or Histoplasma infections (these pathogens are usually ruled out with serum or urine testing). Beta-D-glucan assays have lower specificity as they are positive with a wider variety of fungal pathogens (eg, Candida, Pneumocystis). Sputum fungal stain and culture-sensitivity is 25%-50% Serum fungal biomarkers (eg, galactomannan, beta-D-glucan)-serum galactomannan assays are relatively specific (>75%) for Aspergillus, but false positives can occur with Blastomyces or Histoplasma infections (these pathogens are usually ruled out with serum or urine testing). Beta-D-glucan assays have lower specificity as they are positive with a wider variety of fungal pathogens (eg, Candida, Pneumocystis). If noninvasive testing is inconclusive, patients typically undergo bronchoscopy with bronchoalveolar lavage (microscopy, culture, and galactomannan assay), transbronchial biopsy, or CT-guided transthoracic biopsy. (Choice B) Patients with symptomatic histoplasmosis usually have subacute pulmonary symptoms and imaging evidence of a patchy/nodular infiltrate with enlarged mediastinal and hilar lymph nodes. Although histoplasmosis can be associated with a positive serum galactomannan assay, this patient's negative urine Histoplasma antigen makes this condition unlikely. (Choice C) Although pulmonary tuberculosis occurs more commonly in patients who are immunosuppressed, most cases are marked by subacute, not acute, pulmonary symptoms. In addition, tuberculosis is not associated with a positive serum galactomannan test. (Choice D) Patients who do not have HIV who develop Pneumocystis pneumonia usually have fulminant respiratory failure, fever, and dry cough. Beta-D-glucan assay is often positive, but galactomannan testing is generally negative. (Choice E) Squamous cell lung cancer can cause hemoptysis, pleuritic chest pain, and a cavitary lung lesion, but the presence of fever and a positive serum galactomannan assay make Aspergillosis far more likely. Educational objective: Invasive pulmonary aspergillosis typically occurs in the setting of a severely immunocompromised state. Patients commonly have fever, pleuritic chest pain, and hemoptysis; imaging often reveals nodular disease with ground-glass opacities or cavitary lesions with air fluid levels. Diagnosis is usually made with sputum fungal stain and culture and serum fungal biomarkers (eg, galactomannan, beta-D-glucan). A positive serum galactomannan assay has a specificity >75%. __________

A 62-Year-Old Woman Comes to the Emergency Department Due to 3