A 54-year-old man comes to the office due to fatigue, a productive cough with blood-tinged sputum, and a 7-kg (15.4-lb) weight loss over the past few months. He has no fever, chest pain, or night sweats. Ten years ago, the patient emigrated from Vietnam, where he received treatment for pulmonary tuberculosis. He has no other medical history. He does not use tobacco or illicit drugs but drinks alcohol occasionally. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 82/min. Lung auscultation reveals right-sided rhonchi and crackles. Creatinine is 1.1 mg/dL and urinalysis is normal. CT scan of the chest is shown in the image below. Which of the following is the most likely diagnosis for this patient?

Question

A 54-year-old man comes to the office due to fatigue, a productive cough with blood-tinged sputum, and a 7-kg (15.4-lb) weight loss over the past few months.  He has no fever, chest pain, or night sweats.  Ten years ago, the patient emigrated from Vietnam, where he received treatment for pulmonary tuberculosis.  He has no other medical history.  He does not use tobacco or illicit drugs but drinks alcohol occasionally.  Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, and pulse is 82/min.  Lung auscultation reveals right-sided rhonchi and crackles.  Creatinine is 1.1 mg/dL and urinalysis is normal.  CT scan of the chest is shown in the image below.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d0ff_4621_bc81_75274bf75bd0_MD0003_00 Aspergillus is a ubiquitous fungus that most people encounter daily. Conidia are inhaled into the lung and convert to potentially pathogenic hyphae. Patients with immunocompetency rapidly clear the organism and rarely develop infection; however, a subset of immunocompetent patients with a history of pulmonary disease (eg, cavitary tuberculosis) may develop chronic pulmonary aspergillosis (CPA) at sites of lung damage. Diagnosis is made by the presence of all 3 of the following: >3 months of symptoms - fever, weight loss, fatigue, cough, hemoptysis, and/or dyspnea Cavitary lesion(s) containing debris, fluid, or an aspergilloma (fungus ball) Positive Aspergillus IgG serology Therapy depends on symptoms and severity of disease; antifungal medication (eg, itraconazole, voriconazole), surgery (to prevent hemoptysis), and bronchial artery embolization (for hemoptysis with extensive disease) may be used together or separately. A simple aspergilloma is sometimes categorized as CPA but is typically quiescent (aside from occasional mild cough or hemoptysis) with no systemic symptoms. This patient has CPA rather than simple aspergilloma. (Choice A) Actinomyces israelii is an anaerobic bacterium that usually causes cervicofacial infections. Rarely, Actinomyces may cause an indolent pneumonia with weight loss, fever, cough, and CT scan findings of pulmonary nodules or lobar consolidation (not a cavitary lesion with a fungus ball). (Choice B) Bacterial lung abscess causes indolent symptoms of fever, cough, dyspnea, weight loss and CT scan findings of an infiltrate with a cavity. Lung abscesses usually have necrotic tissue with air fluid levels and do not have evidence of fungal balls. infiltrate with a cavity (Choice D) Granulomatosis with polyangiitis often causes chronic fever, fatigue, and weight loss. Pulmonary disease is common, and imaging may reveal cavitary nodules. However, most patients also have nasal, sinus, or ear symptoms, and many have renal insufficiency and active urine sediment (unlike this patient). (Choice E) Histoplasmosis is an endemic mycosis of the central and midwestern United States that rarely causes illness in immunocompetent individuals but may occasionally cause subacute pulmonary symptoms (<5%). However, pulmonary histoplasmosis usually causes focal infiltrates with hilar lymphadenopathy (not cavitary lesions). (Choice F) Small cell lung cancer almost never causes cavitation. It most commonly presents as a hilar mass with lymphadenopathy and is often characterized by widespread metastases at presentation due to its rapid growth rate. Educational objective: Chronic pulmonary aspergillosis manifests with >3 months of weight loss, cough, hemoptysis, and fatigue in patients with a history of underlying lung disease. Imaging usually reveals >1 apical cavitary lesions with or without an aspergilloma. Diagnosis is made with Aspergillus IgG serology in the setting of characteristic symptoms and radiographic findings. > References: Pulmonary aspergillosis: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/21881144)

A 54-Year-Old Man Comes to the Office Due to Fatigue