On-line version ISSN 1678-9946
Rev. Inst. Med. trop. S. Paulo vol. 40 n. 4 São Paulo July/Aug. 1998
A case of a solitary pulmonary nodule due to Scedosporium apiospermum (Pseudallescheria boydii) is related. A review of the pertinent literature was done and, in addition, similar lesions caused by other opportunistic fungi are commented.
KEYWORDS: Solitary pulmonary nodule; Fungal pulmonary nodule; Scedosporium apiospermum. Scedosporiosis; Pseudallescheriosis.
The pathogenic spectrum of pulmonary infection caused by Scedosporium apiospermum (Pseudallescheria boydii) may be roughly classified in three groups: allergic, intracavitary colonization and invasive disease3,11,13. Furthermore, the fungus can be a transient colonizer of the bronchial tree13. Invasive pulmonary infection can vary from an assymptomatic solitary nodule6,13,18 to a deadly necrotizing pneumonia3.
Herein is reported a case of a patient presenting a solitary pulmonary nodule due to S. apiospermum , disclosed by chance at the radiological control of a previous fungus ball by Aspergillus flavus. A review of literature, encompassing similar lesion caused by other opportunistic fungi is also commented .
Prior to admission (Feb., 1986) the patient, a 41-year-old white woman had a long history of diseases. Twenty years ago, she had pulmonary tuberculosis, cured with antituberculous drugs; 4-years ago, carcinoma of the left breast, treated by mastectomy, radiation and chemotherapy; and, 2 years ago, polyomiositis, treated with azathioprin and high doses of steroids. In consequence of this last treatment she acquired diabetes.
At admission, the patient complained of ten-months fever, cough with purulent expectoration. A chest roentgenogram revealed atelectasis and a cavitation filled by homogeneous material in the left upper lobe (Fig. 1). Small clumps were observed in her sputum. These clumps dissected and mounted in potassium hydroxide revealed to be composed of a tangled mass of hyaline, branched, septate hyphae. Similar hyphae were observed in the sediment of the bronchial washing. No acid fast bacilli or neoplastic cells were disclosed in sputum and bronchial washing sediment. Culture of sputum in Sabouraud-chloramphenicol yielded colonies of Aspergillus flavus. No precipitin bands were observed in the immunodiffusion test with aspergilli (A. fumigatus, A. flavus, and A. niger). No specific treatment was appointed, but insulin and prednisone were maintained from Feb. 1986 to Oct. 1986.
In October 1986 a chest X-ray revealed that spontaneous lysis of the intracavitary ball had occurred, but a juxta hilar nodule and a mass (3 x 4 cm) had appeared in the right lower lung (Fig. 2). A transthoracic needle aspiration biopsy was performed. The specimen was examined unstained (Fig. 3) and also planted onto Sabouraud-chloramphenicol. Hyaline septate, branched hyphae were observed and S. apiospermum was isolated. No bands were seen in immunodiffusion test with S. apiospermum antigen. The patient was treated with ketoconazole (400 mg/day), prednisone (20 mg/day) and insulin (NPH 15 mg/day), and was maintained in ambulatorial control.
During 1987 the clinical condition of the patient deteriorated and she died at home. No autopsy was performed.
Three cases of S. apiospermum infection of the lung presenting as a solitary pulmonary nodule were reported6,13,18. The patients, two males and one female, 50 to 70 years-old,were assymptomatic and their lesions disclosed by chance. Two of the patients presented no predisposing condition13,18, the third, a cardiac transplant recipient, was under prednisone therapy6. Two patients13,18, were submitted to a segmentectomy and the diagnosis was achieved by histological examination and culture18 or only culture13 of the excised lesion; in the third patient, a transthoracic needle aspiration was performed and the diagnosis obtained by examination of stained smeared specimen and culture6. Histopathological examination of the lesion of two patients13,18 revealed: a fibrous encapsulated granulomatous nodule with central necrosis and gray granules in one18 and a small abscess in the other13.
|Fig. 1 - Chest roentgenogram in February 1986. A irregular cavity (2.5 cm) surrounded by opacification and containing mass or liquid, may by seen in the left upper lobe.|
|Fig. 2 - Chest X-ray in October 1986. Note spontaneous resolution of the upper lobe infiltrate. Appeared two nodular images in the right lung: perihilar mass (3 x 4 cm) and a nodule (0.8 cm) in the projection of the posterior arc of the eighth rib.|
|Fig. 3 - Hyaline septate hyphae and conidia in unstained aspirated specimen. Phase contrast, x 630.|
It is interesting to quote that small intracavitary fungus ball (2.5 and 3 cm in diameter) by S. apiospermum can simulate a solitary nodule on X-ray, but they were recognized on the tomogram1,8.
It is worth to remember that fungal solitary pulmonary nodules are usually caused by pathogenic dimorphic fungi4,14,15,17 and usually are the result of a self-limited infection. But, the most important, pulmonary nodular lesion may be produced by opportunistic fungi. There are reports of solitary lung nodular lesions due to Aspergillus fumigatus12,15, A. flavus9, Aspergillus spp.9,15,17,19, Cladophialophora bantiana2, Penicillium spp.7 and Zygomycetes 5,10,15. These nodules were observed in patients with more than 45 years of age. One of these patients had diabetes5, another one leukemia on chemotherapy and prednisone19 and the remaining one had no predisposing conditions2,5,7,10,12. Histopathological study of the nodule was done in some patients, it revealed: a round pulmonary ischemic infartion due to arterial invasion of the fungus5; a partially calcified lesion7; fibrosis mixed with granuloma and microabscess2; or an abscess19.
The main purpose of diagnostic evaluation and management of solitary pulmonary nodules is to avoid thoracotomy in non-malignant nodule. Needle aspiration biopsy is very useful to establish the diagnosis17 and to guide the treatment, as it occurred in our patient. Obtained specimens can be cultured for specific identification of the agent. In this case, S. apiospermum, the treatment requires ketoconazole or itraconazole, because this fungus was not susceptible to amphotericin B.
É relatado caso de nódulo solitário pulmonar por Scedosporium apiospermum (Pseudallescheria boydii). Foi feita uma revisão da literatura pertinente e, além disso, casos com lesões similares causadas por outros fungos oportunistas são comentados.
We wish to thank Dr. Leo Kaufman (CDC, Atlanta, GA, U.S.A.) for performing the immunodiffusion tests.
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(1) Pesquisador do CNPq; Instituto de Pesquisa e Diagnóstico (IPD), Santa Casa, Porto Alegre, RS, Brasil.
(2) Pavilhão Pereira Filho, Santa Casa, Porto Alegre, RS, Brasil.
(3) Universidade Federal de Santa Maria, RS, Brasil.
Correspondence to: L.C. Severo, IPD-Santa Casa, Annes Dias 285, 90020-090 Porto Alegre, RS, Brazil. Fax 55.51 214 8435 E-mail firstname.lastname@example.org
Received: 06 May 1998
Accepted: 16 June 1998