case_images: PMC6918496_01
case_images: (a) Chest X-ray at initial presentation; (b) Chest-CT-Scan at initial presentation; (c) Chest-CT-Scan at readmission 3 months later, following 3 month treatment with prednisone (1 mg/kg bodyweight); (d) Histology of lung samples obtained during VATS at initial presentation, haematoxylin&eosin stain plus Grocott stain (dark nodules) demonstrate yeast cells with multipolar budding, bar indicates 5 microm; (e) Cytology of BAL sample obtained shortly after transfer to our clinic, Grocott stain (dark nodules); (f) Chest-CT-Scan 8 weeks after initiation of antifungal therapy; (g) Chest-CT-Scan 6 months after initiation of antifungal therapy; and (h) Endobronchial photography in the left main bronchus, showing an exophytic lesion before antifungal therapy (left panel) and on control bronchoscopy after 6 months of antifungal therapy (right panel).. BAL, broncheoalveolar lavage; CT, computed tomography; VATS, video-assisted thoracoscopy.
case_images: 10.1177_1753466619894913-fig1.jpg
case_images: PMC6918496_01_10.1177_1753466619894913-fig1.jpg
case_images: fig1-1753466619894913
case_images: A 57-year-old woman was hospitalized due to dyspnoea, cough, and bilateral interstitial infiltrates on chest X-ray (Figure 1a). A chest computed tomography (CT) showed diffuse interstitial changes (Figure 1b). In combination with elevated serum interleukin-2-receptor levels (1654 U/ml, normal 220-710 U/ml), pulmonary sarcoidosis was diagnosed and systemic corticosteroid therapy (1 mg per kg bodyweight) was initiated; 3 months later clinic and chest CT remained unchanged (Figure 1c), as did the lesion in the left main bronchus under bronchoscopy. While initial stains showed small yeasts more in line with Histoplasmosis, more in depth examination of the samples showed multi-budded yeasts (Figure 1d) more closely resembling Paracoccidioides, albeit not matching the textbook description of a multipolar 'pilot's wheel' configuration. In conclusion, the patient had paracoccidioidomycosis as suggested by the detection of antibodies, histology (Figure 1d,e) and PCR from FFPE tissue. Chest CT showed decreasing pulmonary infiltrates (Figure 1f) which resolved completely after 6 months (Figure 1g). To monitor the lesion in the left main bronchus, another flexible bronchoscopy was performed after 6 months, showing a decrease in size of the fungal lesion (Figure 1h).