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Presented by Dr. Pedram Argani and prepared by Dr. Jennifer Bynum
Case 2: This is a lung nodule in a 49 year old female renal transplant patient.
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Question 1 of 1
1. Question
Week (623): Case 2
This is a lung nodule in a 49 year old female renal transplant patient.
Correct
Answer: Angioinvasive fungal disease
Histology: The lung contains a well delineated nodule of necrotic, lung parenchyma. Surrounding the necrosis are areas of organizing pneumonia. Within the necrotic lung tissue, and emanating from necrotic blood vessels, one can appreciate fungal hyphae which radiate out from the vessels into the necrotic tissue. These hyphae are pauci-septate, and appear flimsy in that their walls are thin and appear to fold on each other. These features are typically seen with Zygomycetes, though definitive identification rests with cultures in the microbiology laboratory.
Discussion: CMV pneumonitis is infrequently associated with extensive necrosis, as it predominantly involves pneumocytes rather than the vasculature of the lung. One would appreciate markedly enlarged pneumocyte nuclei with prominent intranuclear and cytoplasmic inclusions. A fungus ball (mycetoma) typically occurs in cavities of a lung showing preexisting damage (cavitary change). One should not appreciate tissue necrosis in a setting in which the fungus is a colonizer. Infarction is seen in the current case; however, instead of being associated with merely hemorrhage as one would expect with vascular inclusion or trauma, the infarction here is associated with invasive fungus.
Angioinvasive fungal disease such as the current case is a medical emergency. One may need to report the margins of excision of a specimen such as this, as the goal of surgery is to completely remove the fungus which is notoriously resistant to antifungal chemotherapy.
Incorrect
Answer: Angioinvasive fungal disease
Histology: The lung contains a well delineated nodule of necrotic, lung parenchyma. Surrounding the necrosis are areas of organizing pneumonia. Within the necrotic lung tissue, and emanating from necrotic blood vessels, one can appreciate fungal hyphae which radiate out from the vessels into the necrotic tissue. These hyphae are pauci-septate, and appear flimsy in that their walls are thin and appear to fold on each other. These features are typically seen with Zygomycetes, though definitive identification rests with cultures in the microbiology laboratory.
Discussion: CMV pneumonitis is infrequently associated with extensive necrosis, as it predominantly involves pneumocytes rather than the vasculature of the lung. One would appreciate markedly enlarged pneumocyte nuclei with prominent intranuclear and cytoplasmic inclusions. A fungus ball (mycetoma) typically occurs in cavities of a lung showing preexisting damage (cavitary change). One should not appreciate tissue necrosis in a setting in which the fungus is a colonizer. Infarction is seen in the current case; however, instead of being associated with merely hemorrhage as one would expect with vascular inclusion or trauma, the infarction here is associated with invasive fungus.
Angioinvasive fungal disease such as the current case is a medical emergency. One may need to report the margins of excision of a specimen such as this, as the goal of surgery is to completely remove the fungus which is notoriously resistant to antifungal chemotherapy.
