Medical Image of the Month: Penicillium Pneumonia Presenting as a Lung Mass

Figure 1. Representative image from thoracic CT scan in lung windows.

Figure 2. Panel A: Culture plate showing growth on culture plate. Panel B: Photomicrograph showing the dimorphic fungus taken from the culture plate.

A 72-year-old woman who is a non-smoker was referred for evaluation of a suspected lung cancer. She had progressive shortness of breath at rest for 5 months associated with right-sided chest pain, cough and yellowish sputum. She failed multiple courses of antibiotics.

Her past medical history was significant for hypertension, dyslipidemia, hypothyroidism and poorly controlled diabetes mellitus type 2. She also had mild coronary artery disease for which she was on dual antiplatelet therapy. On physical examination, her oxygen saturation was 94% on room air her other vital signs also being unremarkable. Her physical exam revealed decreased breath sounds on the right associated with dullness to percussion.

Her chest radiograph demonstrated right middle lobe opacities. Her chest CT showed a right hilar mass surrounded by multiple nodules along with interlobular septal thickening, a right middle lobe consolidation with air bronchograms, and multiple mediastinal lymph nodes – all suggestive of malignancy (Figure1).

The patient underwent bronchoalveolar lavage and multiple transbronchial biopsies from the right upper and right middle lobes. The lung biopsy showed nonspecific lymphocytic inflammatory infiltrates. Her bronchoalveolar lavage was positive for fungus on PAS stain. The BAL culture showed germ tube negative yeast, which were identified to be Penicillium species (Figure 2).

Fungi are uncommon causes of pneumonia in the general population, but they are more prevalent in immunocompromised hosts with HIV infection, bone marrow transplant, patients on steroids, or patients with neutropenia (1). Penicillium are thermally dimorphic fungi, widely spread in the environment (2). They found especially in soil or where decaying organic material is present. They are saprophytic and capable of causing food spoilage. Patients usually inhale the spores of penicillium present in soil, and so lungs are the primary site of infection. However, disseminated Penicilliosis with lymphadenopathy and organomegaly (especially in immunocompromised patients) can be seen. There was no evidence of disseminated Penicilliosis in our patient. She was not immunocompromised, and her only risk factor was poorly-controlled diabetes mellitus. If not recognized early, Penicillium pneumonia can be fatal. The diagnosis depends on obtaining tissue, sputum and/or BAL samples for fungal cultures. Use of a serum galactomannan antigen assay may facilitate earlier diagnosis of Penicillium infections, however it is not specific for this pathogen as it is a polysaccharide cell wall component of most Aspergillus species as well (3).

There is no consensus about the treatment of Penicillium pneumonia, however standard therapy consists of intravenous amphotericin B, followed by oral itraconazole for several weeks. The optimal duration of treatment is unknown as several cases of relapse have been reported in the literature.

The patient received two weeks of intravenous amphotericin B deoxycholate followed by 12 months of oral itraconazole. The patient improved significantly with resolution of the consolidation seen on her previous chest radiography.

Hasan S. Yamin MD¹, Amro Alastal MD², Abbas Iter MD¹, Murad Azamttah¹

¹Pulmonary and Critical Care, An-Najah University Hospital, Nablus, Palestine

²Pulmonary and Critical Care, Marshall University, WV, USA

References

1. Kang Y, Feitelson M, de Hoog S, Liao W. Penicillium marneffei and its pulmonary Involvements. Current Respiratory Medicine Reviews. 2012;8(5):356-64. [CrossRef]
2. Visagie CM, Houbraken J, Frisvad JC, Hong SB, Klaassen CH, Perrone G, Seifert KA, Varga J, Yaguchi T, Samson RA. Identification and nomenclature of the genus Penicillium. Stud Mycol. 2014 Jun;78:343-71. [CrossRef] [PubMed]
3. Hung CC, Chang SY, Sun HY, Hsueh PR. Cavitary pneumonia due to Penicillium marneffei in an HIV-infected patient. Am J Respir Crit Care Med. 2013 Jan 15;187(2):e3-4. [CrossRef][PubMed]

Cite as: Yamin HS, Alastal A, Iter A, Azamttah M. Medical image of the month: Penicillium pneumonia presenting as a lung mass. Southwest J Pulm Crit Care. 2019;19:164-6. doi: https://doi.org/10.13175/swjpcc033-19 PDF 

Medical Image of the Month: Pneumoperitoneum with Rigler’s Sign

Figure 1. CT of the abdomen with contrast showing a large quantity of free air within the peritoneal cavity. The etiology of her free intraperitoneal air was not evident on this imaging study.

Figure 2. An upright chest radiograph performed six months later again demonstrates a large amount of free air under the hemidiaphragms, outlining both the spleen and the superior surface of the liver. Rigler’s sign (air on both the peritoneal and luminal side of bowel wall (arrows) - which clearly delineates the bowel wall) is in noted and supports the diagnosis of free intraperitoneal air.

Clinical Presentation: A 70-year-old Asian-American woman presented to the hospital with a distended and tympanic abdomen. She was otherwise asymptomatic. Her past medical history was significant only for an uncomplicated colonoscopy the previous summer. A CT scan showed free air within the peritoneal cavity (Figure 1). She was managed conservatively without a surgical intervention. After six months without a chest x-ray continued to show free air (Figure 2). She underwent an elective exploratory laparotomy without identification of a cause for her free intraperitoneal air. Her pneumoperitoneum completely resolved on follow up imaging.

Discussion: Pneumoperitoneum is a condition which commonly presents as an acute abdomen (1). Causes are numerous and include penetrating and blunt abdominal trauma, perforation of viscus, diaphragmatic rupture, fistula formation – among other etiologies. Work-up of pneumoperitoneum varies depending on the suspected etiology. In the presence of hemodynamic instability or peritoneal signs, the patient should proceed to an exploratory laparotomy immediately following airway maintenance and resuscitation. In the setting of a perforation or sepsis, broad-spectrum intravenous antibiotics are indicated. Stable patients are managed expectantly with NPO status, intravenous fluids resuscitation, serial vitals/abdominal imaging/labs, and nasogastric tube decompression if indicated for obstructive etiologies.

Rigler’s sign is well-demonstrated in the abdominal radiograph (figure 2). Rigler’s sign is the presence of air on both the luminal and peritoneal side of the bowel wall – which clearly delineates the bowel wall (1). This sign is highly suggestive of free intraperitoneal air. Rigler’s sign can be seen on a supine abdominal radiograph and can be helpful in the identification of free intraperitoneal air in a patient who may be too ill for upright radiographs or CT imaging.

Mohammad A. Mahmoud MD DO, Jonathon P. Mahn DO, and Alexander E. Brahmsteadt, MSIV.

Midwestern University | Arizona College of Osteopathic Medicine

Canyon Vista Medical Center

Sierra Vista, AZ USA

Reference

1. Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol. 1991 Apr;156(4):731-5.

Cite as: Mahmoud MA, Mahn JP, Brahmsteadt AE. Medical image of the month: pneumoperitoneum with Rigler's sign. Southwest J Pulm Crit Care. 2019;19(6):156-7. doi: https://doi.org/10.13175/swjpcc047-19 PDF