A solitary pulmonary nodule caused by Mycobacterium tuberculosis var. BCG after intravesical BCG treatment: a case report.

BACKGROUND: Intravesical instillation of bacillus Calmette-Guérin (BCG) as a treatment for superficial bladder cancer rarely causes pulmonary complications. While published cases have been pathologically characterized by multiple granulomatous lesions due to disseminated infection, no case presenting as a solitary pulmonary nodule has been reported. CASE PRESENTATION: A man in his 70 s was treated with intravesical BCG for early-stage bladder cancer. After 1 year, he complained of productive cough with a solitary pulmonary nodule at the left lower lobe of his lung being detected upon chest radiography. His sputum culture result came back positive, with conventional polymerase chain reaction (PCR) identifying Mycobacterium tuberculosis complex. However, tuberculosis antigen-specific interferon-gamma release assay came back negative. Considering a history of intravesical BCG treatment, multiplex PCR was conducted, revealing the strain to be Mycobacterium tuberculosis var. BCG. The patient was then treated with isoniazid, ethambutol, levofloxacin, and para-aminosalicylic acid following an antibiotic susceptibility test showing pyrazinamide resistance, after which the size of nodule gradually decreased. CONCLUSION: This case highlights the rare albeit potential radiographic presentation of Mycobacterium tuberculosis var. BCG, showing a solitary pulmonary nodule but not multiple granulomatous lesions, after intravesical BCG treatment. Differentiating Mycobacterium tuberculosis var. BCG from Mycobacterium tuberculosis var. tuberculosis is crucial to determine whether intravesical BCG treatment could be continued for patients with bladder cancer.

Nódulo pulmonar solitario como forma de presentación de la criptococosis en el trasplantado renal / Solitary Pulmonary Nodule as a Form of Presentation of Cryptococcosis in a Renal Transplant Recipient

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Coexistence of nontuberculous mycobacterium and IgG4-related disease in a solitary pulmonary nodule: A case report.

RATIONALE: Immunoglobulin G4-related disease (IgG4-RD) is regarded as an immune-mediated systemic fibroinflammatory disease. Several studies have linked IgG4-RD to infections such as tuberculosis and actinomycosis. However, the coexistence of IgG4-RD and non-tuberculous mycobacterium (NTM) in a single pulmonary nodule has not been reported yet. PATIENT CONCERNS: A 76-year-old male patient presented with cough and sputum. A solitary pulmonary nodule suspicious of lung cancer was found on chest CT. DIAGNOSIS: Through video-assisted thoracoscopic biopsy, a diagnosis of co-existing NTM and IgG4-RD in a single nodule was made. INTERVENTIONS: Antibiotic treatment was applied for pneumonia developed after surgery. The patient was also supported by extracorporeal membrane oxygenation and mechanical ventilation since his pneumonia was refractory to medical treatment. OUTCOMES: The patient expired on the 60th postoperative day due to multiple organ failure. LESSONS: IgG4-RD can occur singularly or accompanied by other diseases. We report a solitary pulmonary nodule caused by NTM and concurrent IgG4-RD, suggesting a possible association between these 2 entities. Immunologic relations between IgG4-RD and accompanying infection should be further investigated.

Solitary pulmonary nodules caused by Mycobacterium avium complex.

BACKGROUND: The prevalence of Mycobacterium avium complex (MAC) pulmonary disease (PD) is increasing significantly in Japan. Among the patterns of MAC-PD, a solitary pulmonary nodule (SPN) is less common and often resembles lung cancer. The aim of this study was to identify the clinical features of MAC-SPN. METHODS: SPNs culture-positive for MAC (definite cases) and culture-negative SPNs showing nucleic acid amplification test (NAAT)-positive status (probable cases) that presented between January 2007 and December 2017 were enrolled. The patients' clinical, laboratory, radiological, and microbiological findings and outcomes were investigated. RESULTS: This study included 28 patients (median age, 66 years; 16 men, 12 women). All patients were asymptomatic when the disease was detected. Median SPN size was 23.5 mm. Twenty-six patients underwent video-assisted thoracoscopic surgery, while the others underwent percutaneous needle biopsy for diagnosis. Granulomatous inflammation was confirmed in all cases. Microbiologically, the 28 cases were divided into 17 in the definite group and 11 in the probable group. In both groups, M. avium was predominant. There were no significant differences in clinical and radiological findings and follow-up periods between the 2 groups. After diagnosis, 6 patients received medical treatment, while the others did not. The median follow-up period was 42 months, and no recurrence was observed in both groups. CONCLUSIONS: MAC should be considered in the differential diagnosis of SPNs in asymptomatic patients. To overcome the difficulties in diagnosing MAC-SPN, this study underscores the importance of diagnostic interventions and identification of MAC by culture and/or NAAT in biopsied specimens.

Radiopathological Features and Identification of Mycobacterial Infections in Granulomatous Nodules Resected from the Lung.

BACKGROUND: Pulmonary granulomas are sometimes resected because they resemble lung cancer and false-positive findings come through from positron emission tomography (PET) using 18fluorine-fluorodeoxyglucose (18F-FDG). Mycobacterial infection is a common cause of granulomas. OBJECTIVE: The purpose of this study was to evaluate the radiopathological features and the methods for identifying mycobacterial infections in granulomatous nodules resected from the lung. METHODS: Thirty-five solitary lesions resected because of suspected lung cancer were enrolled, including 22 nonfungal granulomatous lesions and 13 benign lesions as controls. The radiological, microbiological, and histological findings were reviewed. To identify mycobacterial infection, immunohistochemical (IHC) staining, IS6110 polymerase chain reaction (PCR), and real-time PCR for the detection of Mycobacterium tuberculosis (TB) were performed using formalin-fixed and paraffin-embedded tissue specimens. The correlations between the radiopathological features and the median maximum standardized uptake value (SUVmax) of 18F-FDG PET were also evaluated. RESULTS: Mycobacteria were isolated from the cultures of 10 of the granulomatous lesions, including TB from 2 and Mycobacterium avium complex from 8. The mean size of the nodules in the culture-positive group was significantly larger than that of those in the culture-negative group (30.5 ± 13.1 vs. 15.1 ± 6.3 mm, p = 0.003). IHC stainings were positive in 15 granulomas. Eight granulomas were positive in IS6110 PCR, and 7 of them were also positive in real-time PCR. SUVmax was ≥2.5 in all of the PCR-positive granulomas. CONCLUSION: The most frequent cause of granulomatous lesions was mycobacterial infection. It seemed that the culture result was associated with nodule size and that the results of IS6110 were associated with 18F-FDG-uptake.

Aspergillus nodules; another presentation of Chronic Pulmonary Aspergillosis.

BACKGROUND: There are a number of different manifestations of pulmonary aspergillosis. This study aims to review the radiology, presentation, and histological features of lung nodules caused by Aspergillus spp. METHODS: Patients were identified from a cohort attending our specialist Chronic Pulmonary Aspergillosis clinic. Patients with cavitating lung lesions, with or without fibrosis and those with aspergillomas or a diagnosis of invasive aspergillosis were excluded. Demographic, laboratory, and clinical data and radiologic findings were recorded. RESULTS: Thirty-three patients with pulmonary nodules and diagnostic features of aspergillosis (histology and/or laboratory findings) were identified. Eighteen (54.5 %) were male, mean age 58 years (range 27-80 years). 19 (57.6 %) were former or current smokers. The median Charleston co-morbidity index was 3 (range 0-7). All complained of a least one of; dyspnoea, cough, haemoptysis, or weight loss. None reported fever. Ten patients (31 %) did not have an elevated Aspergillus IgG, and only 4 patients had elevated Aspergillus precipitins. Twelve patients (36 %) had a single nodule, six patients (18 %) had between 2 and 5 nodules, 2 (6 %) between 6 and 10 nodules and 13 (39 %) had more than 10 nodules. The mean size of the nodules was 21 mm, with a maximum size ranging between 5-50 mm. No nodules had cavitation radiographically. The upper lobes were most commonly involved. Histology was available for 18 patients and showed evidence of granulation tissue, fibrosis, and visualisation of fungal hyphae. CONCLUSION: Pulmonary nodules are a less common manifestation of aspergillosis in immunocompetent patients. Distinguishing these nodules from other lung pathology may be difficult on CT findings alone.

Solitary pulmonary nodules due to non-tuberculous mycobacteriosis among 28 resected cases.

BACKGROUND: In some patients, non-tuberculous mycobacteria (NTM) infections manifest in solitary nodules (solitary nodular [SN] type) generally caused by Mycobacterium avium complex (MAC). In patients treated using surgical resection, the American Thoracic Society guidelines state that postoperative chemotherapy is not necessary in the absence of lesions, although there have been a few reports of such cases. METHODS: Twenty-eight patients diagnosed with NTM who underwent solitary pulmonary nodule resection at Toneyama Hospital, Osaka, Japan, between January 2000 and October 2012 were enrolled. We evaluated the influence of the surgical procedure and chemotherapy on outcomes in this retrospective study. RESULTS: Of the 28 patients, 12 were males and 16 were females; the mean age was 58.6 ± 13.2 years. Twenty-five patients were asymptomatic and bronchoscopy was performed in 18; only 2 had a definitive diagnosis of NTM. The pathogen responsible was MAC in 27 patients and M. kansasii in 1. The surgical procedure used was wedge resection in 22 patients, segmentectomy in 1 and lobectomy in 5. Postoperative chemotherapy was administered to 9 patients. Twenty-six patients had no recurrence. CONCLUSION: We believe that wedge resection is a valid surgical intervention for SN type NTM; additional postoperative chemotherapy is unnecessary in cases with no residual lesions in the operated lung lobe.

Characteristics of pulmonary Mycobacterium avium complex disease diagnosed later in follow-up after negative mycobacterial study including bronchoscopy.

BACKGROUND: We occasionally experience cases suspected of pulmonary Mycobacterium avium complex (MAC) disease without positive bacterial cultures. OBJECTIVE: To evaluate features of pulmonary MAC cases diagnosed later in the follow-up after negative intensive investigation. METHODS: We defined and compared three groups; the first study negative (FSN) group, the first study positive (FSP) group, and MAC negative group. The FSN group consisted of patients negative for MAC isolation by bronchial washing performed between 2007 and 2011, but positive later. Patients with positive MAC cultures in the first study were incorporated into the FSP group. MAC negative group consisted of MAC suspects without MAC isolation in the follow-up. RESULTS: Twenty-four patients were classified as FSN group, 61 as MAC negative group and 265 as FSP group. FSN group exhibited more solitary nodule pattern (n = 7 in FSN, n = 6 in FSP; p < 0.001) and less nodular/bronchiectatic (NB) diseases (n = 17 in FSN, n = 245 in FSP; p < 0.001). When limited to NB type, the FSP group had more cavitations (6% in FSN, 32% in FSP; p = 0.028). Patients with more than three lung lobes involved were more frequent in the FSN group compared with FSP group with negative sputum cultures (65% vs 34%; p = 0.014) and with MAC negative group (65% vs 28%; p = 0.009). CONCLUSIONS: Patients diagnosed as pulmonary MAC disease in the follow-up duration tend to show solitary nodular pattern or NB pattern without cavitation. In FSN patients with NB pattern, more lung lobes were involved in the first study, suggesting subsequent MAC infection onto the underlying ectatic bronchi.

Nocardiosis presenting as a lung mass in a kidney transplant recipient.

Nocardiosis is a potentially life-threatening disease in renal transplant recipients. It is an uncommon infection with high lethality if left untreated. We report a case of a 67 year-old kidney transplant recipient who developed pulmonary nocardiosis and presented with pleural effusion along with an underlying lung mass, which was successfully treated with trimethoprim-sulphamethoxazole in conjunction with a reduction in immunosuppressive therapy. Five months later, graft function remains stable with complete regression of radiological abnormalities and absence of symptoms. Nocardiosis should be suspected in the presence of pulmonary symptoms in a transplant patient with unusual radiological presentation.

Single nodular opacity of granulomatous pneumocystis jirovecii pneumonia in an asymptomatic lymphoma patient.

The radiologic findings of a single nodule from Pneumocystis jirovecii pneumonia (PJP) have been rarely reported. We described a case of granulomatous PJP manifesting as a solitary pulmonary nodule with a halo sign in a 69-year-old woman with diffuse large B cell lymphoma during chemotherapy. The radiologic appearance of the patient suggested an infectious lesion such as angioinvasive pulmonary aspergillosis or lymphoma involvement of the lung; however, clinical manifestations were not compatible with the diseases. The nodule was confirmed as granulomatous PJP by video-assisted thoracoscopic surgery biopsy.

Single Nodular Opacity of Granulomatous Pneumocystis Jirovecii Pneumonia in an Asymptomatic Lymphoma Patient

The radiologic findings of a single nodule from Pneumocystis jirovecii pneumonia (PJP) have been rarely reported. We described a case of granulomatous PJP manifesting as a solitary pulmonary nodule with a halo sign in a 69-year-old woman with diffuse large B cell lymphoma during chemotherapy. The radiologic appearance of the patient suggested an infectious lesion such as angioinvasive pulmonary aspergillosis or lymphoma involvement of the lung; however, clinical manifestations were not compatible with the diseases. The nodule was confirmed as granulomatous PJP by video-assisted thoracoscopic surgery biopsy.

Pulmonary hyalinizing granuloma detected in a family member after confirmation of tuberculosis in his father.

Pulmonary hyalinizing granuloma (PHG) is an uncommon lung disease that usually presents as bilateral multiple nodules, and more rarely as a solitary nodule. An exaggerated immune response to antigenic stimuli resulting from infection or an autoimmune process has been suggested as the cause of PHG. Here, we describe a rare case of solitary PHG that was detected in a family member after tuberculosis had been confirmed in his father, without any background of infectious disease or autoimmune abnormality.

Comparison of quantitatively analyzed dynamic area-detector CT using various mathematic methods with FDG PET/CT in management of solitary pulmonary nodules.

OBJECTIVE: The objective of our study was to prospectively compare the capability of dynamic area-detector CT analyzed with different mathematic methods and PET/CT in the management of pulmonary nodules. SUBJECTS AND METHODS: Fifty-two consecutive patients with 96 pulmonary nodules underwent dynamic area-detector CT, PET/CT, and microbacterial or pathologic examinations. All nodules were classified into the following groups: malignant nodules (n = 57), benign nodules with low biologic activity (n = 15), and benign nodules with high biologic activity (n = 24). On dynamic area-detector CT, the total, pulmonary arterial, and systemic arterial perfusions were calculated using the dual-input maximum slope method; perfusion was calculated using the single-input maximum slope method; and extraction fraction and blood volume (BV) were calculated using the Patlak plot method. All indexes were statistically compared among the three nodule groups. Then, receiver operating characteristic analyses were used to compare the diagnostic capabilities of the maximum standardized uptake value (SUVmax) and each perfusion parameter having a significant difference between malignant and benign nodules. Finally, the diagnostic performances of the indexes were compared by means of the McNemar test. RESULTS: No adverse effects were observed in this study. All indexes except extraction fraction and BV, both of which were calculated using the Patlak plot method, showed significant differences among the three groups (p < 0.05). Areas under the curve of total perfusion calculated using the dual-input method, pulmonary arterial perfusion calculated using the dual-input method, and perfusion calculated using the single-input method were significantly larger than that of SUVmax (p < 0.05). The accuracy of total perfusion (83.3%) was significantly greater than the accuracy of the other indexes: pulmonary arterial perfusion (72.9%, p < 0.05), systemic arterial perfusion calculated using the dual-input method (69.8%, p < 0.05), perfusion (66.7%, p < 0.05), and SUVmax (60.4%, p < 0.05). CONCLUSION: Dynamic area-detector CT analyzed using the dual-input maximum slope method has better potential for the diagnosis of pulmonary nodules than dynamic area-detector CT analyzed using other methods and than PET/CT.