Central America Hemoptysis Case Analysis
Case Name
Case Name
A man from Central
America with a 2-month
history of hemoptysis
Presented for blind review
HPI:
40 yo M from Central America presented with a 2
month history of hemoptysis. He reported red blood
mixed with yellow sputum. Also noted dyspnea on
exertion and diffuse pleuritic chest pain. He
complained of night sweats, decreased appetite and
weight loss.
Denied fevers or chills. Denied any other sites of
bleeding. Denied sick contacts, including anyone with
tuberculosis.
PMH:
None
Meds:
None
SH:
Immigrated to the U.S. from Central
America 2 years ago. Remote history of
smoking. Denied drug of alcohol use.
PE:
T: 99.8
°F
, BP: 120/52, HR: 62, RR: 18, O2
saturation: 90% on 2L.
Pleasant, cachectic male, no distress.
HEENT: within normal limits, no oral lesions.
Chest: Crackles at left base. Remainder of exam
normal.
Studies:
WBC 14.6 (80%P). Hb 12.6. Platelets 502.
Chemistries & LFTs: normal.
Sputum gram stain: many PMN & mononuclear cells,
no organisms.
Sputum AFB smear negative x 3
HIV ELISA: negative
Chest imaging
Multiple scattered nodular opacities w/ cavitary lesions
Extensive mediastinal and hilar LAD
Irregular foci of airspace disease, especially in BLL
Diagnostic testing
•
Patient underwent bronchoscopy with BAL and
biopsy. Stains from tissue revealed:
Lung, GMS stain, 40X (Courtesy of Judith Rhodes, PhD)
Differential Diagnosis
1.
Histoplasma capsulatum
2.
Blastomyces dermatidis
3.
Cryptococcus neoformans
4.
Paracoccidioides brasiliensis
5.
Pneumocystis jiroveci
Diagnosis and Follow-up
•
Biopsy revealed acute and chronic
inflammation, with poorly-formed granulomas.
AFB stain negative. Fungal organisms were
seen that were morphologically consistent
with
Paracoccidioides.
•
6 weeks later, the fungal culture grew
Paracoccidioides brasiliensis.
•
He was treated with oral itraconazole, with
clinical improvement: the hemoptysis and
dyspnea resolved, his appetite improved and
he went back to work.
Paracoccidioides brasiliensis
•
Dimorphic fungus
•
Multiple sporulation
of small buddings
covering whole surface
of the mother cell
•
Steering wheel
appearance=
PATHOGNOMONIC
Paracoccidioidomycosis
•
Endemic in Latin America, between
Mexico 20
º
N and Argentina 35
º
S
•
Most published cases from Brazil,
Venezuela, Colombia
•
Not described in the Caribbean or Chile
•
Adult, chronic progressive form
•
Reactivation of quiescent lung lesions
•
Fever is rare
•
Symptoms include: weight loss, malaise, cough,
eventually hemoptysis
•
May be misdiagnosed as TB (which can coexist)
Paracoccidioidomycosis: Clinical aspects
•
Adult disseminated form
•
Multifocal dissemination to skin, oral mucosa,
tongue, palate, vocal cords
•
Skin lesions (25%): hyperkeratotic plaques or
ulcerative crusted lesions
•
Cervical, axillary, mediastinal lymphadenopathy
•
Adrenal insufficiency (15%)
•
Can also involve spleen, liver, male GU tract,
vascular system
Paracoccidioidomycosis: Clinical aspects
(Continued)
•
Visualization by direct
microscopy (GMS,
H&E stains)
•
Isolation in culture
can take >1 month
•
Must be handled
inside biohazard
safety hood
Lung, H&E stain, 40X
(Courtesy of Judith Rhodes, PhD)
Paracoccidioidomycosis: Diagnosis
Paracoccidioidomycosis of the lung
Final Diagnosis
Contributor:
Presented for blind review.
A 40-year-old male from Central America presented with 2-month hemoptysis history, dyspnea, chest pain, weight loss, and night sweats. Initial tests showed nodular opacities and cavitary lesions. Biopsy revealed Paracoccidioides infection treated with itraconazole. Clinical improvement noted.
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Presentation Transcript
Case Name A man from Central America with a 2-month history of hemoptysis Presented for blind review
HPI: 40 yo M from Central America presented with a 2 month history of hemoptysis. He reported red blood mixed with yellow sputum. Also noted dyspnea on exertion and diffuse pleuritic chest pain. He complained of night sweats, decreased appetite and weight loss. Denied fevers or chills. Denied any other sites of bleeding. Denied sick contacts, including anyone with tuberculosis.
PMH: None Meds: None SH: Immigrated to the U.S. from Central America 2 years ago. Remote history of smoking. Denied drug of alcohol use.
PE: T: 99.8F, BP: 120/52, HR: 62, RR: 18, O2 saturation: 90% on 2L. Pleasant, cachectic male, no distress. HEENT: within normal limits, no oral lesions. Chest: Crackles at left base. Remainder of exam normal. Studies: WBC 14.6 (80%P). Hb 12.6. Platelets 502. Chemistries & LFTs: normal. Sputum gram stain: many PMN & mononuclear cells, no organisms. Sputum AFB smear negative x 3 HIV ELISA: negative
Chest imaging Multiple scattered nodular opacities w/ cavitary lesions Extensive mediastinal and hilar LAD Irregular foci of airspace disease, especially in BLL
Diagnostic testing Patient underwent bronchoscopy with BAL and biopsy. Stains from tissue revealed: Lung, GMS stain, 40X (Courtesy of Judith Rhodes, PhD)
Differential Diagnosis Histoplasma capsulatum Blastomyces dermatidis Cryptococcus neoformans Paracoccidioides brasiliensis Pneumocystis jiroveci 1. 2. 3. 4. 5.
Diagnosis and Follow-up Biopsy revealed acute and chronic inflammation, with poorly-formed granulomas. AFB stain negative. Fungal organisms were seen that were morphologically consistent with Paracoccidioides. 6 weeks later, the fungal culture grew Paracoccidioides brasiliensis. He was treated with oral itraconazole, with clinical improvement: the hemoptysis and dyspnea resolved, his appetite improved and he went back to work.
Paracoccidioides brasiliensis Dimorphic fungus Multiple sporulation of small buddings covering whole surface of the mother cell Steering wheel appearance= PATHOGNOMONIC
Paracoccidioidomycosis Endemic in Latin America, between Mexico 20 N and Argentina 35 S Most published cases from Brazil, Venezuela, Colombia Not described in the Caribbean or Chile
Paracoccidioidomycosis: Clinical aspects Adult, chronic progressive form Reactivation of quiescent lung lesions Fever is rare Symptoms include: weight loss, malaise, cough, eventually hemoptysis May be misdiagnosed as TB (which can coexist)
Paracoccidioidomycosis: Clinical aspects (Continued) Adult disseminated form Multifocal dissemination to skin, oral mucosa, tongue, palate, vocal cords Skin lesions (25%): hyperkeratotic plaques or ulcerative crusted lesions Cervical, axillary, mediastinal lymphadenopathy Adrenal insufficiency (15%) Can also involve spleen, liver, male GU tract, vascular system
Paracoccidioidomycosis: Diagnosis Visualization by direct microscopy (GMS, H&E stains) Isolation in culture can take >1 month Must be handled inside biohazard safety hood Lung, H&E stain, 40X (Courtesy of Judith Rhodes, PhD)
Final Diagnosis Paracoccidioidomycosis of the lung Contributor: Presented for blind review.
