SCIENTIFIC
Recurrent Pneumothorax and a Solitary Pulmonary Nodule : A Case Report of a Rare Sequelae of Histoplasmosis
AUTHORS :
Hamrick , L . West Virginia University Department of Pediatrics , Internal Medicine and Pediatrics Residency Program
Balakrishnan , B . West Virginia University Department of Medicine , Section of Pulmonary Critical Care , and Sleep Medicine .
ABSTRACT
Histoplasmosis is a fungal infection caused by a histoplasma species known to be endemic to the Ohio River valley region . Commonly encountered as a solitary pulmonary nodule , histoplasmosis has both acute and chronic forms . We present a case of a 36-year-old woman with multiple episodes of pneumothorax who was ultimately diagnosed with pulmonary histoplasmosis , demonstrating a complication of chronic pulmonary histoplasmosis , which has not been reported in the medical literature .
CASE PRESENTATION
A 36-year-old otherwise healthy woman from the Ohio River valley region in western West Virginia presented for management of a solitary pulmonary nodule ( SPN ). The patient was a nonsmoker and denied any significant occupational or environmental exposures . Her physical examination , including vital signs , was unremarkable . Her history was significant for three episodes of spontaneous left-sided pneumothoraxes that occurred 12 years ago . At that time , she was found to have a 7 mm calcified nodule abutting the pleural lining at the left lower lobe . She underwent chemical pleurodesis and was lost to follow-up . A computed tomogram ( CT ) of the chest completed during an emergency visit for chest pain now several years later demonstrated interval growth of the solitary nodule to 10 mm ( Figure 1 ). The nodule was mildly hypermetabolic ( 5.7 standardized uptake value [ SUV ]) on a positron emission tomography ( PET ) scan ( Figure 2 ), and it was decided that she undergo wedge resection of the nodule . Pathological analysis of the resected nodule revealed benign granulomatous tissues ( Figure 3 ) and scant Histoplasma organisms ( Figure 4 ). As the patient was asymptomatic and the SPN was now resected , a treatment plan constituting watchful monitoring with repeat imaging was agreed upon . Antifungal therapy was not initiated .
DISCUSSION
Pulmonary nodule identification has become more common with the increasing use of chest CT . In the United States ( US ), approximately 70 million CT scans are done each year . 1 There are a multitude of etiologies for pulmonary nodules , including malignant conditions ; benign lipomas ; non-infectious granulomas such as in rheumatoid arthritis , vasculitis , vascular anomalies , and tuberculosis ; and mycotic infections such as histoplasmosis . 2 There are various approaches to risk assessment and management for patients with nodules with guidelines published from the Fleischner
FIGURE 1
Society , American College of Chest Physicians , National Comprehensive Cancer Network , and others . 3 Many of these clinical guidelines recommend PET for evaluation of nodules ≥ 8 mm detected on chest CT . 2 A lesion ’ s PET uptake activity is compared to that of the surrounding tissue and quantified by its SUV . 4 It is vital to consider , however , that the sensitivity and specificity of PET for the detection of malignancy are ~ 90 % and 75 %, respectively , 5 as the tracer ,
Non contrasted CT of the chest showing the left lower lobe 10mm pulmonary nodule .
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