OrganizingPneumoniabyParagonimiasisandCoexistent ... · 2019. 7. 31. · hydropneumothorax, pulmonary nodules or air-space con-solidation, and cysts [1]. Of the nodular lesions, subpleural

Hindawi Publishing CorporationCase Reports in RadiologyVolume 2011, Article ID 692405, 4 pagesdoi:10.1155/2011/692405

Case Report

Organizing Pneumonia by Paragonimiasis and CoexistentAspergilloma Manifested as a Pulmonary Irregular Nodule

In Jae Lee,1, 2 Jinwon Seo,3 and Dong Gyu Kim4

1 Department of Radiology, Hallym University College of Medicine, Seoul 150-030, Republic of Korea2 Department of Radiology, Hallym University Sacred Heart Hospital, 896, Pyungchon-dong, Dongan-gu,Anyang-city, Gyeonggi-do 431-070, Republic of Korea

3 Department of Pathology, Hallym University College of Medicine, Seoul 150-030, Republic of Korea4 Department of Internal Medicine, Hallym University College of Medicine, Seoul 150-030, Republic of Korea

Correspondence should be addressed to In Jae Lee, [email protected]

Received 16 May 2011; Accepted 5 June 2011

Academic Editors: E. Marchiori and R. Murthy

Copyright © 2011 In Jae Lee et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Organizing pneumonia by paragonimiasis and coexistent aspergilloma as a pulmonary nodule is a rare case of lung disease. Itsradiographic or CT feature has not been described before in the radiologic literature. We present organizing pneumonia by para-gonimiasis and coexistent aspergilloma manifested as a pulmonary irregular nodule on CT.

1. Introduction

The CT features of pleuropulmonary paragonimiasis includepleural effusion, hydropneumothorax, pulmonary noduleor air-space consolidation, and cysts [1]. The classical CTfeature of aspergilloma is a discrete lesion within the cavitiesof healed pulmonary tuberculosis and other fibrotic lung dis-eases [2]. To our knowledge, there was rare radiologic reportabout organizing pneumonia by pulmonary paragonimiasisand coexistent aspergilloma. We demonstrate organizingpneumonia by paragonimiasis and coexistent aspergillomamanifested as a pulmonary irregular nodule on CT.

2. Case Report

A 48-year-old woman was found to have an incidental rightlung nodule on a routine chest radiograph (Figure 1). Thelesion was dumbbell-shaped nodule in the right lung base.She was asymptomatic including without any chest dis-comfort. The patient had no history of tobacco smoking,pneumothorax or pleural effusion. Physical examination andblood tests including serum eosinophil count were normal.CT scan of the thorax confirmed the presence of a right lowerlobe posterior basal segment nodule (Figures 2 and 3). Thelesion was irregular 2.5 cm solid subpleural nodule with focal

peripheral ground-glass opacity and partly spiculate margin.The lesion had partly broad pleural attachment and severalpleural tags with adjacent pleural thickening and extrapleuralfat thickening. The lesion was slightly heterogeneously lowattenuation without calcification. There was no significantenhancement of the lesion following intravenous contrastadministration. Surrounding panlobular emphysema wasalso noted. There was no large hilar or mediastinal lymphnode, pleural effusion, or pneumothorax. Other lung lesionwas not noted on CT. Other respiratory examinations includ-ing pulmonary function test and bronchoscopy showed noremarkable finding.

A wedge resection was performed of the nodule in theposterior basal segment of the right lower lobe. About 2.5 cmsoft nodule was detected in this area with pleural adhesion.Yellow punctate spots were also noted in the adjacent visceral,parietal pleura, and diaphragm. On histopathology, periph-eral organizing pneumonia by paragonimiasis and coexistentsmall subpleural aspergilloma was noted (Figure 4). Therewere dilated peripheral bronchus and terminal bronchiolewithin the organizing pneumonia. The dilated peripheralbronchus and terminal bronchiole were filled with necroticmaterial and scattered degenerated parasitic eggs (Figure 5).On the high power field view of microscopic examination,intra-alveolar macrophages, scattered parasitic eggs, and

2 Case Reports in Radiology

Figure 1: Chest radiograph shows dumbbell-shaped nodule (ar-row) in right lung base.

Figure 2: Axial contrast-enhanced CT scan shows irregular 2.5 cmsolid irregular nodule with slightly heterogeneously low attenuationwithout significant enhancement. Note partly broad pleural attach-ment with adjacent pleural thickening and extrapleural fat thicken-ing.

Figure 3: CT scan at lung window setting shows subpleural nodulewith pleural tags and partly spiculate margin. Note panlobular em-physema in adjacent area.

Figure 4: Photomicrograph of H&E stained pathologic specimenfrom wedge resection of lung shows histologic changes compatiblewith organizing pneumonia. Note a small subpleural cavitary lesion(arrow) and a dilated small bronchus filled with necrotic materials(arrowhead).

some infiltrating eosinophils were noted. These scattereddegenerated parasitic eggs were morphologically consistentwith ova of Paragonimus westermani. However, there wasno living larva in the area of organizing pneumonia. In theperipheral portion of the organizing pneumonia, smallsubpleural intracavitary aspergilloma was also combined(Figure 6). The aspergilloma was about 2 mm in diameter.Fibrosis and foreign body reaction were also noted in thesurrounding pulmonary parenchyma. Final diagnosis wasorganizing pneumonia by paragonimiasis and coexistent as-pergilloma.

3. Discussion

Paragonimiasis is an infection caused by the lung flukeParagonimus westermani. The disease is endemic in SoutheastAsia and the Far East [1, 3–5]. The common CT findingsof pleuropulmonary paragonimiasis include pleural effusion,hydropneumothorax, pulmonary nodules or air-space con-solidation, and cysts [1]. Of the nodular lesions, subpleuralor subfissural nodule with low attenuation is common [1].Bronchial wall thickening is also common CT finding, andit reflects inflammatory process along the airway [3, 4]. Inthis case, the lesion was irregular subpleural solid nodulewith internal low attenuation and focal peripheral ground-glass opacity. Considering other report about pulmonaryparagonimiasis, this focal peripheral opacity may repre-sent hemorrhage or inflammation in the lesion [4]. Onhistopathology of this case, multiple degenerated parasiticeggs with chronic inflammation and focal hemorrhage werenoted, and this finding may represent low attenuation ofthe lesion and surrounding focal ground-glass opacity. Thedegenerated parasitic eggs were morphologically consistentwith ova of Paragonimus westermani. Organizing pneumoniawas developed by paragonimiasis in this case. However, therewas rare radiologic report about organizing pneumonia byparagonimiasis. No significant enhancement of the lesionon CT was possibly due to necrotic material within the

Case Reports in Radiology 3

(a) (b)

Figure 5: (a) The dilated bronchus is filled with necrotic materials and scattered parasitic eggs (arrows) (H&E, ×100). (b) Scattered degene-rated parasitic eggs (arrow) morphologically consistent with ova of Paragonimus westermani, intra-alveolar macrophages, and someinfiltrating eosinophils (arrowheads) are noted in organizing pneumonia area (H&E, ×200).

dilated bronchus and very mild chronic inflammation bydegenerated parasitic eggs. Living larva was not detected onhistopathologic examination, and it supports no presence ofsubpleural streaky opacity suggesting worm migration trackon CT in this case [1, 3]. It also supports no elevation ofserum eosinophil count in this patient. Degenerated parasiticeggs were scattered within dilated bronchi, bronchioles, andalveolar spaces, and bronchial walls were thickened. Thesefindings support inflammatory process along the airway[3, 4]. Pleural or fissural thickening is common in parago-nimiasis [1]. In this case, adjacent pleural and extrapleuralfat thickening was also noted without pleural effusion.Considering degenerated parasitic worm on histopathology,these findings suggested chronic organizing pneumonia byparagonimiasis. And there was small combined subpleuralintracavitary aspergilloma in the peripheral portion of thisorganizing pneumonia. However, the cavity was not notedon CT. In this case, the cavity could be formed by parago-nimiasis considering other radiologic reports about it [1, 3].

Radiologically aspergilloma is a discrete lesion thatAspergillus fumigatus colonizes within the cavities of healedpulmonary tuberculosis and other fibrotic lung diseases [2].The common sites of aspergillomas are upper lobe and lowerlobe superior segment [6]. A typical radiologic finding ofaspergilloma is a solid, round, or oval mass with soft-tissueopacity within a lung cavity, manifesting an “air crescentsign” without significant enhancement [6]. In this caseof intracavitary aspergilloma, air halo was interrupted onradiographs and CT probably due to the limit of radio-graphic or CT resolution. Moreover the lesion showed nosignificant enhancement, and it was located in the lower lobeposterior basal segment. The intracavitary aspergilloma was

Figure 6: The subpleural cavitary lesion is filled with fungus ball,and the surrounding stroma shows fibrosis and foreign bodyreaction (H&E, ×100). These fungal hyphae are highlighted onGomori methenamine silver stain (lower right, ×200) and are mor-phologically compatible with aspergillus species.

small subpleural lesion in the periphery of organizing pneu-monia in this case. Considering the location of the lesionand characteristics of paragonimiasis, the cavity containingaspergilloma could be formed by this parasite. However,there was no radiologic report about aspergilloma followingorganizing pneumonia by paragonimiasis. Considering thecause of lung lesion and location of the aspergilloma in thiscase, it is different from the usual features of pulmonaryaspergilloma.

In conclusion, organizing pneumonia might be occurredby paragonimiasis and aspergilloma can be combined, and itcan be manifested as a pulmonary irregular nodule.

4 Case Reports in Radiology

References

[1] T. S. Kim, J. Han, S. S. Shim et al., “Pleuropulmonary parag-onimiasis: CT findings in 31 patients,” American Journal ofRoentgenology, vol. 185, no. 3, pp. 616–621, 2005.

[2] C. M. Roberts, K. M. Citron, and B. Strickland, “Intrathoracicaspergilloma: role of CT in diagnosis and treatment,” Radiology,vol. 165, no. 1, pp. 123–128, 1987.

[3] J. G. Im, H. Y. Whang, W. S. Kim, M. C. Han, Y. S. Shim, and S.Y. Cho, “Pleuropulmonary paragonimiasis: radiologic findingsin 71 patients,” American Journal of Roentgenology, vol. 159, no.1, pp. 39–43, 1992.

[4] M. Kuroki, H. Hatabu, H. Nakata et al., “High-resolution com-puted tomography findings of P. westermani,” Journal of Tho-racic Imaging, vol. 20, no. 3, pp. 210–213, 2005.

[5] T. Singcharoen and W. Silprasert, “CT findings in pulmonaryparagonimiasis,” Journal of Computer Assisted Tomography, vol.11, no. 6, pp. 1101–1102, 1987.

[6] Y. Park, T. S. Kim, C. A. Yi, E. Y. Cho, H. Kim, and Y. S.Choi, “Pulmonary cavitary mass containing a mural nodule:differential diagnosis between intracavitary aspergilloma andcavitating lung cancer on contrast-enhanced computed tomog-raphy,” Clinical Radiology, vol. 62, no. 3, pp. 227–232, 2007.

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Documents

OrganizingPneumoniabyParagonimiasisandCoexistent ... · 2019. 7. 31. · hydropneumothorax, pulmonary nodules or air-space con-solidation, and cysts [1]. Of the nodular lesions, subpleural