Rasamsonia argillacea (formerly known as Geosmithia argillacea) is a fungus recently recognized as a pathogen of immunocompromised patients. Here we report the first case of Rasamsonia infection in an immunocompetent host, presenting as a pulmonary and aortic graft infection. Its morphological similarity to nonpathogenic Penicillium species delayed the diagnosis and initiation of appropriate treatment. CASE REPORTA 56-year-old man presented to our clinic in 2009 for evaluation of progressive, chronic necrotizing pulmonary aspergillosis. In 1998, he had been diagnosed with an aneurysm of the proximal descending thoracic aorta, believed to be secondary to a traumatic aortic injury suffered during a motor vehicle accident in 1979. An endovascular stent graft was placed for treatment of his aortic aneurysm, and he was followed with serial imaging. On routine follow-up imaging of his aneurysm in 2005, he was found to have a cavitary lesion in the left upper lobe of his lung. A bronchoscopy was performed, and cultures revealed Aspergillus fumigatus. He was treated with itraconazole following this diagnosis, and subsequent chest computed tomography (CT) later that year revealed radiographic improvement. In January 2009, repeat CT showed an increase in the size of the cystic cavities in the left lung, and new lesions were visualized in the left lower lobe. He was referred to our clinic for evaluation.At the time of his visit, the patient described a mild cough and scant hemoptysis several times per week. He denied any constitutional symptoms or pleuritic chest pain. Given the concern for a poorly controlled Aspergillus infection, a decision was made to change to voriconazole, but due to financial constraints, itraconazole was continued. The patient continued to suffer from hemoptysis. The close proximity of the pulmonary infection to the aortic aneurysm was concerning for future direct spread of infection, so the decision of surgical therapy was made. In August 2010, the patient underwent a left lower lobectomy with resection of the pulmonary cavity. The infection was found to abut the aortic aneurysm, but there was no evidence of invasion. Pathological examination of the resected lung lesion revealed pleural and subpleural fibrosis with septate fungal hyphae thought to be consistent with an Aspergillus species (Fig. 1). The intraoperative fungal cultures were reported as Penicillium. It was concluded that the cultures at the time of surgery were negative for Aspergillus due to the concurrent itraconazole therapy and that the Penicillium species was a colonizer, not a pathogen. Shortly after surgery, the patient was switched to voriconazole at 200 mg by mouth twice daily.Following surgery, the patient continued to complain of cough and hemoptysis. A CT scan in September 2011 revealed communication between the superior lingual bronchus and new left-sided loculated hydropneumothorax, as well as fluid within the aneurysm sac near the aortic graft (Fig. 2). These findings were very suspicious for progressive infection now i...
Cardiac electrophysiology is an evolving specialty that has seen rapid advances in recent years. Concurrently, there has been much progress in the field of cardiac imaging. Electrophysiologists are increasingly requesting cross-sectional imaging in advance of many procedures. Pulmonary vein isolation and left atrial appendage (LAA) occlusion are now an established treatment options for atrial fibrillation. In patients undergoing pulmonary vein isolation, applications of computed tomography (CT) include evaluating the left atrial and pulmonary venous anatomy, excluding LAA thrombus and assessing for pulmonary vein stenosis. In those undergoing LAA occlusion, CT may be of value in assessing the size, position, and morphology of the LAA as well as for determining correct positioning of the device and evaluating for peri-device leak. Implantable cardiac devices are now commonly used in the management of cardiac failure and cardiac arrhythmias. Applications of CT prior to device implantation include detecting myocardial scar, evaluating for mechanical dyssynchrony as well as visualising the coronary venous anatomy.
CTNB offers a high yield in establishing a histopathologic diagnosis of subsolid pulmonary lesions, with both ground-glass and solid-predominance. The pure ground-glass category of lesions requires further research to determine the true diagnostic yield and diagnostic accuracy of core needle biopsies.
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