Cavitated Pulmonary Nodules: Systemic Mycoses as a Differential Diagnosis of Rheumatological Diseases

Abstract

BACKGROUNDIn the etiological investigation of cavitated pulmonary nodules, special attention should be paid to the possibility that these correspond to the pulmonary manifestation of systemic granulomatous diseases. Among those of infectious etiology, tuberculosis and systemic mycoses, such as histoplasmosis and paracoccidioidomycosis, stand out. Among those of inflammatory etiology, sarcoidosis and granulomatosis with polyangiitis should be remembered. The presence of systemic disease, with constitutional symptoms and involvement of other organs, increases the probability of having one of these causes. CASE REPORTA 60-year-old male, paving technician, was hospitalized for investigation of dry cough, progressive dyspnea, weight loss and fever that had started 40 days ago. Laboratory tests with altered acute phase tests, chest X-ray with sparse consolidations. Antibiotic therapy with ceftriaxone was started and chest computed tomography was performed, which showed the presence of multiple solid nodules with irregular contours, some cavitated, diffuse and confluent in both lungs. TRM-TB undetectable; PPD, serology for hepatitis, HIV and HTLV nonreactive. In consultation with the Rheumatology team, assistance in differential diagnosis was requested. The patient was in good general condition, without involvement of other organs, ANA reagent homogeneous nucleolar pattern with negative fractionation, negative ANCA, facial sinus tomography without alterations. He referred to a recent stay in "Zona da Mata", in the state of Minas Gerais for work. A suspicion of systemic mycosis was raised, bronchoalveolar lavage was performed, with bacterial culture without growth, negative AFB, negative fungal investigation, oncotic cytology with absence of neoplastic cells, anatomopathological evidence showing a mild nonspecific chronic inflammatory process and focal squamous metaplasia. Extended propaedeutic, with segmentectomy for lung biopsy. Macroscopically, the lung surface was irregular, with a hardened and multinodular consistency on palpation diffusely. Pathology with findings compatible with pulmonary paracoccidioidomycosis-Paracoccidioides brasiliensis. Treatment with itraconazole was initiated and referred to the infectiology outpatient clinic for follow-up. CONCLUSIONAs seen in the case report above, in the care of patients who present with constitutional symptoms associated with nodular pulmonary involvement, it is important for the medical team to have high suspicion for granulomatous diseases, especially if the epidemiology is compatible. These mimic each other, making the differential diagnosis difficult, often requiring extensive propaedeutic.