The Uncommon Suspect: Pseudomonas aeruginosa and Cavitary Lung Lesions in an Immunocompetent Patient.

Cavitary lung lesions pose a formidable diagnostic challenge due to their multifaceted etiologies. While tuberculosis and other prevalent pathogens typically dominate discussions, instances of community-acquired Pseudomonas aeruginosa (P. aeruginosa) pneumonia leading to cavitation in immunocompetent individuals remain exceptionally rare. Herein, we present a compelling case of such pneumonia in a 61-year-old man with a past medical history of hypertension and coronary artery disease who presented with cough, chest pain, and subjective fever. Chest imaging revealed cavitary lung lesions, which is atypical for community-acquired pneumonia (CAP). Initial workup excluded common CAP pathogens, following which bronchoscopy with bronchoalveolar lavage (BAL) definitively diagnosed P. aeruginosa, prompting targeted antibiotic therapy. Treatment led to clinical and radiographic improvement. P. aeruginosa rarely causes CAP, especially in immunocompetent patients, and cavitary lesions further complicate diagnosis. This case highlights the importance of considering P. aeruginosa in CAP with unusual features and emphasizes the utility of bronchoscopy with BAL for diagnosis and guiding management.

Clinical and radiological features associated with rupture of pulmonary artery pseudoaneurysm: a retrospective study.

BACKGROUND: Hemoptysis resulting from rupture of the pulmonary artery pseudoaneurysm (PAP) is massive and fatal, while factor contributing to the rupture of pseudoaneurysm remains elusive. This study aimed to elucidate the clinical and radiological features of PAP and identify the risk factors associated with rupture. METHODS: Patients who developed hemoptysis with PAP were collected from January 2019 to December 2022 retrospectively. Clinical data of the demographic characteristics, radiological findings, treatment strategies, and prognosis were collected. A comparative analysis was performed on the characteristics in the ruptured and non-ruptured cases. RESULTS: A total of 58 PAPs were identified in the 50 patients. The most common causes were infection (86%) and cancer (8%). The PAPs were located predominantly in the upper lobes of both lungs, and 57 (99.3%) were distributed in the segmental or subsegmental pulmonary arteries. The median diameter was 6.1(4.3-8.7) mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations, with the median diameter of the cavity being 18.9 (12.4-34.8) mm. Rupture of pseudoaneurysm occurred in 21 cases (42%). Compared to unruptured group, the ruptured group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, p < 0.001), larger pseudoaneurysm diameter (8.1 ± 3.2 mm vs. 6.0 ± 2.3 mm, p = 0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, p = 0.027), and larger cavitation diameters (32.9 ± 18.8 mm vs. 15.7 ± 8.4 mm, p = 0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group [23.9 ± 7.4 mmHg vs. 19.2 ± 5.0 mmHg, p = 0.011]. Endovascular treatment was successfully performed in all 21 patients with ruptured PAP, of which the clinical success rate was 96.0%. Five patients experienced recurrent hemoptysis within one year. CONCLUSIONS: Massive hemoptysis, pseudoaneurysm diameter, pulmonary cavitation, and elevated mPAP were the risk factors for rupture of pseudoaneurysm. Our findings facilitate early identification and timely intervention of PAP at high risk of rupture.

[Cavitary lung lesions in COVID-19 associated pneumonia: a single-center study of 40 cases]. / Polostnye obrazovaniya legkikh pri COVID-19-assotsiirovannoi pnevmonii.

OBJECTIVE: To demonstrate clinical features and outcomes in patients with cavitary lung lesions and COVID-19 associated pneumonia. MATERIAL AND METHODS: A retrospective analysis of electronic medical records of 8261 patients with COVID-19 was performed. We selected 40 patients meeting the inclusion criteria. Sex, age, hospital-stay, lung tissue lesion, comorbidities, treatment, methods of respiratory support, complications and outcomes were evaluated. RESULTS: Cavitary lung lesions were more common in men (67.5%). Age of patients ranged from 28 to 88 (mean 64.9±13.7) years. Hospital-stay in patients with cavitary lung lesions was 9-58 (median 27.5) days. There were 18 complications in 14 (35%) patients. Pneumothorax, isolated pneumomediastinum, pleural empyema, hemoptysis and sigmoid colon perforation were considered as complications of cavitary lung lesions. Nine (22.5%) patients died (5 of them with complications). Three patients died after surgical treatment. Long-term results were analyzed in 8 (25.8%) patients. Patients were followed-up for 3 months after discharge. Shrinkage of lesions occurred after 7-60 (mean 23) days, and complete obliteration of cavities came after 32 (range 14-90) days. CONCLUSION: Cavitary lung lesions are a rare complication of COVID-19 pneumonia. There was no significant correlation of complications with age, sex, therapy, volume of lung lesions and non-invasive ventilation (NIV). Despite more common fatal outcomes in older patients undergoing NIV, the last one was prescribed exclusively due to disease progression and respiratory failure. Further research on this problem is necessary to identify possible risk factors of cavitary lung lesions.

[Risk factors of pulmonary cavitation in COVID-19 pneumonia]. / Faktory riska poyavleniya polostnykh obrazovanii legkikh pri COVID-19-pnevmonii.

OBJECTIVE: To identify the risk factors of pulmonary cavitation in COVID-19 pneumonia. MATERIAL AND METHODS: A retrospective study included 8261 patients with COVID-19 between April 2020 and March 2022. Inclusion criteria: age >18 years, COVID-19 confirmed by polymerase chain reaction. Two cohorts of patients were formed: 40 patients with pulmonary cavitation and 40 patients without these lesions. Both groups were comparable in age, lung lesion volume and oxygenation. Sex, age, length of hospital-stay, CT grade of lung lesion, comorbidities, treatment, respiratory support, oxygen saturation and in-hospital outcomes were evaluated. The highest lung lesion volume during hospitalization was assessed. CT was performed upon admission and approximately every 5 days for evaluation of treatment. Statistical analysis was performed using the IBM SPSS Statistics software (IBM Corporation, USA). RESULTS: Patients with pulmonary cavitation significantly differed in age, SpO2, lung lesion volume, more common non-invasive ventilation and prolonged hospital-stay. Cardiovascular diseases were more common in both groups. Univariate logistic regression analysis revealed age, cardiovascular diseases, CT-based severity of lung damage, absence of biological therapy and non-invasive ventilation as risk factors of pulmonary cavitation. According to multivariate logistic regression analysis, these predictors were CT-based severity of lung damage and absence of biological therapy. Univariate logistic regression analysis showed that pulmonary cavitation had no significant effect on mortality (OR=2.613, 95% CI: 0.732-9.322, p=0.139). CONCLUSION: The risk of pulmonary cavitation in COVID-19 is directly related to advanced lung damage and untimely or absent biological therapy with IL-6 inhibitors. Pulmonary cavitation in COVID-19 is not a typical manifestation of disease and can be caused by some factors: fungal infection, secondary bacterial infection, tuberculosis and pulmonary infarction. Further study of this problem is required to develop diagnostic algorithms and treatment tactics.

A Case of Lung Cavity Incidentally Discovered Following Evaluation for Pulmonary Embolism.

Cavitary lung lesions manifest following a wide variety of pathological processes, which are typically delineated as infectious and non-infectious. With respect to noninfectious causes, malignancies are among the most worrisome, while autoimmune and embolic processes are less frequent and less severe in prognosis. While it is important to differentiate between these etiologies, treatment may resort to surgical procedures for both diagnostic and curative intent. This case involves the incidental finding of a cavitary lung lesion following pulmonary embolism evaluation. Following confirmation of deep venous thrombosis and pulmonary embolism, the patient was admitted to the hospital, administered anticoagulants, and monitored for changes in respiratory status. Outpatient follow-up showed vast improvement in the cavity without antibiotic/chemotherapeutic treatment. Embolic events were attributed to Factor V Leiden diagnosis. This manuscript aims to discuss etiologies of lung cavities and how treatment strategies may differ depending on pathological processes and concomitant patient comorbidities. Special attention will be paid to pulmonary cavity evaluation in the acute hospital setting.

TB or Not TB: Lung Nocardiosis, a Tuberculosis Mimicker.

Nocardia, a gram-positive bacterium found in soil and water, rarely causes infections in immunocompetent patients. Diagnosing and treating nocardiosis can be challenging due to its infrequency and the similarity of its symptoms to other diseases. We describe the case of a middle-aged male with a history of latent tuberculosis who presented with hemoptysis. Imaging revealed a persistent lung mass, and pathology and microbiology studies confirmed Nocardia infection. The patient was treated with antibiotics and discharged home. Pulmonary nocardiosis can mimic tuberculosis, fungal infections, or malignancies. Immunocompetent patients make up one-third of the cases. Diagnosis can be difficult, as the organism takes time to grow in culture, but molecular techniques and histology can aid in diagnosis. Treatment often involves a six- to 12-month course of trimethoprim-sulfamethoxazole (TMP-SMX). Prompt identification of the etiological agent is essential for effective treatment, especially for immunocompetent patients who may not exhibit typical risk factors.

Cryptococcosis with pulmonary cavitation in an immunocompetent child: a case report and literature review.

BACKGROUND: Pulmonary cryptococcosis (PC) rarely occurs in immunocompetent children. CASE PRESENTATION: A 13-year-old boy was admitted to the First Affiliated Hospital of Ningbo University in February 2023 with complaints of cough and chest pain. Physical examination showed slightly moist rales in the right lung. Chest computed tomography (CT) suggested a lung lesion and cavitation. Blood routine test, lymphocyte subsets, immunoglobulin, and complement tests indicated that the immune system was normal. However, the serum cryptococcal antigen test was positive. Next-generation sequencing revealed Cryptococcus infection. The child was diagnosed with PC and was discharged after treating with fluconazole 400 mg. Four months later, chest CT showed that the lung lesion diminished, and reexamination of serum cryptococcal antigen test turned positive. CONCLUSION: PC should be considered in an immunocompetent child with pulmonary cavities with nonspecific symptoms.

The association between type 2 diabetes and pulmonary cavitation revealed among IGRA-positive tuberculosis patients.

The co-occurrence of tuberculosis (TB) and diabetes mellitus (DM) presents a significant obstacle to TB eradication. Pulmonary cavitation can occur in severe cases of TB, particularly in patients with DM. From 1 May 2014 through 30 June 2019, we conducted a cross-sectional study of 1,658 smear- or culture-confirmed pulmonary TB (PTB) patients at the Second Department of Pulmonary Medicine and Tuberculosis, Shenzhen, China. A total of 861 participants who satisfied the criteria (chest CT scan for cavitation, interferon-gamma release assay (IGRA), diagnosis of diabetes mellitus), with the median age of 36.7 years, 63.6% of male, 79.7% IGRA positive, 13.8% with diabetes, and 40.8% with pulmonary cavitation, were included in the study. The association between diabetes and pulmonary cavitation was confirmed in these TB patients (adjusted OR, 2.54; 95% CI, 1.66-3.94; p < 0.001). No associations were observed between diabetes and IGRA, as well as between lung cavitary and IGRA. Based on the criteria of IGRA+/-, pulmonary cavitation+/-, and DM+/-, the further analysis with univariate and multivariate logistic regression were conducted in six subgroups. The significant association between diabetes and pulmonary cavitation was further confirmed in the IGRA+ subgroup (adjusted OR, 3.07; 95% CI, 1.86-5.16; p < 0.001) but not observed in IGRA- individuals. This observation suggests that different immunological mechanisms of pulmonary cavitary/DM may be employed in IGRA+ TB patients from IGRA- TB patients.

Therapeutical strategies in cavitary legionnaires' disease, two cases from the field and a systematic review.

BACKGROUND: Legionnaires' Disease (LD) rarely evolves into pulmonary abscesses. The current systematic review has been designed to explore therapeutical strategies in pulmonary cavitary LD. METHODS: A research strategy was developed and applied to the databases Embase, Pubmed, and Web of Science from the 1st of January 2000 to the 1st of November 2022. Original articles, case series, case reports, and guidelines written in English, French, German, Italian, and Dutch were considered. Furthermore, medical records of patients treated at the University Hospital UZ Brussel for LD cavitary pneumonia, between the 1st of January 2016 to the 1st of January 2022, were reviewed. RESULTS: Two patients were found by the UZ Brussel's medical records investigation. Through the literature review, 23 reports describing 29 patients, and seven guidelines were identified. The overall evidence level was low. RESULT OF SYNTHESIS (CASE REPORTS): The median age was 48 years and 65% were male. A polymicrobial infection was detected in 11 patients (44%) with other aerobic bacteria being the most commonly found. At diagnosis, 52% of patients received combination therapy, and fluoroquinolones were the preferred antimicrobial class. Anaerobic coverage was neglected in 33% of patients. RESULT OF SYNTHESIS (GUIDELINES): Three guidelines favor monotherapy with fluoroquinolones or macrolides, while one suggested an antimicrobial combination in case of severe LD. Four guidelines recommended anaerobic coverage in case of lung abscesses. CONCLUSION: To date, the evidence supporting cavitary LD treatment is low. Monotherapy lowers toxicity and might be as effective as combination therapy. Finally, anaerobes should not be neglected.

Post-COVID-19 cavitary lung lesion due to Aspergillus flavus and Enterobacter cloacae in a patient suffering from COVID-19 pneumonia - a case report.

The coronavirus disease 2019 (COVID-19) pandemic has manifested as a multifaceted paradigm but has primarily affected the respiratory system. Though a rare sequela after-COVID-19, we present a case of cavitary lung lesion in an adult patient, which manifested with common symptoms such as fever, cough and dyspnoea during the post-COVID-19 recovery period. Aspergillus flavus and Enterobacter cloacae were found to be the main causative organisms. Fungal and bacterial coinfection may be thought of in similar situations and appropriate treatment may be given to prevent further morbidity and mortality.

Pulmonary Mycetoma With a Concomitant Reactivation of Pulmonary Tuberculosis Infection: A Case Report and Clinical Pathological Review.

Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis. It primarily affects the lungs but can also spread to other body parts. One of the possible symptoms of pulmonary tuberculosis (TB) is hemoptysis. In the case of TB, aspergillomas can develop in the cavitary lesions of TB and result in a deteriorating clinical situation. The current case report describes a 63-year-old female previously treated for TB who presented with hemoptysis, fever, and a 4 cm focal density in the right upper lobe on chest X-ray. The patient was found to have concomitant TB and aspergillosis, manifesting as a pulmonary aspergilloma. The co-occurrence of TB and aspergillosis can occur, particularly in patients with weakened immune systems. This case report highlights the importance of considering concomitant TB and pulmonary mycetoma in patients with a history of treated TB who present with pulmonary symptoms.

Post-COVID-19 Pulmonary Infarction Complicated by Spontaneous Pneumothorax: A Case Report.

Pulmonary cavitation is an atypical finding in COVID-19 patients. In this rare case report, a 63-year-old woman (35 days from COVID-19 symptom onset) presented to our emergency department with acute chest pain and shortness of breath. A chest X-ray established right-sided total pneumothorax, hence a tube thoracostomy was performed. Due to a persistent air leak, chest computed tomography was performed, which showed areas of lung consolidation and a cavitary mass in the upper lobe of the right lung. The woman undertook a thoracoscopy, which established multiple petechiae on the lung surface and a bronchopleural fistula of the right lung's upper lobe. The treatment of choice was an atypical lung resection to remove the necrotic cavitary lesion. Histological and microbiological examination of the resected lung specimen showed a bland (aseptic) cavitary pulmonary infarct. Pulmonary infarction is a rare cause of cavitation in COVID-19 patients, nonetheless, something that should be considered in those presenting with respiratory symptoms or complications during or post-COVID-19.

Massive Cavitation by Pneumocystis jirovecii in an Immunocompromised Patient.

Since the development of antiretroviral therapy (ART) and antibiotic prophylaxis, the incidence of opportunistic infections in human immunodeficiency virus-acquired immunodeficiency syndrome (HIV-AIDS) has been drastically reduced. However, third-world countries remain a fertile ground for medication nonadherence and inappropriate patient follow-up. Here, we present the case of a 42-year-old male with a history of HIV who presented with worsening shortness of breath and atypical chest pain. A chest X-ray and chest computed tomography scan revealed a left parahilar cavitation measuring 86 mm in diameter. A percutaneous lung biopsy revealed Pneumocystis jirovecii. Appropriate antibiotics were started, and the patient's clinical status significantly improved. This case illustrates the devastating consequences of uncontrolled HIV-AIDS. ART and prophylactic antibiotics remain the cornerstone of treatment to ameliorate progressive lung damage in patients.

Pulmonary cavitation in a patient with coronavirus disease 2019 during lenvatinib treatment for thyroid carcinoma: a case report.

Lenvatinib, a multi-tyrosine kinase inhibitor, is used for the treatment of thyroid carcinoma. However, it can cause pneumonia and pulmonary cavitation leading to pneumothorax. The mechanism underlying the occurrence of cavitation and pneumothorax is not well understood. Coronavirus disease 2019 (COVID-19), which is an infectious condition characterized primarily by pneumonia, is sometimes accompanied by pulmonary cavitation. Patients with COVID-19 who present with pulmonary cavitation may have a poor prognosis. In the present case, a patient with papillary thyroid carcinoma presented with multiple pulmonary metastatic tumors that were treated with lenvatinib. After 9 weeks from treatment initiation, he experienced fever and presented with pulmonary consolidation and ground-glass opacity (GGO). Pneumonia improved after the withdrawal of lenvatinib. After 21 weeks from treatment initiation, he developed fever again and the clinical tests led to the diagnosis of COVID-19. Computed tomography (CT) showed new GGO in both sides of the lung. Therefore, the patient was diagnosed with moderate COVID-19. He was treated with dexamethasone plus remdesivir, and GGO due to COVID-19 disappeared. However, the previous pulmonary shadow associated with lenvatinib became a cavitary lesion. The initial CT findings of COVID-19 and pneumonia associated with lenvatinib are similar. Thus, both conditions must be considered for a differential diagnosis in patients presenting with GGO during lenvatinib treatment.

Granulomatous Polyangiitis With Renal Involvement: A Case Report and Review of Literature.

Granulomatosis with polyangiitis (GPA), formerly named Wegner's granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consolidation, and bronchoscopy findings of friable tissue that was not amenable for biopsy. Methylprednisolone and rituximab (RTX) were administered, which resulted in marked clinical improvement. Therefore, a keen eye for details is necessary to diagnose GPA early, which can improve disease outcomes dramatically.

Non-surgical management of an abrupt cavitation and large oval-shaped lung abscess secondary to acute thromboembolic pulmonary infarction: a case report.

Infected cavitating pulmonary infarction is a rare complication of pulmonary embolism with a high mortality rate. Surgical excision for this complication has been used in past decades. Abrupt cavitation and a large oval-shaped lung abscess caused by acute thromboembolic pulmonary infarction during anticoagulation are rare. We present a 70-year-old man who suffered from pleuritic pain and breathlessness, accompanied by nausea and vomiting for 1 day. A physical examination showed tachycardia and tachypnea with moist rales in the left upper chest. High D-dimer levels, leukocytosis, respiratory failure and left upper lobe consolidation were found on plain computed tomography (CT). CT pulmonary angiography was performed 2 days after the previous CT scan because pulmonary embolism was suspected. This scan showed emboli in the main, right upper, middle, lower and left upper pulmonary arteries with deteriorated left upper lobe consolidation and cavitation. Thromboembolic pulmonary infarction and an abscess were diagnosed. Enoxaparin 60 mg was administered every 12 hours for 10 days, followed by rivaroxaban, antibiotics and drainage of the hydrothorax. The patient improved after the strategy of non-surgical treatment and was discharged approximately 1 month later. The patient had an uneventful course during rivaroxaban 20 mg once daily for 1 year.

Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease.

BACKGROUND: Pulmonary radiological findings of the novel coronavirus disease 2019 (COVID-19) have been well documented and range from scattered ground-glass infiltrates in milder cases to confluent ground-glass change, dense consolidation, and crazy paving in the critically ill. However, lung cavitation has not been commonly described in these patients. The objective of this study was to assess the incidence of pulmonary cavitation in patients with COVID-19 and describe its characteristics and evolution. METHODS: We conducted a retrospective review of all patients admitted to our institution with COVID-19 and reviewed electronic medical records and imaging to identify patients who developed pulmonary cavitation. RESULTS: Twelve out of 689 (1.7%) patients admitted to our institution with COVID-19 developed pulmonary cavitation, comprising 3.3% (n = 12/359) of patients who developed COVID-19 pneumonia, and 11% (n = 12/110) of those admitted to the intensive care unit. We describe the imaging characteristics of the cavitation and present the clinical, pharmacological, laboratory, and microbiological parameters for these patients. In this cohort six patients have died, and six discharged home. CONCLUSION: Cavitary lung disease in patients with severe COVID-19 disease is not uncommon, and is associated with a high level of morbidity and mortality.

Immunonutritional status and pulmonary cavitation in patients with tuberculosis: A revisit with an assessment of neutrophil/lymphocyte ratio.

BACKGROUND: Several reports have described the importance of immunological and nutritional factors in the morbidity and/or mortality of patients with tuberculosis. The aim of this study was to evaluate the association between pulmonary cavitation and immunonutritional status, assessed by parameters such as neutrophil/lymphocyte ratio (NLR) and prognostic nutritional index (PNI), in patients with pulmonary tuberculosis. METHODS: We retrospectively analyzed the data of 137 patients with culture-positive active pulmonary tuberculosis without bacterial pneumonia diagnosed at Kainan Hospital between April 2008 and March 2016. The associations between the levels of serum albumin, lymphocytes, NLR, PNI, platelet to lymphocyte ratio (PLR), and body mass index (BMI) and pulmonary cavitation were evaluated in the patients. RESULTS: A total of 83 men and 63 women (median age, 75 years; range, 16-94 years) were included in the study. Sixty-six patients had smoking history; 55 patients had respiratory symptoms, while 44 patients did not have any symptoms. Patient׳s delay, defined as medical examination performed over 60 days after the onset of symptoms was observed in 25 patients. Univariate analysis showed that high NLR (≥ 5), high PLR (≥200), low serum albumin (<3 g/dL), high neutrophil count (≥6000/mm3), and low lymphocyte count (<1000/mm3) were associated with pulmonary cavitation. Multivariate analysis showed that high NLR and low serum albumin were associated with pulmonary cavitation. CONCLUSION: Malnutrition and increased severity of inflammation may be associated with pulmonary cavitation in patients with tuberculosis. Further studies are warranted to confirm the findings of the present study.

Nontuberculous mycobacterial disease concomitant with a pulmonary artery occlusion caused by Takayasu's arteritis.

We herein describe a surgical case of pulmonary involvement in Takayasu's arteritis with pulmonary infections of nontuberculous mycobacteria. A 24-year-old female was admitted to our hospital because of a recurrent fever, and contrast-enhanced computed tomography of the chest revealed the occlusion of the right pulmonary artery and cavitary lesions in the right lower lobe of the lung. A further examination of the neck revealed the occlusion of aortic branches, and the patient was diagnosed with Takayasu's arteritis. The cavitary lesions were diagnosed as nontuberculous mycobacteria disease according to the sputum culture result of Mycobacterium intracellulare. After antibiotic treatment for 6 months, the right pneumonectomy was performed with a good result. We should be aware of Takayasu's arteritis as a disease which can lead to the development of unexplained respiratory symptoms due to pulmonary artery involvement in young adults.