Non-Tuberculous Mycobacterial Pulmonary Disease with Detection of Mycobacterium Tuberculosis in Pleural Fluid.

BACKGROUND: Tuberculous pleurisy (TP) is one of the most common types of extrapulmonary tuberculosis, often secondary to tuberculosis (TB). Clinical and imaging manifestations of non-tuberculous mycobacterial pulmonary diseases (NTM-PD) are usually similar to those of tuberculosis. Because of their similarity and the high incidence of tuberculosis, non-tuberculous mycobacterial infections are often overlooked for a long time. Especially in people without immunodeficiency. METHODS: Mycobacterium tuberculosis (MTB) in pleural effusion was found by metagenomic next-generation sequencing (mNGS). During anti-tuberculosis treatment, mNGS of lung tissue by ultrasound-guided percutaneous lung puncture revealed that this patient had combined NTM-PD. RESULTS: Mycobacterium chelonae (M. chelonae) was detected by mNGS, and after anti-NTM treatment, the patient's chest CT showed that the inflammation was absorbed more than before, and the patient's symptoms improved. CONCLUSIONS: When TB is poorly treated with standardized anti-tuberculosis therapy, comorbid non-tuberculous mycobacterial infections may be considered, and mNGS may complement traditional pathogenetic testing.

Initial Misdiagnosis of Lung Cancer due to Elevated Carcinoembryonic Antigen in a Patient with Tuberculosis.

BACKGROUND: Tuberculosis often presents on imaging in the form of a solitary nodule, sometimes accompanied by elevated CEA, which is clinically difficult to differentiate from lung cancer and prone to misdiagnosis. METHODS: Lung tissue taken by lung biopsy and sent for NGS and Xpert MTB/RIF finally led to the definitive diag-nosis of nodular foci in the upper lobe of the left lung caused by tuberculosis. RESULTS: Enhanced CT of the chest showed nodular foci in the upper lobe of the left lung. Initially the nodules were thought to be malignant, but after a series of tests, were finally confirmed to be tuberculosis. CONCLUSIONS: In patients with lung disease, when chest imaging reveals a space-occupying lesion accompanied by an elevated CEA level, a comprehensive analysis of the type of lung disease, the patient's age, and comorbidities should be performed before final diagnosis to avoid misdiagnosis and delay in appropriate treatment.

Allergic Bronchopulmonary Mycosis with Eosinophilia Caused by Schizophyllum Infection.

BACKGROUND: As an opportunistic pathogenic fungus, Schizophyllum has been rarely reported to infect humans. By reporting a case of definite diagnosis of Schizophyllum infection, we aim to improve clinicians' understanding of this bacterium. METHODS: By reporting a case with cough and sputum as the main manifestations, after empirical antiinfective chest CT suggesting a more progressive inflammatory lesion and a mass-like lesion in the paratracheal area of the main airways, a diagnosis of Schizophyllum infection was finally made by bronchoscopy with the delivery of metagenomic next-generation sequencing (mNGS). RESULTS: The patient was finally diagnosed with rare Schizophyllum infection. After antifungal treatment, the symptoms improved, and the patient was discharged. CONCLUSIONS: Although Schizophyllum is a rare fungal infection, it should be taken seriously in patients with diabetes or who are immunocompromised. At the same time, mNGS plays a key role in the detection of rare and emerging pathogens, which is worthy of clinical interest.

Respiratory Syncytial Virus Infection in an Adult with Immunodeficiency.

BACKGROUND: Respiratory syncytial virus (RSV) is a single-stranded RNA virus that commonly causes symptoms of upper respiratory tract infections in humans, with a clear seasonal trend. However, in immunocompromised and elderly patients, RSV infections still result in high rates of hospitalization and even risk of death. METHODS: We report a case of RSV infection in an adult with immunodeficiency, which initially showed only mild symptoms of upper respiratory tract infection, which did not improve after receiving empirical anti-infective treatment, and the foci of infection in the lungs continued to expand, which led to the aggravation of the disease. The diagnosis of RSV infection was finally confirmed by electron bronchoscopy and pathogenetic examination of the bronchoalveolar lavage fluid. The patient was given intravenous ribavirin treatment for one week. After one week of intravenous ribavirin treatment, the patient's symptoms improved significantly. A repeat chest CT suggested that the lung lesions were smaller than before. In order to improve clinicians' awareness of this disease, we jointly conducted a literature analysis. RESULTS: The final diagnosis of RSV was made by analyzing the patient's history, symptoms, and signs and performing relevant examinations. CONCLUSIONS: For patients with poor results of empirical application of antibiotics, electronic bronchoscopy and pathogenetic examination should be carried out at an early stage to clarify the nature of the lesions and to avoid rapid deterioration of the condition leading to life-threatening conditions in the patients. More consideration should be given to the possibility of disease diagnosis to avoid misdiagnosis and underdiagnosis, and appropriate treatment should be given at an early stage.

Multiple Postoperative Lung Infections after Thymoma Surgery Diagnosed as Nontuberculous Mycobacterial Infection.

BACKGROUND: Thymomas are thymic epithelial-derived, most common primary anterior mediastinal masses. Non-tuberculous mycobacteria (NTM) are species that do not cause leprosy and belong to species outside the Mycobacterium tuberculosis complex. METHODS: With the clinical application of targeted next-generation sequencing (tNGS), we promptly confirmed a case of NTM infection combined with NTM infection after thymoma surgery, and we performed a joint literature analysis of the two diseases to improve clinicians' understanding and recognition of lung infections after thymoma surgery. RESULTS: Chest CT of both lungs showed multiple hyperdense shadows. Sputum bacterial culture and characterization detected Neisseria Dryad and Streptococcus Grass Green. The presence of Mycobacterium abscessus infection was confirmed by alveolar lavage fluid sent for second-generation macro gene sequencing. CONCLUSIONS: The body's immune function decreases after thymoma surgery. When empirical anti-infection treatment for recurrent pneumonia in the lungs is ineffective, we should be alerted to the possibility of the presence of pulmonary non-tuberculous mycobacterial infection, and next-generation sequencing should be performed promptly to arrive quickly at a diagnosis.

A Case of Invasive Pulmonary Mycosis (Rhizopus microspores) secondary to Hematological Disease.

BACKGROUND: Pulmonary mucormycosis is most common in patients with hematologic malignancies and transplant recipients. This article describes a case of mucormycosis in the lungs secondary to a hematologic disorder with suspected lung cancer. METHODS: Rhizopus (Rhizopus microspores) was detected by blood NGS and bronchoalveolar lavage fluid NGS, and pulmonary mucormycosis was confirmed. RESULTS: Secondary to hematologic disease, pulmonary pneumonia, mycosis, and symptoms improved after comprehensive treatment. CONCLUSIONS: Clinical data and radiologic knowledge are combined to diagnose invasive pulmonary mycoses; early empirical medicine is very important.

A Case of Invasive Pulmonary Aspergillosis.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) is a deep fungal infection caused by invasion of Aspergillus mycelium into the lung parenchyma resulting in tissue destruction and necrosis, which occurs more often in im-munosuppressed populations. The severity of the disease and the rapid progression of the lung lesions puts pa¬tients at high risk of death and poor prognosis if the correct therapeutic intervention is not given as early as possible. METHODS: Here we report a case of IPA, which was initially diagnosed as community-acquired pneumonia in a local hospital. The symptoms did not improve after receiving anti-infective treatment. The patient was diagnosed with IPA after completing a chest CT examination and an electronic bronchoscopy, as well as pathogenetic examination of the bronchoalveolar lavage fluid and pathological examination of the left bronchial mass in the respiratory department of our hospital, which was finally diagnosed as IPA. After one week of administration of voriconazole for anti-fungal infection treatment, the patient's symptoms improved significantly, and a repeat chest CT suggested that the lung lesions were better than before. In order to raise clinicians' awareness of this disease, we also conducted a literature analysis. RESULTS: The final diagnosis of IPA was made by analyzing the patient's history, symptoms, signs, and relevant findings. CONCLUSIONS: When the patient's clinical symptoms and imaging manifestations are consistent with IPA, electronic bronchoscopy and pathogenetic and pathological examinations may be appropriately performed to clarify the na-ture of the lesion. More consideration should be given to the possibility of disease diagnosis to avoid misdiagnosis and underdiagnosis. Appropriate treatment should be given at an early stage.

A Case of IgG4 Related Lung Disease.

BACKGROUND: IgG4-related disease (IgG4-RD) is an immune-mediated systemic inflammatory fibrotic disease, which is a relatively rare and novel disease that can involve multiple organs or tissues, with variable clinical manifestations, and for which pulmonary involvement has been reported relatively infrequently. METHODS: Here we report a case of pulmonary infection that was initially suspected and received anti-inflammatory treatment, but the symptoms did not improve. CT examination indicated progression of the pulmonary lesion, and the nature of the lesion could not be determined by tracheoscopy and bronchoalveolar lavage. The diagnosis of IgG4 related lung disease (IgG4-RLD) was confirmed by percutaneous lung biopsy. A joint literature analysis was conducted to improve clinicians' understanding of this disease. RESULTS: The patient's history, symptoms, signs and relevant examination results were analyzed. The final diagnosis was IgG4-RLD. CONCLUSIONS: When the clinical symptoms and imaging manifestations of the patients are consistent with IgG4-RLD, pathological examination can be appropriately performed to clarify the nature of the lesions. More consideration should be given to the possibility of disease diagnosis to avoid misdiagnosis and underdiagnosis, and proper treatment should be given at an early stage.

Complication of Intrapulmonary Cavitary Lesions after COVID-19 Finally Proved as Pulmonary Aspergillosis.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus type 2, which is characterized by high infectiousness and diverse clinical manifestations. They are more likely to become critical in people who have underlying diseases or are immunocompromised. In the daunting task of treating patients with COVID-19, those with comorbid fungal infections are susceptible to underdiagnosis or misdiagnosis, which can ultimately lead to increased morbidity and mortality in this group of patients. We report a case of intrapulmonary cavitary lesions after COVID-19, which was eventually diagnosed as pulmonary aspergillosis (PA) by metagenomic Next Generation Sequencing (mNGS) to improve our understanding of the disease. METHODS: Appropriate laboratory tests, chest computed tomography (CT), mNGS, and serologic tests were performed for diagnosis. RESULTS: Laboratory tests showed Glactomannan (GM) of 1.41, multiple cavitary lesions in both lungs on chest CT and the presence of aspergillus infection was confirmed by sputum sent for mNGS. CONCLUSIONS: In the case of cavitary lesions after COVID-19, we should be alert to the possibility of combined fungi and should promptly perform mNGS to clarify whether there is a combination of specific pathogenic fungal infections.

Organizing Pneumonia due to Secondary Invasive Pulmonary Mycosis and Cytomegalovirus Infection in a Patient with Lymphoma.

BACKGROUND: Reactivation of cytomegalovirus is more common in lymphoma patients undergoing hematopoietic stem cell transplantation, but reactivation of cytomegalovirus due to chemotherapy for lymphoma has rarely been reported. We report a case of a lymphoma patient with secondary pulmonary fungal infection and cytomegalovirus infection after chemotherapy, which ultimately led to organizing pneumonia. METHODS: Percutaneous lung biopsy, Next Generation Sequencing (NGS). RESULTS: NGS examination suggestive of cytomegalovirus infection, percutaneous lung biopsy suggests the presence of organizing pneumonia. The patient was discharged after a combination of antifungal and antiviral treatment with posaconazole, ganciclovir, and anti-inflammatory treatment with methylprednisolone. CONCLUSIONS: In patients with lymphoma, one should be alert for fungal and viral infections of the lungs when lung related clinical manifestations occur. Patients with persistent unrelieved symptoms after treatment should undergo lung biopsy or bronchoscopy to obtain pathologic tissue for definitive diagnosis.

Neglected Mycobacterium Avium Complex Infection in a Patient with Prolonged Pneumonia.

BACKGROUND: Non-tuberculous mycobacterial pulmonary infections (NTM-PD) are becoming increasingly common in clinical practice, and early detection and accurate determination of the infecting pathogen is crucial for subsequent treatment. We report a case of NTM-PD in a healthy middle-aged female with Mycobacterium tuberculosis complex group (MAC) infection confirmed by mNGS examination. METHODS: Appropriate laboratory tests, chest CT scan, bronchoscopic alveolar lavage fluid (BALF) examination, and macrogenomic next-generation sequencing (mNGS) were performed to establish the diagnosis. RESULTS: Chest CT showed multiple inflammatory lesions in the right middle lobe, and BALF sent for mNGS finally confirmed the diagnosis of MAC infection. After symptomatic treatment with azithromycin combined with ethambutol and rifampicin, the patient improved and was discharged from the hospital. CONCLUSIONS: In patients with pulmonary infections, pathogens should be clarified early to determine the diagnosis. mNGS of BALF samples have high specificity in detecting pathogens of infectious diseases, especially complex mixed infectious disease pathogens.

Neglected Right Hemidiaphragmatic Angle Soft Tissue Shadow in a Renal Transplant Recipient Diagnosed as Lymphoma.

BACKGROUND: Post-transplant lymphoproliferative disorders are characterized by atypical clinical manifestations, high mortality, and missed diagnosis rates. METHODS: We report a case of renal transplantation in a patient with unexplained soft-tissue nodular shadows, and the type of the post-transplant abnormal soft-tissue shadows was clarified by puncture biopsy. RESULTS: The pathologic returns were consistent with the post-transplant lymphoproliferative disease, and the immunohistochemical returns supported a diffuse large B-cell lymphoma (non-growth center origin). CONCLUSIONS: In organ transplant patients, when unexplained soft tissue nodular shadows are present, the possibility of post-transplant lymphoproliferative disorders should be considered, and an aggressive puncture biopsy should be performed to clarify the diagnosis.

A Prediction Model for Prolonged Hospital Length of Stay (ProLOS) in Coronavirus Disease 2019 (COVID-19) Patients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an acute respiratory infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the normalization of COVID-19 globally, it is crucial to construct a prediction model that enables clinicians to identify patients at risk for ProLOS based on demographics and serum inflammatory biomarkers. METHODS: The study included hospitalized patients with a confirmed diagnosis of COVID-19. These patients were randomly grouped into a training (80%) and a test (20%) cohort. The LASSO regression and ten-fold cross-validation method were applied to filter variables. The training cohort utilized multifactorial logistic regression analyses to identify the independent factors of ProLOS in COVID-19 patients. A 4-variable nomogram was created for clinical use. ROC curves were plotted, and the area under the curve (AUC) was calculated to evaluate the model's discrimination; calibration analysis was planned to assess the validity of the nomogram, and decision curve analysis (DCA) was used to evaluate the clinical usefulness of the model. RESULTS: The results showed that among 310 patients with COVID-19, 80 had extended hospitalization (80/310). Four independent risk factors for COVID-19 patients were identified: age, coexisting chronic respiratory diseases, white blood cell count (WBC), and serum albumin (ALB). A nomogram based on these variables was created. The AUC in the training cohort was 0.808 (95% CI: 0.75 - 0.8671), and the AUC in the test cohort was 0.815 (95% CI: 0.7031 - 0.9282). The model demonstrates good calibration and can be used with threshold probabilities ranging from 0% to 100% to obtain clinical net benefits. CONCLUSIONS: A predictive model has been created to accurately predict whether the hospitalization duration of COVID-19 patients will be prolonged. This model incorporates serum WBC, ALB levels, age, and the presence of chronic respiratory system diseases.

A Case of Organizing Pneumonia Resembling Lung Cancer.

BACKGROUND: Organizing pneumonia (OP) is a pathologic diagnosis with clinical and imaging manifestations that often resemble other diseases, such as infections and cancers, which can lead to delays in diagnosis and inappropriate management of the underlying disease. In this article, we present a case of organized pneumonia that resembles lung cancer. METHODS: We report a case of initial suspicion of pulmonary malignancy, treated with anti-inflammatory medication and then reviewed with CT suggesting no improvement, and finally confirmed to be OP by pathological biopsy taken via transbronchoscopy. A joint literature analysis was performed to raise clinicians' awareness of the diagnosis and treatment of OP. RESULTS: Initially, because of the atypical auxiliary findings, we thought that the disease turned out to be a lung tumor, which was eventually confirmed as OP by pathological diagnosis. CONCLUSIONS: The diagnosis and treatment of OP requires a combination of clinical information and radiological expertise, as well as biopsy to obtain histopathological evidence. That is, clinical-imaging-pathological tripartite cooperation and comprehensive analysis.

A Case of Tuberculosis Misdiagnosed as Sarcoidosis and then Confirmed by NGS Testing.

BACKGROUND: Pulmonary tuberculosis (PTB) is an important infectious disease that threatens the health and life of human beings. In the diagnosis of PTB, imaging plays a dominant role, but due to the increasing drug resistance of Mycobacterium tuberculosis, atypical clinical manifestations, "different images with the same disease" or "different diseases with the same image" in chest imaging, and the low positivity rate of routine sputum bacteriology, which leads to a high rate of misdiagnosis of PTB. We report a case of pulmonary tuberculosis that was misdiagnosed on imaging. We report a case of pulmonary tuberculosis that resembled sarcoidosis on imaging and was negative for antacid staining on sputum smear and alveolar lavage fluid, and was later diagnosed by microbial next-generation sequencing (NGS). The case was initially misdiagnosed as sarcoidosis. METHODS: Alveolar lavage fluid NGS, chest CT, bronchoscopy. RESULTS: Chest CT showed multiple inflammatory lesions in both lungs, multiple nodular foci in both lungs, and multiple enlarged lymph nodes in the mediastinum and hilar region on both sides. Fiberoptic bronchoscopy was performed in the basal segment of the left lower lobe of the lungs to carry out bronchoalveolar lavage, and the lavage fluid was sent to the NGS test and returned the following results: Mycobacterium tuberculosis complex group detected in the number of sequences of 293. Based on the results of the NGS test, the diagnosis of pulmonary tuberculosis could be confirmed. CONCLUSIONS: The diagnosis of pulmonary tuberculosis cannot be easily excluded in patients with "different images with the same disease" or "different diseases with the same image" on chest imaging without the support of sputum positivity. The goal was to improve the alertness of medical personnel to the misdiagnosis of tuberculosis and the application of NGS technology.

Positive Herpesvirus IgG Antibodies in Lung Cancer Patients Finally Proved as Drug-induced Pemphigus.

BACKGROUND: Herpesvirus IgG antibody positivity can be a lifelong burden of disease replication and reinfection or recent viruses can be reactivated and play an important role in the diagnosis and monitoring of herpesvirus [1]. However, sometimes serum IgG antibody positivity is of limited help in determining the onset of disease. We reported a case of herpesvirus IgG antibody positive in a patient with lung cancer who was initially misdiagnosed as herpes simplex and later confirmed drug-induced pemphigus (DIP) by histological and immunofluorescence studies. METHODS: Appropriate laboratory tests, enzyme-linked immunosorbent assay (ELISA), immunofluorescence and histological tests were performed for diagnosis. RESULTS: In lung cancer patients who were positive for herpesvirus IgG antibodies, were initially misdiagnosed as herpes simplex and eventually confirmed by histological and immunofluorescence examinations as DIP. CONCLUSIONS: Positive herpesvirus IgG antibody is not a specific manifestation of herpesvirus infection. For patients with unexplained skin blisters, we should improve histological examinations as soon as possible to clarify the type of lesion.

Left Lung High-Density Shadow Combined with Elevated NSE Ultimately Confirmed as Pulmonary Aspergillosis.

BACKGROUND: Detection of serum neuron specific enolase (NSE) has high sensitivity and specificity in the diagnosis of lung cancer, especially small cell lung cancer, but sometimes serum NSE provides limited help. We report a case of high-density shadow of the left lung and elevated serum NSE which mimicked lung cancer. It was ultimately confirmed to be pulmonary aspergillosis (PA) by bronchoscopic alveolar lavage fluid (BALF) and next-generation sequencing (NGS). METHODS: Appropriate laboratory tests, chest computed tomography (CT) scan, bronchoscopic alveolar lavage fluid, and next-generation sequencing were used to explore latent causes. RESULTS: NSE level was elevated, chest CT scan showed high-density shadow of the left lung, bronchoscopy showed flesh-colored new organisms in the lower lobe of the left lung, BALF and NGS revealed the presence of Aspergillus. CONCLUSIONS: Elevated NSE is not a typical manifestation of lung cancer, and we should perform BALF and NGS early to determine whether there is infection with special pathogenic bacteria.

Elevated CEA Misdiagnosed as Lung Cancer Ultimately Confirmed Pulmonary Cryptococcosis.

BACKGROUND: Carcinoembryonic antigen (CEA) is a polysaccharide complex present in the human respiratory system, which can reflect the presence of tumors in the human body and has important value in the monitoring of lung cancer [1], but sometimes serum CEA provides limited help. We reported a case of multiple consolidation of the lungs with elevated serum CEA, initially misdiagnosed as lung cancer and eventually confirmed by bronchoscopic lung biopsy as pulmonary cryptococcosis (PC). METHODS: Appropriate laboratory examination, chest computed tomography (CT) scan, and bronchoscopy lung biopsy were used to explore the latent etiology. RESULTS: CEA level was elevated, chest CT scan showed multiple consolidation of the lungs, serum cryptococcal antigen was positive, and pathological findings on bronchoscopic lung biopsy confirmed pulmonary cryptococcosis. CONCLUSIONS: Elevated CEA is not typical of lung cancer. We should also consider the possibility of specific pathogenic infection. Bronchoscopic lung biopsy is the gold standard should be performed as soon as possible to identify the lesion.

Acute Heart Failure due to Pulmonary Aspergillus Fumigatus and Cryptococcus Neoformans Infection Associated with COVID-19.

BACKGROUND: Current studies have reported that it is rare for the coronavirus disease 2019 (COVID-19) to be combined with two fungal infections and that COVID-19 can be combined with multiple cardiovascular complications, both of which can complicate the condition and increase the risk of death. METHODS: We report a case of COVID-19 in which Aspergillus fumigatus and Cryptococcus neoformans were detected by sputum targeted next-generation sequencing (tNGS) and cardiac monitoring during treatment revealed cardiovascular complications. RESULTS: We consider that this patient's fungal infection was associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the application of corticosteroids. In addition, cardiovascular complications were associated with an inflammatory response and increased sympathetic stimulation due to SARS-CoV-2 infection. CONCLUSIONS: The presence of COVID-19-associated fungal infections cannot be excluded when multiple risk factors for fungal infections are present in patients with COVID-19 and the condition is rapidly deteriorating. Effective long-term monitoring of cardiac function during the patient's hospitalization is necessary to reduce morbidity and mortality.

Positive PPD Test and TB-Ab Misdiagnosed as Tuberculosis Finally Proved as Sarcoidosis by Thoracoscopy: a Case Report.

BACKGROUND: Tuberculosis (TB) is a common infectious disease in developing countries. Tuberculosis and sarcoidosis are difficult to differentiate. We report a case of a patient who was initially misdiagnosed as tuberculosis due to positive tuberculin test (PPD test) and tuberculosis antibody (TB-Ab), which was eventually proven as sarcoidosis by thoracoscopy. METHODS: Appropriate laboratory tests are carried out and a chest CT scan, bronchoscopy, thoracoscopic pathological biopsy were done. RESULTS: Serum sedimentation was increased and tuberculosis antibody was positive. The chest CT scan showed multiple pulmonary nodules in both lungs. The bronchoscopy demonstrated no abnormality. Thoracoscopic pathology showed noncaseating granulomas and acid-fast staining was negative. CONCLUSIONS: When a patient has multiple pulmonary nodules and lymphadenopathy without obvious tuberculosis poisoning symptoms, physicians should pay attention to tuberculosis, sarcoidosis, and lung cancer. Pathology is crucial for the ultimate diagnosis.