대한흉부영상의학회 Weekly Chest Cases

Case No : 1242 Date 2021-08-10

Courtesy of Jong Eun Lee, Won Gi Jeong, Yun Hyeon Kim / Chonnam national university hospital, Chonnam national university hwasun hospital
Age/Sex 67 / M
Chief ComplaintChest discomfort, history of Cushing`s disease

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Diagnosis With Brief Discussion

Diagnosis: Nocardiosis
Radiologic Findings: Fig. 1. Chest radiograph showing an approximately 2.5-cm nodular opacity in the right hilar area and tiny micronodular opacities in the right upper lung field.
Figs. 2 and 3. Contrast-enhanced axial computed tomography (CT) images showing an approximately 4.5-cm heterogeneously enhancing mass in the central aspect of the right upper lobe. Patchy ground-glass opacities, ill-defined branching opacities, and septal line thickening are also noted in the right upper lobe.
Figs. 4 and 5. Contrast-enhanced axial CT images taken after 2 weeks demonstrating progressive consolidation with internal low attenuation and cavitation in the right upper lobe. Patchy ground-glass opacities, ill-defined branching opacities, and septal line thickening are also present in the contralateral left upper lobe.
Brief Review: The patient underwent surgical resection of the right upper lobe because of uncontrolled hemoptysis. Microbiological analysis of the surgical specimen revealed Nocardia species.
Nocardia is a genus of filamentous gram-positive, weakly acid-fast, aerobic bacteria found in dust, soil, water, decaying vegetation, and stagnant matter. Lung infection can occur through direct inhalation of Nocardia, which accounts for 73%–77% of all infection cases. Although pulmonary nocardiosis often occurs in immunocompromised patients, especially in those with impaired cell immunity related to acquired immunodeficiency syndrome and transplantation, one-third of patients with nocardiosis have normal immunity. Norcardia species are one of the known causes of opportunistic infections in Cushing’s syndrome. A series of case reports have described Nocardia species infection in patients with endogenous and ectopic Cushing’s syndrome.
The computed tomographic findings are diverse and nonspecific; however, the most common findings are consolidation and nodules/masses, which may progress to cavitation in some cases. Furthermore, in > 60%, cavitations occur within 2 weeks. Central low attenuation, centrilobular nodules, bronchial wall thickening, and septal line thickening have also been reported. Nocardia invades and colonizes the respiratory tracts, thereby causing bronchopneumonia. Therefore, findings suggestive of bronchopneumonia, such as bronchial wall thickening and centrilobular nodules, can be observed in patients with nocardial pneumonia.
In some clinical settings, such as in immunocompromised patients or in those with some underlying diseases, consolidation or nodules/masses with cavitation may suggest the possibility of pulmonary nocardiosis.
References: 1. Junjun Chen, Hua Zhou, Panfeng Xu et al. Clinical and radiographic characteristics of pulmonary nocardiosis: clues to earlier diagnosis. PLoS One. 2014 Mar 3;9(3):e90724.
2. Baoliang Liu, Yuanlong Zhang, Jingshan Gong et al. CT findings of pulmonary nocardiosis: a report of 9 cases. J Thorac Dis. 2017 Nov;9(11):4785-4790.
3. Naoki Tsujimoto, Takeshi Saraya, Ken Kikuchi et al. High-resolution CT findings of patients with pulmonary nocardiosis. J Thorac Dis. 2012 Dec;4(6):577-82.
4. Brian J Sutton, Graham E Parks, Cyrus K Manavi et al. Cushing's syndrome and nocardiosis associated with a pulmonary carcinoid tumor: report of a case and review of the literature. Diagn Cytopathol. 2011 May;39(5):359-62
Please refer to: Case 899 Case 630 Case 549 Case 117 Case 76
Keywords

No. of Applicants : 85

▶ Correct Answer : 14/85, 16.5%

- Affilitated Hospital of Jining Medical college , China JIANG SHENG HUA
- Asan Medical Center , Korea (South) EUNJI CHOI
- , Korea (South) JIN YOUNG LEE
- Muhimbili National Hospital , Tanzania FREDERICK RICHARD LYIMO
- Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
- Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
- Yeungnam University Medical Center , Korea (South) JONGSOO PARK
- Mallinckrodt Institute of Radiology , United States NAGANATHAN MANI
- Seoul National University Hospital , Korea (South) SE WOO KIM
- Osmania Medical College, Hyderabad , India PURUSHOTHAMA RAO TUMMALA
- Toranomon Hospital , Japan KAORU SUMIDA
- , Japan KAZUMA TERAUCHI
- Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
- , Korea (South) WONJU HONG

▶ Correct Answer as Differential Diagnosis : 19/85, 22.4%

- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- Other , Korea (South) HYEJIN YANG
- Chonbuk National University Hospital , Korea (South) MINGI SHIN
- Inje University Haeundae Paik Hospital , Korea (South) HYUNGIN PARK
- , Italy PAOLO BALDASSARI
- , Japan CHIAKI SATO
- Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
- Osaka City General Hospital , Japan SHU MATSUSHITA
- Chungbuk National University Hospital , Korea (South) MIHYEON PARK
- Seoul Veterans Hospital , Korea (South) SEONG WON JANG
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Other , Korea (South) KYU-CHONG LEE
- Paras hospital, Panchkula , India SHALEEN RANA
- Private sector , Greece VASILIOS TZILAS
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Semi-Correct Answer : 6/85, 7.1%

- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- Showa General Hospital , Japan MASAFUMI KAIUME
- , Brazil FERNANDO MORANDINI
- , Korea (South) SEUNGHYUN LIM
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1242 Date 2021-08-10

Discussion

No. of Applicants : 85