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Weekly Chest CasesArchive of Old Cases

Case No : 630 Date 2009-11-23

  • Courtesy of Kyung Hee Lee / Inha University Hospital
  • Age/Sex 56 / F
  • Chief ComplaintIncidental lung lesion at the preoperative chest X-ray for splenectomy due to idiopathic thrombocytopenia
  • Figure 1
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Diagnosis With Brief Discussion

Diagnosis
Nocardiosis
Radiologic Findings
Chest Radiograph shows well-defined round mass like opacity in LUL with small cavity and small nodule in RUL. Contrast enhanced CT scans show mass like consolidation in LUL with internal low attenuation with cavity and surrounding GGO and small nodules. Another small nodule is seen in RUL with cavity and GGO.
Brief Review
Nocardia are aerobic gram (+) bacilli found in the soil and distributed throughout the world. The moste common pathogen is N. asteroids, which accounts for approximately 80% of pulmonary infection. Nocardiosis is more common in men than in women (male-to-female ration 2:1 to 3:1) and in immunocompromised patients, particularly with lymphoma, with organ transplant, on corticosteroid therapy, and with AIDS. The most common clinical symptoms are low-grade fever, productive cough, and weight loss. In most cases, the clinical course is chronic, with a duration of symptoms before diagnosis of 3 weeks or more.
Plain chest radiography shows homogenous nonsegmental airspace consolidation, which is peripheral , abuts the adjacent pleura, and is often extensive. The consolidation tends to involve multiple lobes and reveals no predilection for the lower lobes. Multifocal peripheral nodules or masses with irregular margins also may be seen. Cavitation is common, being seen in one third or more of patients, and may occur within areas of consolidation, nodular opacity, or masses.
CT may be helpful in assessing the extent of disease and as a guided to obtain material for a definitive diagnosis. The predominant abnormality consisted of homogenous mulltilobar consolidation. Localized areas of low attenuation with rim enhancement suggestive of abscess formation were present within the areas of consolidation or cavitations. Pleural involvement and effusion is common and cavitation occurs in 35% of cases.

References
1. Mendez R, Codero PJ, Santos M, et al. Pulmonary infection with Nocardia species: a report of 10 cases and review: Eur Respir J 1997; 0:1542-1546
2. Raby N, Forbes G, Williams R. Nocardia infection in patients with liver transplants or chronic liver disease: radiologic finding. Radiology 1990;174:713-716
3. Yoon HK, Im JG, Ahn JM, et al. Pulmonary nocardiosis: CT findings. J Comput Assist Tomogr 1995;19:52-55
4. Franquet T. Respiratory infection in the AIDS and immunecompromised patient. Eur Radiol 2004;14;21-33
Keywords
Lung, Infection, Bacterial infection,

No. of Applicants : 104

▶ Correct Answer : 13/104,  12.5%
  • - All India Institute of Medical Sciences , India Jitesh Ahuja
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Retd. Prof Thoracic Surgery B.J.MEDIDCAL COLLEGE Punr India , India Bankim Amin
  • - CHRU Lille , France Benjamin Damarey
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Uzunkopru Devlet Hastanesi , Turkey Armagan Sarac
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - DCA, , India Rajesh Gothi
  • - SacrCoeur , Canada Andrea Ojanguren
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - NASA SCANS , India RAKESH BHATIA
  • - Saga University , Japan Ryoko Egashira
  • - Asan Medical Center , Korea (South) Seong Yun Kim
▶ Correct Answer as Differential Diagnosis : 22/104,  21.2%
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - All India Institute of medical sciences , India Justin Moses
  • - NTUH , Taiwan Kuei-pin Chung
  • - KMC,Manipal , India satish maddukuri
  • - CHRU lille , France manuel toledano
  • - partner, aditya imaging centre , India vivek patel
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - ministry of health and population , Egypt hanan tolba
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - CHUV , Switzerland ANNE-SOPHIE KNOEPFLI
  • - Samsung Medical Center , Korea (South) Eun Kim
  • - CH de la Ce Basque , France Paul ARDILOUZE
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - IRSA , France jean-luc BIGOT
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
  • - vinayaka missions medical college , India k bhaskar
  • - Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Louisiana State University - Shreveport , United States Carlos Previgliano
  • - Hopital du SacrCoeur , Canada Abraham Bohadana
  • - Trakya University School of Medicine , Turkey Umut Ugur
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