A 46-year-old man, who was a nonsmoker, presented to a hospital in Missouri for evaluation of a left upper lobe lung mass. He had initially presented to his primary care physician 7 months earlier, complaining of throat irritation, cough, and hemoptysis. He had reported coughing up about a tablespoon of bloody sputum in the mornings. Chest radiographs at that time were interpreted as normal, and the patient was prescribed a course of antibiotics. After completion of treatment, his symptoms persisted and progressed to feelings of shortness of breath. He was prescribed a second course of antibiotics and prednisone, after which his hemoptysis improved but he still felt the need to “cough something up.” Four months after his initial presentation, a computed tomography (CT) scan revealed a left upper lobe lung mass. Bronchoscopy was performed, which demonstrated inflammation and was otherwise nondiagnostic, and the patient was prescribed a third course of antibiotics and asked to follow up in 2 months. The CT scan at the follow-up demonstrated persistence of the mass, and he was scheduled at our institution for a wedge biopsy. The presurgical laboratory results were remarkable only for a mild increase in absolute eosinophils (350 cells/μl [normal range, 0 to 220 cells/μl]) and monocytes (830 cells/μl [normal range, 140 to 660 cells/μl]). Tissue specimens were obtained during surgery, with histologic examination revealing a mixed inflammatory response, granulomas, and multiple refractile structures measuring ∼80 μm within the lung parenchyma (Fig. 1).
(Left) Acute and chronic inflammation with numerous eosinophils and nonnecrotizing granulomata, with concentric fibrosis surrounding refractile structures (hematoxylin and eosin stain; magnification, ×200). (Right) Refractile structure. Magnification, ×1,000.
For answer and discussion, see page 1975 in this issue (https://doi.org/10.1128/JCM.02204-15 ).
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