Multiple pulmonary nodules after recovery from chickenpox in a patient with chronic lymphocytic leukaemia

Chickenpox-related pulmonary granulomas in immunocompetent adults: clinicopathologic and molecular features of an underrated occurrence

Pulmonary granulomas represent a common inflammatory reaction to several lung infective or noninfective diseases. However, little is known about the histology and clinical presentation of chickenpox-related granulomas in immunocompetent subjects. We collected a series of 8 adult patients (mean age, 40 y; range, 33 to 53 y) with several bilateral pulmonary granulomas incidentally discovered after imaging studies. All patients were asymptomatic and had experienced a varicella-zoster virus (VZV) infection as adults but were clinically suspected to have a metastatic neoplasm of unknown origin. Chest computed tomography scan revealed numerous, tiny (few millimeters to 1 cm in size) nodules randomly dispersed through the lungs. Positron emission tomography scan performed in 4 patients was negative. All patients underwent video-assisted thoracoscopic surgical resection and were still alive and well. At histology, granulomas consisted of well-defined, rounded, small nodules centered by a deeply eosinophilic, acellular necrosis rimmed by lamellar dense collagen and a chronic inflammatory infiltrate with or without multinucleated giant cells. Chickenpox-related granulomas were included in the differential diagnosis along with several other granulomatous diseases. Polymerase chain reaction-based molecular analysis for VZV performed on paraffin sections detected VZV DNA in all 8 cases. By contrast, 85 cases of pulmonary granulomas of different etiologies were simultaneously studied by molecular analysis with negative results. Pathologists should be familiar with the peculiar morphologic appearance of chickenpox-related granulomas. A careful search for a history of VZV infection in adulthood and molecular studies may be very helpful in confirming the diagnosis.

Open-lung biopsy in patients with undiagnosed lung lesions referred at a tertiary cancer center is safe and reveals noncancerous, noninfectious entities as the most common diagnoses

We evaluated the diagnostic yield of open-lung biopsies (OLBs) in a large tertiary cancer center to determine the role of infectious diseases as causes of undiagnosed pulmonary lesions. All consecutive adult patients with either single or multiple pulmonary nodules or masses who underwent a diagnostic OLB over a period of 10 years (1998-2007) were retrospectively identified. Their risk factors for malignancy and clinical and radiological characteristics were reviewed, and their postoperative complications were assessed. We evaluated 155 patients with a median age of 57 years (range, 19-83 years). We identified infectious etiologies in 29 patients (19 %). The most common diagnosis in this group was histoplasmosis (12 [41 %]), followed by nontuberculous mycobacterial infection (7 [24 %]) and aspergillosis (4 [14 %]). The majority of the 126 remaining patients had nonmalignant diagnoses, the most prevalent being nonspecific granuloma (26 %), whereas only 17 % had malignant diagnoses. We observed no significant differences among the patients with infectious, malignant, or both noninfectious and nonmalignant final diagnoses regarding their demographic, laboratory, and clinical characteristics. Six percent of the patients had at least one post-OLB complication, and the post-OLB mortality rate was 1 %. OLB is a safe diagnostic procedure which frequently identifies a wide variety of infectious and inflammatory diseases.

Pulmonary manifestations of Pyoderma gangrenosum

INTRODUCTION

Pyoderma gangrenosum is an uncommon ulcerative cutaneous disorder. Extracutaneous localizations are rare. Respiratory system involvement has been described in a few cases, but the pulmonary features reported were highly variable.

CASE

We report two cases of patients with Pyoderma gangrenosum combining cutaneous and pulmonary manifestations. One case presented multiple nodular lesions, some with cavitation. The underlying disease was varicella-zoster virus infection. The second presented pneumonitis with bronchiolar micronodules.

DISCUSSION

Few cases have reported Pyoderma gangrenosum with pulmonary involvement, which appears to be manifested mainly as nodules or interstitial lung disease. The principal differential diagnosis is Wegener's granulomatosis.

Persistent multiple pulmonary nodules in a nonimmunocompromised woman after varicella-related myelitis treated with acyclovir

Persistent multiple pulmonary nodules were observed on the chest X ray of a nonimmunocompromised woman 6 months after she was treated with acyclovir for a varicella-related myelitis without respiratory symptoms. Early antiviral therapy given for varicella infections might decrease the intensity of clinical symptoms without actually preventing the occurrence of varicella-zoster virus-related lesions such as the persistent pulmonary nodules reported here.

Varicella-zoster virus detection by polymerase chain reaction using bronchoalveolar lavage specimens

We report the use of polymerase chain reaction (PCR) techniques from a bronchoalveolar lavage (BAL) specimen for the successful early diagnosis in a case of atypical but severe varicella-zoster virus (VZV) pneumonitis. Atypical presentations of disseminated VZV frequently prolong the time required for accurate diagnosis, resulting in increased morbidity, or mortality. Although further investigation is necessary to determine the sensitivity and positive predictive value of this test, PCR analysis of bronchoscopic specimens may expedite the diagnosis of disseminated VZV.