The differential diagnosis for endobronchial lesions includes but is not limited to neoplastic causes, benign tumors, infections, and foreign objects. We report a case of an unusual cause of endobronchial lesions.
The case
A 47-year-old man with a 45-pack-year tobacco history presented to his primary care physician with a 50-lb unintentional weight loss over 3 months, a cough productive of white phlegm, and mouth ulcers. His vital signs were remarkable for the absence of both fever and tachypnea. Physical examination findings were significant for mild cachexia and oral aphthous ulcers.
Laboratory evaluation revealed a normal complete blood cell count but mildly elevated levels of transaminases. A chest radiograph revealed a 2-cm cavitary right upper lobe (RUL) lesion (Figure 1). CT scans of the chest and abdomen revealed the solitary lung lesion, on a background of centrilobular emphysema (Figure 2), and bilateral non-homogeneous adrenal glands, with the left gland appearing larger than the right one (Figure 3). CT scans did not reveal any mediastinal lymphadenopathy or pleural effusions.
Figure 1 – A cavitary upper lobe mass appears behind the right clavicle in this posteroanterior chest radiograph (arrow).
Figure 2 – A 2-cm thick-walled cavitary lesion in the right upper lobe, on a background of emphysema, is revealed in this chest CT scan (5-mm axial cuts, lung window setting).
Figure 3 – Bilateral non-homogeneous densities in the adrenal glands can be seen in this abdominal CT scan (5- mm axial cuts) after oral and intravenous administration of contrast (arrows).
Figure 4 – Ring-enhancing lesions in the right cerebral hemisphere are revealed in this CT scan of the patient's head.
Figure 5 – This CT scan of the chest shows a polypoid endobronchial lesion in the left main-stem bronchus and a calcified periaortic lymph node (5-mm axial cuts, mediastinal window setting).
Before referral to the pulmonary service, the following workup was performed. Initially, CT-guided fine-needle aspiration of the RUL lesion was performed using a 19-gauge needle. Cytological analysis revealed rare atypical cells, suggesting malignancy. Also, pathology revealed necrotizing granulomas, and stains were negative for fungi and mycobacteria. Two subsequent CT-guided left adrenal core biopsies, using a 19-gauge needle, demonstrated necrotic tissue, debris, and a few yeast forms morphologically suggestive of Candida species.
The patient was referred to otolaryngology for a biopsy of the mouth ulcers. The pathology of the left arytenoid and anterior subglottic region revealed ulcers with acute and chronic inflammation, reactive atypia, and yeast-like organisms. After the patient was referred to the oncology clinic with the presumptive diagnosis of metastatic cancer, CT scans revealed numerous small ring-enhancing cortical brain lesions (Figure 4) and a left main-stem endobronchial mass (Figure 5).
