British Journal of Radiology (2006) 79, e174-e176
© 2006 British Institute of Radiology
doi: 10.1259/bjr/17487872
Multiple cavitating masses in an immunocompromised host with rheumatoid arthritis-related interstitial lung disease: an unusual expression of cytomegalovirus pneumonitis
A P Ayyappan, MD
1
R Thomas, MD
2
S Kurian, MD
3
D J Christopher, MD
2 and
R Cherian, DMRD, FRCR
1
Departments of 1Radiodiagnosis 2Respiratory Medicine and 3Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632 004 India
Correspondence: Dr Anoop P Ayyappan, Department of Radiodiagnosis, Christian Medical College and Hospital, Ida Scudder Road, Vellore, Tamil Nadu, 632004, India. E-mail: dranoopayyappan{at}gmail.com.
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Abstract
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Cytomegalovirus is a known opportunistic infection in immunocompromised individuals. We document multiple cavitating lung masses caused by cytomegalovirus in a patient with rheumatoid arthritis-induced interstitial lung disease on immunosuppressant medication, an unusual expression of CMV pneumonitis. With increasing use of immunosuppressive therapy and increase in AIDS, pulmonary cytomegalovirus infection is expected to be a more frequently encountered disease and familiarity with its uncommon radiological manifestations will be advantageous.
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Introduction
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Human cytomegalovirus (CMV), a member of herpes viridae, commonly infects healthy individuals. Symptomatic disease in immunocompetent individuals is rare and the course is typically benign. Like all herpes viruses it remains latent for the life of the host with potential for re-activation. Under conditions of immune system compromise and impaired cell-mediated immunity, such as Acquired Immune Deficiency Syndrome (AIDS), CMV can re-activate. The spectrum of radiological appearances in pulmonary disease following CMV infection in immunocompromised patients has been documented previously [1–3]. Our case illustrates an unusual and interesting expression of CMV pneumonitis in a patient with rheumatoid arthritis-related interstitial lung disease who was being administered immunosuppressant medication.
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Case report
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A 72-year-old male with rheumatoid arthritis-related interstitial lung disease (Figure 1
), on corticosteroids and cyclophosphamide, was admitted with fever, productive cough, worsening breathlessness and tenderness in the epigastrium. Chest radiograph showed bilateral consolidation (Figure 2). Thin-section CT of the chest revealed cavitating masses in the right upper lobe (Figure 3) and lingula (Figure 4) on a background of diffuse interstitial fibrosis. Oesophagogastroduodenoscopy revealed multiple antral and pyloric-channel ulcers. Gastric biopsy (Figure 5) demonstrated intracytoplasmic viral inclusions in keeping with CMV gastritis. Sputum smears for acid-fast bacilli were negative. Bronchoalveolar lavage fluid stains and culture for bacteria, Mycobacteria, fungus and Pneumocystis carinii were negative. Polymerase chain reaction assay of bronchoalveolar lavage fluid was positive for CMV. Transbronchial lung biopsy from the lung lesion (Figure 6) demonstrated intracytoplasmic viral inclusions. Disseminated CMV infection was diagnosed. The patient was initiated on Gancyclovir following which he improved clinically and there was radiological resolution (Figure 7).
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Figure 1. Thin-section (1 mm collimation) CT scan through the basal segments demonstrates areas of ground-glass attenuation, intralobular reticular opacities and honey combing (black arrows).
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Figure 2. Frontal chest radiograph obtained at presentation shows consolidation with cavitation(black arrow) in the right upper lobe. There is an area of consolidation (white arrow) in the left middle lung zone.
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Figure 3. Thin-section (1 mm collimation) CT scan of the right lung obtained 2 cm above the tracheal carina demonstrates dense cavitating mass in the upper lobe (black arrow) contiguous with the pleura. Tracheal lumen shows mucus (white arrow).
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Figure 4. Thin-section (1 mm collimation) CT scan of the left lung shows a small cavitating mass in the lingula (black arrow) abutting the pleura.
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Figure 5. Photomicrograph of the gastric biopsy specimen. Haematoxylin-eosin, original magnification x400. Gastric mucosa shows intracytoplasmic viral inclusions (black arrow).
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Figure 6. Photomicrograph of the trans-bronchial lung biopsy specimen. Haematoxylin-eosin, original magnification x400. Lung alveolar epithelium shows viral inclusions (black arrow).
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Discussion
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Chest radiography is the first radiological investigation performed when pneumonia is suspected in an immunocompromised individual. The most common manifestations of CMV pneumonitis on conventional radiographs are parenchymal consolidation and multiple nodules measuring less than 5 mm in diameter.
CT findings mirror the radiographic appearances and comprise areas of ground-glass attenuation, parenchymal consolidation, and nodular or reticulonodular opacities. In the immunocompromised population, pulmonary manifestations of CMV infection in patients with AIDS appear to be different from those without AIDS. McGuinness et al [1] observed dense consolidation and mass-like opacities in CMV pneumonitis among patients having AIDS, while the areas of consolidation were neither mass-like nor dense in those without AIDS.
The most frequent thin-section CT manifestation in immunocompromised patients without AIDS was ground-glass opacities which were bilateral without zonal predisposition and patchy in distribution. These opacities corresponded histopathologically to areas of diffuse alveolar damage [2, 3]. Small, poorly defined centrilobular nodules representing focal areas of inflammation or haemorrhage and areas of air-space consolidation were also frequently seen [2, 3]. Consolidations were mostly bilateral and associated with ground-glass opacities and nodules [2, 3].
In individuals on immunosuppressant medications, CMV pneumonia is caused by immune mechanisms mediated by a T-cell response to virally-induced antigens expressed in the lungs. In these patients, necrotizing inflammation is dominant and relatively few CMV-infected cells are revealed by histopathological examination [3]. In patients with AIDS, lung damage may directly be due to cytopathogenetic effects of CMV, related to the extent of active virus replication [4]. These patients reveal a high density of CMV inclusion bodies. This difference in pathogenic mechanisms may result in different radiological and histopathological features among AIDS and non-AIDS immunocompromised population.
There are only a few documented cases of cavitating lung masses caused due to CMV as a sole pathogen [5–7]. In immunocompromised individuals with suspected infection, cavitating lung masses are generally attributed to polymicrobial infections [5, 6]. In 20 cases of AIDS with cavitary lung disease, CMV was attributed as the sole pathogen in only one individual [6]. Karakelides et al [7] documented CMV pneumonia presenting as a cavitating mass in an immunocompentent individual that mimicked malignancy. Recently, Najjar et al [5] reported cavitating lung masses following CMV infection in two patients with systemic lupus erythematosus on immunosuppressant medication. Differential diagnosis of cavitating masses in the immunocompromised individuals includes bacterial, fungal, tuberculous, Pneumocystis carinii infections, septic emboli and malignancy.
With increasing use of immunosuppressive therapy and increasing AIDS, pulmonary CMV infection is expected to be a more frequently encountered disease and familiarity with its uncommon radiological manifestations will be advantageous. Our case illustrates that the CMV can be the sole pathogen responsible for multiple cavitating lung masses. In the appropriate clinical setting, CMV infection should be considered and excluded as effective antiviral therapy is available.
Received for publication September 15, 2005.
Revision received December 5, 2005.
Accepted for publication January 19, 2006.
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References
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Abstract
Introduction
