Infectious Disease Edition

20 January 2015

Here are a few cases from the last week with a particular theme...

Case #1
History: 
29-year-old male with history of multiple courses of treatment for Mycobacterium tuberculosis. He now presents with moderately severe hemoptysis. 
Gross: Partial resection of upper lung lobe. There is a cavity lined by apparent bronchial mucosa that is filled with an aggregate of friable brown material, measuring 3 x 2 x 2 cm. 

Lung resection specimen with cavitary lesion filled with brown, friable material

 

Low power image of lung and friable mass

High power view of lung and friable mass

Medium power view of mass

Medium power view of mass

High power view of mass

High power view of mass

High power view of mass

Case #2
History: 19-year-old female with abdominal pain and distention, dilated colon, congested liver with bile-stained fluid. Clinical concern for hepatitis.
Gross: 2 cm liver biopsy.

Low power view of liver

Low power view of liver

Ziehl-Neelsen stain

Ziehl-Neelsen stain

Ziehl-Neelsen stain

 

 

Case #3 (Repeat from previous post with better images)
History: 26 year-old female with HIV (last CD4 count 250 cell/uL) and chronic sacral/gluteal wound that began as a small vesicle.
Gross: Punch biopsy of skin, at the interface of the wound and normal-appearing skin.

Photograph of sacral/gluteal wound

Low power view of normal skin and lesion

Medium power view of lesion

High power view of lesion

Consider the diagnoses and I'll update the post with our interpretations after we return from an attempt on Point Lenana, Mount Kenya (16,355 ft)!

And hopefully the weather looks more like this....

Road to Kijabe on a training hike

And less like this....



 

Monsoon hail storm on the crater rim of Mount Longonot (9,108′). Rochelle is in the blue and white coat. Phillip is well-protected behind the guy in the red shirt (white pant leg).

 

Our interpretations:

Case #1: Left lung, partial lobectomy: Fungal ball consistent with that caused by Aspergillus sp. (aspergilloma, 3 cm) surrounded by granulation tissue, necrotic tissue, and respiratory mucosa; no definitive invasive fungus identified.

Case #2: Liver, biopsy: Granulomatous hepatitis with rare acid-fast bacilli identified on Ziehl-Neelsen stain, consistent with extra-pulmonary Mycobacterium tuberculosis infection. 

Case #3: Skin, sacral and gluteal, biopsy: Ulcerated skin with neutrophilic inflammation and epithelial cells with probable viral inclusions, consistent with herpes simplex virus infection.