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 Table of Contents  
RADIOLOGY QUIZ
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 88-89

Cavitating lung lesion


Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India

Date of Submission11-Jun-2022
Date of Decision18-Jul-2022
Date of Acceptance03-Aug-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. M Vishnu Sharma
Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_16_22

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How to cite this article:
Sharma M V, Mohammed S V. Cavitating lung lesion. J Assoc Pulmonologist Tamilnadu 2022;5:88-9

How to cite this URL:
Sharma M V, Mohammed S V. Cavitating lung lesion. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 Jan 27];5:88-9. Available from: http://www.japt.com/text.asp?2022/5/2/88/365078




  Question Top


A 63-year-old male was admitted for evaluation. He had low-grade, intermittent fever, cough with scanty sputum, and anorexia for the past 2 weeks. No hemoptysis was noted. He was on regular immunosuppressive therapy for rheumatoid arthritis for the past 4 years. His arthritis was under control. He had no previous respiratory symptoms. He had no evidence of rheumatoid lung disease before these symptoms. He was a nonsmoker. A chest X-ray posteroanterior [Figure 1] and lateral view [Figure 2] was taken. What is the most likely diagnosis and what are the differentials?
Figure 1: Chest X-ray posteroanterior view

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Figure 2: Chest X-ray lateral view

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  Answer Top


Chest X-ray shows multiple cavities with small air–fluid level with infiltrates on the left side and a small cavity with surrounding infiltrates on the right side. Most likely diagnosis is pulmonary tuberculosis. Sputum acid-fast Bacillus smear was done, which confirmed the diagnosis. The most common cause of cavitating lung lesion is pulmonary tuberculosis.[1]

Cavity in pulmonary tuberculosis most commonly occurs in the upper lobes, which can be unilateral or bilateral, single or multiple, usually without any significant air–fluid level, thin-walled, and surrounded by parenchymal infiltrates.[1] Cavity may show air–fluid level when there is superadded bacterial infection in a tubercular cavity. Chronic cavity and secondary bacterial infection can lead to increased wall thickness of tubercular cavity.[2]

Differential diagnosis for multiple cavitory lesions in lung

  • Infections


    • Mycobacterial infections


      • Mycobacterium tuberculosis (most common cause worldwide)[3]
      • Nontubercular mycobacterial infections (less common)


    • Bacterial infections[4]


      • Staphylococcus aureus
      • Klebsiella pneumoniae
      • Pseudomonas aeruginosa
      • Anaerobes/aspiration pneumonia
      • Melioidosis
      • Septic emboli
      • Bacterial pneumonia in an immunocompromised host


    • Fungal infections[3],[4]


      • Usually occurs in immunocompromised host


    • Autoimmune diseases


      • Granulomatosis with polyangiitis
      • Rheumatoid arthritis


    • Malignancy
      • Cavitating pulmonary metastasis.[5]


    When a patient is on immunosuppressive therapy, classical symptoms and signs of infection may be masked.[6] Chest radiology can be atypical in such patients. Radiological lesions may progress very fast. In patients with systemic connective tissue/autoimmune disease, infections are the most common cause of cavity in the lung. In countries with a high prevalence of tuberculosis, the most common cause of cavity in the lung in these patients is tuberculosis.[7]

    The pulmonary rheumatoid nodules are rare and occur in less than 1% of patients with rheumatoid arthritis. Up to 70% of these nodules may cavitate. Cavitating rheumatoid nodules are called rheumatic necrobiotic nodules. Pulmonary rheumatoid nodules tend to be peripheral, more commonly seen in the middle and upper zones and subpleural.[6] They can be single or multiple. Chest radiology will often show features of interstitial lung disease in addition to the nodules.[6]

    Systematic approach is essential for definitive diagnosis of cavitating lung lesion.[4] Focused history, physical examination, radiological characteristics, and sputum analysis will yield a diagnosis in majority of the cases. Bronchoscopy and/or biopsy may be required in select cases when the diagnosis is uncertain.

    Learning points

    The most common cause of cavitating lung lesion is tuberculosis. Systematic approach is essential for a definitive diagnosis of cavitating lung lesion.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Jeong YJ, Lee KS. Pulmonary tuberculosis: Up-to-date imaging and management. AJR Am J Roentgenol 2008;191:834-44.  Back to cited text no. 1
        
    2.
    Sharma V, Babu C. (Mangalore, India). A 32-Year-Old Female with High Grade Fever. Case Report; 2018.  Back to cited text no. 2
        
    3.
    Parkar AP, Kandiah P. Differential diagnosis of cavitary lung lesions. J Belg Soc Radiol 2016;100:100.  Back to cited text no. 3
        
    4.
    Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, et al. Cavitary lung diseases: A clinical-radiologic algorithmic approach. Chest 2018;153:1443-65.  Back to cited text no. 4
        
    5.
    Seo JB, Im JG, Goo JM, Chung MJ, Kim MY. Atypical pulmonary metastases: Spectrum of radiologic findings. Radiographics 2001;21:403-17.  Back to cited text no. 5
        
    6.
    Sharma V, Bali A. (Mangalore, India). A 46-Year-Old Woman with Recurrent Mild Hemoptysis. Case Report; 2018.  Back to cited text no. 6
        
    7.
    Shetty AK, Boloor R, Sharma V, Bhat GH. Melioidosis and pulmonary tuberculosis co-infection in a diabetic. Ann Thorac Med 2010;5:113-5.  Back to cited text no. 7
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