A 36-year-old woman residing in the northern suburbs of NYC was referred for outpatient pulmonary evaluation of a lung nodule. Her past medical history was significant for locally advanced endocervical adenocarcinoma, which had been managed with abdominal hysterectomy and bilateral salpingo-oophorectomy one year earlier. No adjuvant therapy was administered. Preoperatively, 18FDG-PET/CT revealed a 1.2cm hypermetabolic RLL PN with a maximal standardized uptake ratio (SUVmax) of 2.3 (Fig. 3A). Transthoracic needle biopsy of this lesion was performed and showed poorly defined granulomatous inflammation with negative stains for microorganisms. Tissue cultures were not obtained. On repeat 18FDG-PET/CT one year after the initial study, the PN was not appreciably changed in size but now had a cavitary appearance with an increase in SUVmax to 5.18 (Fig. 3B). At the time of her visit to the pulmonary clinic, she denied constitutional and respiratory symptoms. She was a never-smoker and had no relevant occupational exposures. Since arriving to suburban NYC from Ecuador three years prior to the visit, she had not traveled. Her vital signs, physical examination, and routine laboratory evaluation were unremarkable. HIV testing was negative, and antibodies against H. capsulatum were not detected. IGRA-MTB was positive, but serial sputum collection for acid fast bacillus smear and culture was negative. She then underwent bronchoscopy with bronchoalveolar lavage (BAL). No microorganisms were seen on cytological and potassium hydroxide (KOH) preparations of the fluid. Eventually, however, BAL fungal culture yielded growth identified as Coccidioides spp. Since she remained asymptomatic, clinical observation was chosen over antifungal therapy. On further questioning, the patient revealed that she had migrated to the United States from Ecuador through northern Mexico, entering into Texas and from there ultimately reaching New York by air. Both northern Mexico and Texas are locations in which Coccidioides spp are endemic.
A, Axial image from the CT portion of a18FDG-PET/CT study set to lung window showing a spherical, solid 1.2cm subpleural nodule in the right lower lobe. The nodule's maximal standardized uptake value on the PET portion (not shown) was 2.33.