A 53-year-old male patient was admitted to a local hospital with recurrent fever and cough in December 2013. He had a smoking history of 40 years, but there was neither immunosuppressive drug intake nor underlying diseases such as tuberculosis, diabetes, and malignancies. Physical examination and laboratory findings were normal except for a body temperature of 37.8 C. Chest computed tomography (CT) showed a 3 x 3 cm mass in the right middle lobe along with multiple nodules in both lungs (fig. 1a). A thoracoscopic wedge resection of the lesion was then performed, and the biopsy showed suppurative granulomatous inflammation. The patient's symptoms improved after surgery and 1 week's use of piperacillin-tazobactam.
However, he was readmitted with cough, fever, and new-onset low back pain in May 2014. Chest CT scan indicated an emerging nodular lesion in the left lower lobe (fig. 1b), and magnetic resonance imaging (MRI) revealed bony destruction in the L5 vertebral body and L2/3 pedicle (fig. 1c). Biopsies from both tracheoscopy and percutaneous vertebral puncture showed chronic inflammation. Meanwhile, tissue sections of lung specimens were rechecked and the suggestion was suppurative inflammation probably caused by Nocardia. However, no further pathogenic evidence was provided. Although the patient was treated with antituberculosis drugs empirically, he still had persistent back pain and developed bilateral lower extremity weakness, which prompted surgical intervention including drainage, debridement, decompression, and stabilization of the lumbar spine.
Nevertheless, he suffered from a repeated moderate fever after surgery and was then transferred to our hospital. A 2 x 2 cm soft mass was palpable in the right paravertebral area. Muscle strength was 4/5 for both lower extremities. A new MRI showed deterioration of the imaging findings (fig. 1d). Consequently, we performed a second surgery including removal of the original internal fixation, debridement, decompression, and drainage. A few spore or hypha analogues were visualized in tissue sections with Gomori methenamine-silver stain and periodic acid-Schiff stain (fig. 1e). Then, the patient was initially treated with voriconazole (a loading dose of 6 mg/kg of body weight on the 1st day followed by 4 mg/kg, every 12 h intravenously). Two weeks later, he had pain relief and recovered his normal temperature. Resolution of the lumbar lesions was also distinctly observed. Notably, specimens from the third lumbar surgery primarily for spinal stabilization revealed septate fungal hyphae, dichotomously branching at acute angles (fig. 1f). So far, the patient had taken voriconazole for more than 3 months, and no recurrence was detected. However, the muscle strength of both lower extremities did not improve significantly.