A 48-year-old man was admitted to our hospital due to prolonged fever and nausea. Physical examination indicated the following: Body temperature, 38.5  C; heart rate, 109 beats/min; blood pressure, 140/80 mmHg and lack of ausculatory sounds in the upper lobe of the left lung. Laboratory examination performed revealed: normal white blood cell count, 8.5 x 109/l, an elevated C reactive protein, 7mg/dl (0.01-0.8mg/dl) and negative tuberculosis antibody test. Computed tomography (CT) showed a large solid mass of the left upper lobe, limited pleural and pericardial effusion and calcified lymphadenopathy of mediastinum, Fig. 1. The patient underwent a CT-guided core biopsy of the lung lesion and three samples were obtained. Specimens were sent for culture, histological and polymerase chain reaction (PCR) assay. The possibility of malignancy was excluded, at the same time culture and PCR were positive for Histoplasma capsulatum and histological findings were compatible with BG, Fig. 2. Due to the positive culture we investigated patient's traveling history and he referred traveling in United States many years ago just for a few days.
Complete laboratory investigation excluded any kind of immunosuppresion in our patient.
The patient was diagnosed as a chronic pulmonary histoplasmosis case with bronchogenic granulomatosis. Initially he was treated with amphotericin B and itraconazole. One month later he revealed complete clinical recovery, improvement of the inflammatory index and decrease of solid mass size, nevertheless, pleural and pericardial effusions increased. Having in mind the histological diagnosis of bronchocentric granulomatosis and the aggravation of effusions, corticosteroids were added to the medication. Our patient was discharged two weeks later, in a good clinical status with itraconazole and methylprednisolone.
CT imaging follow up one month later demonstrated a great decrease of the left lobe mass size. No pleural and pericardial effusion was reported Fig. 3.
a-b. Follow up with CT two months after treatment reveals great decrease of the lung lesion. None pleural and pericardial effusion is reported.