Lung (2016) 194:329–330 DOI 10.1007/s00408-015-9840-5
LUNG IMAGES
Chickenpox-Related Multiple Pulmonary Granulomas: A Poorly Recognized Entity Filippo Lococo1 • Maria Cecilia Mengoli2 • Paolo Spagnolo3 • Alberto Cavazza4 Giulio Rossi2
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Received: 1 December 2015 / Accepted: 26 December 2015 / Published online: 5 January 2016 Ó Springer Science+Business Media New York 2016
A 39-year-old, non-smoker, lady was incidentally found to have small pulmonary nodules on chest X-ray. The clinical examination of the patient was negative and her medical past was unremarkable, while she referred a prior history of chickenpox about 1 year before. At that time, the patient had no respiratory symptoms but a common chickenpox with cutaneous lesions and fever, so no radiologic work-up was performed (Fig. 1). Computed tomography of the lung confirmed the presence of numerous, small, randomly distributed, rounded nodules ranging from 0.5 to 1 cm in diameter (Panel A–B, yellow arrowheads) . Imaging study was considered to be suggestive of lung metastasis without clear primary neoplasm. Routine laboratory tests (including tests for systemic inflammatory or infectious diseases), mammography, and tumor serum markers (CA15.3, CA19.9, CEA, and CA125) were unremarkable. Bronchoscopy with broncho-alveolar lavage, Mantoux, and Quantiferon-TB tests were also negative. The patient therefore underwent double ‘‘wedge resections’’ of the right lung via video-assisted
thoracoscopic surgery. Histology showed rounded, welldefined nodules with a necrotic center, surrounded by a fibrous wall characterized by concentric lamellar distribution of dense collagen rimed by a chronic inflammatory infiltrate with scattered multinucleated giant cells (Panel C). Special stains (Grocott methenamine silver, Ziehl– Neelsen) did not reveal either fungi or alcohol-resistant bacilli. Conversely, PCR-based molecular investigations on microdissected tissue of a nodule from paraffin-embedded blocks revealed the presence of varicella zoster virus (VZV) genome. VZV pneumonia is a serious complication of infection with varicella zoster virus, usually presenting as interstitial pneumonitis, best evident in the periphery of the lung [1]. In immunocompetent adults, the disease may involve the lungs without respiratory symptoms, as in the present case. The pulmonary involvement may persist for long time and, very rarely, remain indefinitely as randomly disseminated small, perfectly rounded (\1 cm) nodules of the
& Filippo Lococo
[email protected] 1
Unit of Thoracic Surgery, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
2
Pathologic Anatomy, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
3
Medical University Clinic, Canton Hospital Baselland, University of Basel, Liestal, Switzerland
4
Unit of Pathology, IRCCS-Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
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Fig. 1 a–b CT-scan evaluation: small round-shape pulmonary nodules. c Microscopic evaluation: well-defined nodules with a necrotic center
lungs, with or without calcification [2] as a residual ‘‘scar’’ of its past presence. This underappreciated and poorly recognized occurrence often leads to suspect a neoplastic spread from unknown primary malignancy, as in the present case. Radiology is characteristic, though not pathognomonic, and recognition of a previous (months to years) chickenpox infection could avoid invasive diagnostic investigations (up to unnecessary surgical biopsy), preferring a strict radiological surveillance [3]. Authors Contribution All authors contributed to patient care and writing of the report. Written consent to publication was obtained.
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Compliance with Ethical Standards Conflict of Interest
None.
References 1. Frangides CY, Pneumatikos I (2004) Varicella-zoster virus pneumonia in adults: report of 14 cases and review of the literature. Eur J Intern Med 15(6):364–370 2. Floudas CS, Kanakis MA, Andreopoulos A et al (2008) Nodular lung calcifications following varicella zoster virus pneumonia. QJM 101(2):159. doi:10.1093/qjmed/hcm132 3. Rossi G, Graziano P, Cavazza A (2014) Chickenpox in unexplained pulmonary necrotizing granulomas. Chest 145(2): 433–434. doi:10.1378/chest.13-2394