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A 35-year-old male suffered from a cough with sputum for one month. He was relatively healthy in the past and had a smoking history of 0.5 PPD for more than 10 years. There was no fever, no dyspnea, no body weight loss and no special travel history. At the OPD, chest radiograph showed a cavity in the upper area of the right lung of 3.5 cm × 4.5 cm with thin wall lesion. Chest computer tomography showed a thin wall cavitary lesion with irregular inner margin over the right apex area and an intracavitary ball-in-hole appearance mass (Fig. 1). Sputum examination showed no evidence of bacterial or tuberculosis infection. However, hemoptysis developed and he was referred to our hospital for surgical intervention due to deteriorating clinical condition. Physical examination was unremarkable and lab data showed leukocytosis and normal liver and renal function.
Fig. 1Chest radiograph (left) and computer tomography (right) showed a thin wall cavitary lesion over the right apex area and an intracavitary ball-in-hole appearance mass.
He received right upper lobe surgical wedge resection and pathology showed pleomorphic carcinoma mixed with aspergillosis infection. Cavitary lesion in the lung is not uncommon in clinical scenarios. Various etiologies contribute to cavity formation, such as tuberculosis, fungus, hydatid cyst, neoplasm [
]. Radiological features such as wall thickness or smooth inner margin were used to differentiate malignancy and non-malignancy but the results were disappointing. Ball-in-hole lesions commonly occur in preexisting, thin wall cavitary lesions and are associated with fungal infections, especial the aspergillosis. Most aspergilloma are asymptomatic and surgical resection is indicated for patients with recurrent hemoptysis. So, the fungus was possibly infected from a tumor with necrotic area. We present this case as fungal infected lung tumor with aggressive behavior similar to pleomorphic carcinoma. This case reminded the clinical physician that a scenario of cavitary cancerous lesion with fungal infection should be kept in mind. Hence, pulmonary cavitary lesion even with common radiological features of an infectious process required further examination in clinical practice.
Conflicts of interest
The authors have no actual or potential conflicts of interest.
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