fungal osteomyelitis masquerading as a chest wall tumor

Fungal Osteomyelitis Masquerading as a Chest Wall Tumor Varun Puri, MD, Steven M. Johnson, MD, and Nabil A. Munfakh, MD Division of Cardiothoracic Surgery, Washington University, St. Louis, and Department of Pathology, Christian Hospital North East, St. Louis, Missouri A 52-year-old immunocompetent man presented with weight loss and a painful, enlarging chest mass. Examination revealed a 6-cm mass inferior to the right pectoralis muscle, and a computed tomography scan showed a tumor with rib destruction (Fig 1). A specimen from a needle biopsy showed necrosis, with suspicion of malignancy. The patient underwent wide en bloc resection of the lower sternum, segments of 4 ribs, and a wedge of the right lower lobe of the lung. The defect was reconstructed using a polymethylmethacrylate-mesh composite and a pectoralis major muscle flap. Microscopic examination showed neutrophilic infiltra- tion with Aspergillus hyphae identified on silver stain, thus diagnosing fungal osteomyelitis (Fig 2, arrow marks rib cartilage; Gomori methenamine silver stain; original magnification 400). No neoplasia was identified. He received intravenous amphotericin for 3 weeks. Infection with Aspergillus, a ubiquitous saprophytic mold, can occur from inhalation of spores. Our patient had a focus of pneumonia in the resected lung that may have led to contiguous chest wall involvement. Immuno- suppression is the predominant risk factor for invasive aspergillosis, and mortality is high [1]. Owing to the rarity of fungal chest wall osteomyelitis in immunocompetent patients, there are no treatment guidelines [2, 3]. References 1. Pagano L, Caira M, Picardi M, et al. Invasive aspergillosis in patients with acute leukemia. Clin Infect Dis 2007;44:1524 –5. 2. Jordan JM, Waters K, Caldwell DS. Aspergillus flavus: an unusual cause of chest wall inflammation in an immunocompetent host. J Rheumatol 1986;13:660 –2. 3. Fisher MS. Aspergillosis of the chest wall in an apparently immunocompetent host. Skeletal Radiol 1992;21:410 –3. Address correspondence to Dr Puri, 660 S Euclid Ave, Campus Box 8234, St. Louis, MO 63110; e-mail: [email protected]. Fig 1. Fig 2. © 2011 by The Society of Thoracic Surgeons Ann Thorac Surg 2011;91:304 • 0003-4975/$36.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2010.04.084 FEATURE ARTICLES

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Page 1: Fungal Osteomyelitis Masquerading as a Chest Wall Tumor

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FEAT

ICLES

ungal Osteomyelitis Masquerading as a Chestall Tumor

arun Puri, MD, Steven M. Johnson, MD, and Nabil A. Munfakh, MDivision of Cardiothoracic Surgery, Washington University, St. Louis, and Department of Pathology, Christian Hospital North

ast, St. Louis, Missouri

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52-year-old immunocompetent man presented withweight loss and a painful, enlarging chest mass.

xamination revealed a 6-cm mass inferior to the rightectoralis muscle, and a computed tomography scanhowed a tumor with rib destruction (Fig 1). A specimenrom a needle biopsy showed necrosis, with suspicion of

alignancy.The patient underwent wide en bloc resection of the

ower sternum, segments of 4 ribs, and a wedge of theight lower lobe of the lung. The defect was reconstructedsing a polymethylmethacrylate-mesh composite and aectoralis major muscle flap.Microscopic examination showed neutrophilic infiltra-

ion with Aspergillus hyphae identified on silver stain, thusiagnosing fungal osteomyelitis (Fig 2, arrow marks ribartilage; Gomori methenamine silver stain; original

ig 1.

3ddress correspondence to Dr Puri, 660 S Euclid Ave, Campus Box 8234,t. Louis, MO 63110; e-mail: [email protected].

2011 by The Society of Thoracic Surgeonsublished by Elsevier Inc

agnification �400). No neoplasia was identified. Heeceived intravenous amphotericin for 3 weeks.

Infection with Aspergillus, a ubiquitous saprophyticold, can occur from inhalation of spores. Our patient

ad a focus of pneumonia in the resected lung that mayave led to contiguous chest wall involvement. Immuno-uppression is the predominant risk factor for invasivespergillosis, and mortality is high [1]. Owing to the rarityf fungal chest wall osteomyelitis in immunocompetentatients, there are no treatment guidelines [2, 3].

eferences

. Pagano L, Caira M, Picardi M, et al. Invasive aspergillosis inpatients with acute leukemia. Clin Infect Dis 2007;44:1524–5.

. Jordan JM, Waters K, Caldwell DS. Aspergillus flavus: anunusual cause of chest wall inflammation in an immunocom-petent host. J Rheumatol 1986;13:660–2.

ig 2.

. Fisher MS. Aspergillosis of the chest wall in an apparentlyimmunocompetent host. Skeletal Radiol 1992;21:410–3.

Ann Thorac Surg 2011;91:304 • 0003-4975/$36.00doi:10.1016/j.athoracsur.2010.04.084

mailto:[email protected]

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