A.J.C.P. • December 1982
FINGERLE AND CHECK
870
Acknowledgments. We thank Dr. E. F. Winton for providing clinical
information, Dr. R. K. Brynes for the pathologic and immunohistochemical evaluation of the bone marrow biopsy specimens, Ms. A.
Pierce for advice on immunohematologic procedures, and Ms. L.
Drummer for performing the electrophoretic procedures.
References
1. Cawley L, Minard B, Tourtellotte W, et al: Immunofixation electrophoretic techniques applied to identification of proteins in
serum and cerebrospinal fluid. Clin Chem 1976; 22:1262-8
2. Feizi T: Lambda chains in cold agglutinins. Science 1967;
156:1111-3
3. Freedman J, Newlands M: Autoimmune haemolytic anaemia with
the unusual combination of both IgM and IgG autoantibodies.
Vox Sang 1977; 32:61-8
4. Harboe M, Van Furth R, Schubothe H, et al: Exclusive occurrence
of K chains in isolated cold hemagglutinins. Scand J Haematol
1965; 2:259-66
5. Harboe M, Torsvik H: Protein abnormalities in the cold hemagglutinin syndrome. Scand J Haematol 1969; 6:416-26
6. Hitzmann JL, Li CY, Kyle RA: Immunoperoxidase staining of
the bone marrow sections. Cancer 1981; 48:2438-46
Non-aspergillus
Kelly RH, Scholl MA, et al: Qualitative testing for circulating
immune complexes by use of zone electrophoresis on Agarose.
Clin Chem 1980; 26(3):396-402
Kuenn JW, Weber R, Teague PO, et al: Cryopathic gangrene with
an IgM lambda cryoprecipitating cold agglutinin. Cancer 1978;
42:1826-33
Kyle RA, Robinson RA, Katzmann JA: The clinical aspects of
biclonal gammopathies. Am J Med 1981; 71:999-1007
10. Otto S, Borzsonyi M, Eckhardt S, et al: Immunochemical and
ultrastructural investigations in a patient with cold-agglutinineactive monoclonal IgM k-gammopathy. Blut 1977; 34:299-304
Potter M: Immunoglobulin-producing tumors and myeloma proteins of mice. Physiol Rev 1972; 52:631-719
12. Pruzanski W, Cowan DH, Parr DM: Clinical and immunochemical studies of IgM cold agglutinins with lambda type light
chains. Clin Immunol Immunopathol 1974; 2:234-45
Ritzmann S, Levin W: Cold agglutinin disease—a type of primary
macroglobulinemia: a new concept. Tex Rep Biol Med 1962;
20:236-49
14. Wollheim FA, Williams RC Jr, Polesky HF: Studies on the macroglobulins of human serum: III. Quantitative aspects related
to cold agglutinins. Blood 1967; 29:203-13
Aspergilloma
SATINDER K. KATHURIA, M.D. AND JOHN RIPPON, M.D.
A case of lung cavity with fungus ball is reported in a patient
subsequent to the treatment of tuberculosis for a year. Fungal
serologic titers for histoplasmin, blastomycin, coccidiodin, and
aspergillin were negative. Surgical resection of the cavity had
to be done because of episodes of hemoptysis. Numerous hyphae formed into a compact mass consistent with aspergilloma
were seen in the cavity. The cultures for fungi were negative
on material from the surgical specimen. Immunodiffusion studies of sera obtained prior to surgery were positive for Pseudallescheria boydii and very informative in assessing the correct morphologic characteristics of the organism. (Key words:
Aspergilloma; Non-aspergillus; Pseudallescheria boydii) Am
J Clin Pathol 1982; 78: 870-873
PETRIELLIDIUM BOYDII recently reclassified as
Pseudallescheria boydii2 usually can be isolated from
soil and other saprobic environment. Its pathogenic potential varies from isolate to isolate. The usual type of
lesion produced is consistent with the clinical entity
known as mycetoma produced in the feet, hands, legs,
Received February 19, 1982; received revised manuscript and accepted for publication April 21, 1982.
Address reprint requests to Dr. Kathuria: Laboratory Service (113),
Hines VA Medical Center, Hines, Illinois 60141.
Laboratory Service, Hines VA Medical Center and
Department of Pathology, Mycology Laboratory and Section
of Dermatology, University of Illinois, Chicago, Illinois
and knees. Fungus ball due to P. boydii in a preformed
lung cavity is very rare. To our knowledge, this is the
third reported case.
Report of a Case
This 50-year-old man was hospitalized in May 1977, with symptoms
of decreased appetite and a 15 pound weight loss for the past two to
three months. He also noticed general weakness for six weeks, and a
chronic productive cough with greenish sputum which had increased
in the past two weeks. He had a history of high alcohol intake of
eighteen years and heavy cigarette smoking. Chest X-ray revealed a
large cavity in the right upper lobe. Sputum smears showed numerous
acid-fast bacilli and cultures were positive for Mycobacterium tuberculosis.
The patient was treated with 300 mg INH, QAM, 1,200 mg ethambutol, QAM, and 600 mg rifampin, QAM. Sputum smear and cultures
became negative after July 1977 and the patient was discharged August
1977 with continuation of the above treatment, and he was to be
followed in the TB Clinic.
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CASE REPORTS
Vol. 78 • No. 6
...-•"
871
V""""\
FIG. 1. Chest X-ray of the fungus ball in the
right upper lobe.
iff^^
•'it*"-
In August 1978, chest X-ray revealed development of a fungus ball
in the right upper lobe. Rifampin was discontinued in October 1978.
The patient completed the course of antituberculous therapy in September 1979. Eight months later, the patient re-entered the hospital
with blood-streaked sputum for one and a half weeks. Chest X-ray
again confirmed the presence of a fungus ball (Fig. 1). During his
hospitalization, sputum cultures only grew normal flora, and fungal
serologic tests for histoplasmin, blastomycin, coccidiodin, and aspergillin were negative. There was no recurrent hemoptysis and the patient
was discharged.
The patient was again hospitalized in November 1980, for production of frankly bloody sputum. Bronchoscopy revealed oozing of blood
from the right upper lobe bronchus. Surgical resection of the lobe was
performed.
Pathologic Factors
The specimen consisted of a right upper lobe containing a thin-walled bronchiectatic cavity measuring
8 X 6 X 6 cm (Fig. 2). The cavity contained irregular,
friable, yellow-black pieces of fungus ball. Wet mount
of the material revealed trichomonads, as well as com-
\
•> s
V
pact, intertwined hyphal strands with evident concentric
rings of growth.
Microscopically, the cavity was lined by respiratory
epithelium with areas of squamous metaplasia. There
was some hemorrhage in the wall along with chronic
inflammation. The cavity contained numerous ill-preserved tangled masses of septate hyphae resembling Aspergillus or some other hyphomycete (Fig. 3). The fungus did not grow on cultures. However, the immunodiffusion studies obtained from sera of the patient before
surgery was positive for P. boydii, negative for Aspergillus species and several other fungi associated with fungus balls. The fungi included Aspergillus niger, Aspergillus fumigatus, Aspergillus terreus, Aspergillus flavus,
Aspergillus polyvalent, Histoplasma, Coccidioides,
Paracoccidioides, Sporothrix schenckii, Candida, Geotrichum, and Blastomyces. There were no lines to any
of these. The patients serum had two lines in common
with control serum from another patient who also had
KATHURIA AND RIPPON
872
A.J.C.P. • December 1982
FIG. 2 (left). Right upper lobe of the lung with bronchiectatic cavity and fungus ball.
FIG. 3 (right). Tangled masses of septate hyphae (X450).
a P. boydii fungus ball3 when tested with the P. boydii
antigen. Directions for preparation of the antigen are
given in Rippon and Carmichael.3
Discussion
Petriellidium boydii, recently reclassified as Pseudallescheria boydii,2 is a common etiologic agent of eumycotic mycetoma. It usually can be isolated from soil.
Involvement of the lung in a preformed cavity is very
rare. To our knowledge, this is the third case of fungus
ball due to P. boydii in a preformed cavity. The first
case also was reported from the same institution.3 Interestingly, that patient also had evidence of trichomonads on wet film, as in this patient. Whether the occurrence of trichomonad with P. boydii is coincidental
or there is some association between the two is difficult
to say at this point.
Tong and co-workers5 reported a case of Allescheria
boydii recovered from sputum cultures. The patient was
treated with chloramphenicol and had a subsequent fatal
course due to pulmonary insufficiency from bilateral
Vol. 78 • No. 6
CASE REPORTS
inflammatory process and presumably invasive infection by Allescheria.
Severe and. colleagues4 reported a case of fungus ball
due to P. boydii occurring in a patient from Brazil with
an active tuberculosis.
Aside from mycetoma, P. boydii has been recovered
from a variety of colonizing and invasive diseases of the
lung and other organs as opportunistic infections. Louria
and associates' reported a case of Pulmonary Mycetoma
due to A. boydii in a benign bronchogenic cyst.
Since the morphologic characteristics of Aspergillus
and P. boydii in a tissue is similar, culture and serology
is important to come to a correct diagnosis. Some of the
cases which are diagnosed as pulmonary aspergillosis
could have been due to P. boydii, if adequate cultures
and serology are done. In this case, culture was negative,
probably due to degenerative state of the hyphae, but
immunodiffusion studies done on the serum were most
informative in assessing a correct diagnosis.
Severo and colleagues4 listed several case reports of
fungus ball as having been noted in the literature. However, if one critically analyzes these case reports, they
can be differentiated into two categories. Almost all cases
recorded consist of loose hyphal strands occurring in
preformed cavities, ectatic bronchi, or other spaces. Fun-
873
gus ball comparable to an aspergilloma is quite different
in its morphologic features. It consists of a tightly intertwined mass of mycelia showing evidence of erratic
growth and enlargement as demonstrated by concentric
rings viewed in cross section. In addition, there is often
evidence of conidiation occurring on the surface where
the mass is in contact with an air space.
Using this stricter criterion, then only the cases of
Rippon and co-workers,3 Severo and associates,4 and
our present case would be valid instances of fungus ball
caused by P. boydii.
References
1. Louria DB, Lieberman PH, Collins HS, Blevins A: Pulmonary
Mycetoma due to Allescheria hovdii. Arch Intern Med 1966:
117:748-751
2. McGinnis MR. Padhye AA, Ajello L: Pseudallescheria Negroni
and Fischer, 1943 and its later Synonym Petriellidium. (Malloch, 1970). Mycotaxon 1982; 14:94-102
3. Rippon JW, Carmichael JW: Petriellidiosis (Allescheriosis). Four
unusual cases and review of literature. Mycopathologia 1976;
58:117-124
4. Severo LC, Londero AT, Picot PD, Rizzon CF, Jarrasconi JC:
Petriellidium boydii fungus ball in a patient with active tuberculosis. Mycopathologia 1982; 77:13-18
5. Tong JL, Valentine EH, Durrance JR, Wilson GM, Fischer AD:
Pulmonary Infection with Allescheria boydii (Report of a fatal
case). Am Rev Tubercul 1958; 78:604-609
Nephrotic Syndrome Developed in the Healing Stage
of Necrotizing Angiitis
BUNSHIRO AKIKUSA, M.D., RYOICHI SUZUKI, M.D., NORITSUGU IRABU, M.D., AND SYOJI YOSHIDA, M.D.
A case of necrotizing angiitis is reported. After acute inflammatory changes had subsided, the patient developed the nephrotic syndrome. Postmortem examination disclosed a unique
sclerotic glomerular lesion with deposition of eosinophilic material which contained IgM, IgA, CI, and C3. The lesion was
distributed in rather selective areas perfused by some of the
arcuate arteries. (Key words: Necrotizing angiitis; Nephrotic
syndrome; Glomerular sclerosis) Am J Clin Pathol 1982; 78:
873-878
SEVERAL FORMS of systemic necrotizing angiitis are
known in which the kidneys are frequently involved.7914'20
This report describes a case of necrotizing angiitis in
Received March 8, 1982; received revised manuscript and accepted
for publication June 1; 1982.
Address reprint requests to Dr. Akikusa: Department of Pathology,
School of Medicine, Chiba University, Inohana 1-8-1, Chiba 280,
Japan.
Department of Pathology, School of Medicine, Chiba
University and Department of Internal Medicine, Asahi
General Hospital, Chiba, Japan
which nephrotic syndrome developed in the healing
stage of the angiitis. A peculiar glomerular lesion, both
in histologic features and distribution, was disclosed at
autopsy.
Report of a Case
A 30-year-old man presented at the Asahi General Hospital because
of epigastralgia and fever in November 1980. The patient had a history
of occasional administrations of methamphetamine between March
and June of that year. Hypertension developed in December 1980. On
January 4, 1981, right hemiplegia occurred and he was admitted to
the hospital.
0002-9173/82/1200/0873 $01.10 © American Society of Clinical Pathologists