Can a history of treated pulmonary (pulm) coccidioidomycosis explain the incidental findings of a borderline dilated ascending aorta, an irregular nodule, and ground-glass opacities in the right lower lobe on a computed tomography (CT) calcium score in a 53-year-old male (M)?

From the Guidelines

The imaging findings of a nodule and ground glass opacities in the right lower lobe could potentially be related to the patient's history of pulmonary coccidioidomycosis, but this cannot be definitively determined from the CT findings alone, and thus a follow-up CT in 3-6 months is recommended to monitor these findings. Treated coccidioidomycosis can leave residual nodules or scarring in the lungs, which might explain the 8 x 5 mm nodule, as noted in the guidelines for coccidioidomycosis management 1. However, the ground glass opacities in a centrilobular distribution are more suggestive of active processes like aspiration or infectious bronchiolitis, as noted in the report. The American College of Radiology (ACR) Appropriateness Criteria for incidentally detected indeterminate pulmonary nodules recommends follow-up tests in patients with an estimated lung cancer risk of 1% or higher, and allows flexibility to accommodate a patient’s risk factors and preferences in management 1. Given the patient's age and history, a pulmonology consultation would be beneficial to correlate these findings with clinical symptoms and determine if any additional workup or treatment is needed beyond the recommended follow-up imaging. The dilated ascending aorta (4.0 cm) is likely unrelated to the lung findings or coccidioidomycosis history and represents a separate incidental finding that may require its own follow-up.

Some key points to consider in the management of this patient include:

• The patient's history of pulmonary coccidioidomycosis and the potential for residual lung abnormalities
• The presence of a nodule and ground glass opacities in the right lower lobe, which may be related to the patient's history or may represent a new process
• The recommendation for follow-up CT in 3-6 months to monitor these findings and ensure they are stable or resolving
• The potential need for a pulmonology consultation to correlate these findings with clinical symptoms and determine if any additional workup or treatment is needed.

It is also important to note that the guidelines for coccidioidomycosis management emphasize the importance of establishing an etiologic diagnosis and explaining the natural history of the illness to the patient, as well as monitoring for potential complications 1. In this case, the patient's history of pulmonary coccidioidomycosis and the presence of residual lung abnormalities highlight the need for ongoing monitoring and follow-up to ensure that any new or worsening symptoms are promptly evaluated and addressed.

From the Research

Imaging Findings

The patient's imaging findings include:

• Borderline dilated ascending aorta measuring 4.0 cm
• Irregular nodule measuring 8 x 5 mm in the right lower lobe
• Ground-glass opacities in a centrilobular distribution in the right lower lobe These findings may be related to aspiration or infectious bronchiolitis, and a CT follow-up is recommended in 3-6 months.

History of Pulmonary Coccidioidomycosis

The patient has a history of pulmonary coccidioidomycosis that was treated in the past.

• According to 2, pulmonary coccidioidomycosis can manifest as acute, disseminated, or chronic forms, each with a spectrum of imaging findings.
• The study by 3 found that chronic pulmonary coccidioidomycosis can present with solitary nodules, ground-glass attenuation, or consolidation on CT scans.
• The patient's current imaging findings, such as the irregular nodule and ground-glass opacities, could be related to residual or chronic changes from the previous coccidioidomycosis infection, as described in 4 and 3.

Possible Explanation

The patient's history of pulmonary coccidioidomycosis could explain the current imaging findings, as:

• Residual nodules and chronic changes are common in patients with a history of coccidioidomycosis, as mentioned in 2 and 4.
• The ground-glass opacities and irregular nodule could be related to granulomatous inflammation or necrotizing granulomas, which are characteristic of chronic coccidioidomycosis, as described in 3. However, the possibility of other conditions, such as aspiration or infectious bronchiolitis, cannot be ruled out without further evaluation, as suggested in 5.