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Solitary Pulmonary Nodule Due to Brucella Suis
Solitary Pulmonary Nodule Due to Bmcella S U P Report of a Case W a ~ u A. y W m ,M.D.AND JAMES C. THOROUOHMAN, MD. Atlanta, Georgia
SINCE
VERY FEW PATIENTS HAVING BRU-
c d b i i p m t with a sditary +anary nodule, this report of the fourth cast documented by culture seans in ordcr. Neither the suio of Davis, Pcabcdy and Kak' nor the recent Vetcrana Adminiatration-Army" d e s of solitary pulmonary nodules S i brucellosis as an ctidogic factor. UMRT T.H.A., a 50-yar-old whitefuma, waa found to have a 1.5 cm. roliuy nodule of the posterior segment of the right upperlobe m roaugcn armirutim of the chat in April, 1956 (Fig. 1). CASE
--*
*?mtheS*Sm*cv~ &~ + d 4 or). University School d M e h .
"
?mu= 1: Density U I d d right 6ihh rib The &on hu increased in *.e.
He refused hospitalization. In September, 1961, the diimeta was noted to be 3.5 c m (Fig. 2). On hospital admirion, he was asymptomatic acept for chmniccough. He was a heavy smoker. He had traveledwidely in the a u t h e ~ n nUnited Stata, South and CentralAmerica, and had had contact with chickens, h e , and cows on his fann. Physical armination and routine labonmy work were unrrmutrble. The hLmphanin *in tea was strongly @tive, while the intermediate PPD, mccidioidin and blaatomyein akin t a u were negative. Both sputum lad bronchial cultum for routine bacteria, m k l e baciUi and fungi were negative. Cytologic a u d i a were aomul. Bmodtorow revaled only chronic bronchitis. Hi vital A h c i t y was 55 cent of predicted normal. No Igllutiaatim titen were done at that
&
time.
pateriorly, April, 1956.
222
? m u u 2:
September, 1961.
vdP*
49
No. 2
SOUTAEY PULM:ONARY NODULE
1666
The patient underwent thoncotomy with wedge sive. G m ' believe that thue is a lack of resection of the nodule on September 21, 1961. awarrnar of pulmonary bruecllosir e v ~ n The preoperative din+ was histopham&, but the pathologic diagnosis pmved by d ~ r e among rhasc specializing in pulmonary d h case. Martin and d t a Uwrite that in was Bnrcrlla mu. This was c o n h e d by thr Communicable D b Cmtcr in Atlanta, Gearthcii wrpcriencc, the lungs alt thc fihh
Bie
Pathology: Gross: The man war hemispherical, m a u u r i q 2 5 cm. in its largest diameter. The cut surface &owed coacmvic calcified layers and acentnl area of nrnorit Microscopic: The laion mcaled a c m t n l area of mcrort with hyalinization, arbon pigment and small deposits of calcium. 'Ihir ama was nhnrply demarcated fmm the adjacent lung by a r u m m e of fibmw h u e within which wm lymphocytes. small numbers of epithelioid cells, and occasinnal giant celh of the Luyh.ns type (Fig. 3). Periodic acid-Schi5, Ziehl-Neelm, Gram. Gomori. andG i m m stains did not reveal any organism. A culture of the granulotnatow lesion rwcaled Bnrcrlla mu. On follow-up examination in Much, 1965, the chat x-ray film was normal, febrile agglutinins were negative, and the bmcdla akin tea was pob itive. The patient suted at this time that prior to his h i r e s he had slaughtered swine,had a t m inadequately cooked port saungq and had worted for a d a i i where he had drunk large quantitn of raw milk.
CUSSIO ION
man common site of localitcd brudlmis. Bogan,' Martin," Laffwty and F'hinips,' Haden and Kyger,' Bcatty,' SpinlqUSpunt and McBrydc,* Grew,' Johnsim,' Math-
ur," Hanise and Harvey' have d a c n i
pleurisy, bronchitis, hilar adenopathy, diffuse fibrosis, bnmchopneumonia and pcribronchial infiltration in brucellosis. Hadcn and Kygcf report one patient with multiple pulmonary noddu and two othm with a solitary noduk, but offer no bacteriologic confirmation of the nature of thac lesions. Lafferty and Phillip* report a patient who had "mall, dense, well cimumuibcd bmnchpneumonic areas" progrrsing to 6brmis. Positive agglutination tests were reported, but there were no positive eulturcs. The only well documented ears we have found in the literahuc am thm reported by Weed, Sloss and CkgatU who repo~t t h e patients whose chest rantgcncgmma
Sia Mamton's work in 1859, David Bruce's in 1886, and H u g h in 1897, vduminous literature on bruccUo& has accumulated. However, emphasis on the pul-
monary manifestations haa not been exten-
FIOUUE3:
The y r u h
of h a p l y cir-
cumscribed hyline .aIIuLr mueri.l nvmvaded by 8 nrmrw zone of lymphHemaand eodn, X4.6.
F I O 4: ~ Th upper *It maL tbc .ccllulu mueri.l. Within th numw rn of lymphcqtes there arc mnl giant ah of the L.ntyp. Hemauqb and eodn, X 135.
224
WEBB
ASD T H O R O U G H M A X
revealed a discrete pulmonary lesion. Bacteriologic studies of the excised tissue showed bmcella.
THERAPY Following excision, no antibiotic therapy was administered to our patient. He was s)mptom-free 36 months later. Martin and co-worken'%lieve that following surgical excision, antibiotic therapy should be individualized, but they usually recommend therapy. Two of Weed and cdlaboraton"' patientc did not receive antibiotic therapy and svmptoms did not recur. KEFE~
I B E A ~ Y0. , A,: $'M_.~ anif~,. 1 BOGART.F. B.: "Pulmonary Changes in Undulant Fever," Southrrn M c d . 1 . 29: 1 1936. 3 D ~ v t s .E W. -~ -r ~- e-o~o uJ., w., 56 * s o ' ~ * r r , S.: "Thc Solitary PIulmonarv Nodule: A 10 Year Suney Based on 215 '~aser." I. T h or. , Surg.. 32: 728. 1965. t Caera, A. E.: "Pulmonary Brucellosis." D u . Chrrr. ?9:408. 1956.
.
.
D rhc ~ Y IChest Y IoI
AND KYOER,E. R.: "Pulmonary Manifestations of Brucellosis," Clrcclnnd Cltn. Quart., 13:?20, 1946. 6 HARRIS,H. J . : "BrucellosL. Diagnosis Diffcr. Y. ential Diagnosis and Treatment." ~ u l i h'. Acod. M c d . , 19:631. 1943. i HAXVEY, W. .4.: "Pulmonary Bruccllorb," Ann. Inr. M e d . , ?8:768. 1948. 8 J o ~ u s o s ,R. M.: "Pneumonia in Undulant Fever. Report of Three Cases," A m . 1. M c d . Sci., 189:483, 1935. 9 LAFFERTY, R. H. Ah.D PHILLIPS,C. C.: "PuImonary Changes in Patienu Suffering from Malta Fever," Southern M c d . 1 , 30:595, 1937 10 M ~ a n s W. , J., S c ~ ~ a o e A., a , ct al.: "Brucel. loris," Pror. Mayo Clin., 35:717. 1960. I1 M*mca, T. N.: "Brucellosis Simulating a Respiratory Illners. A Rcpon of Elcvcn Cases." I n d h n I. M c d . Sri., 14:610, 1960. I? SPIXX. W. W.: T h e Natvrr of BrucrllorL, Cniv. Yinn. Prer. Minneapolis. Minnesota. 1956. 13 SPRVST.D H. ASD McBamr, A,: "Morbid Anatomir Changer in Cases of Bmcella Infection in Man." Arch. Path., ?I :?17, 1936 I t STEELE,J. 0 . : T h r Solitary Pulmonary Hodulr, Charles C. Thomm. Spring6eld, 111.. 1964. L. .4. %LOSS, P. T. AXD ct..&o~TT 15 WEED, 0. T.: "Chronic Localized Pulmonary ~ r u c e l : loris." I A M A . 161 : 1044. 1956.
5 H A D E ~R., L.
1966 .4CCP ESSAY CONTEST 'Members are requested to bring the 1966 Essay Contcrt of the .American College of Chest Physicians to the attention of undergraduate medical students. n h o may write on any subject in the field of chert diseavs (cardiovauular nr pulmonary). Follouing are the ruler for the contest: I ) Complete an application form in dupllhave original by the dean of ,nediral rhool, and return original copy at to the ,[ College of Chert Physicians ? ) Five copies of the manuscript, typewritten in English (double spaced) must be submitted to the .4merican College of Chert Physicians in Chicago not later than March 15. 1966. 3 ) ~h~ length for ?500-4500 uordr ruggertcd. 4 ) The only means of identification of the author shall be a motto or other device on the title page. .4 sealed envelope bearing the same motto on the outride and enclosing the name and addre% of the author mrut accompany the
essay. iMotto may be a word or brief phrase which has a significant meaning to the author ) The first prnze will be $500; second prize will be $300: third prize will be $200. Each -.inner bill also receive a certificate of merit. A trophy. inscribed with the name of the fin1 prize winner and the name of his school will hC awarded Ihe The binning contributions will be selected hy a committee of chest rpecialirtl and will be announced at the 32nd Annual M e e e t i n ~of the American College of Chest Physicians to be held in Chicago, Illinois, June 23-27, 1966. All manuscripts become the property of the American Colllege of Chest Physicians and may be considered for publication ~n the College journal. It is serted that avplicanu study the format of %e College Journal, DLcnrrr of the Chert, to guide them in preparing the essay. A copy will be wnt on q u e s t . For further information and application forms, write the executive officer of the College I I? East Chestnut Street. Chicago, lllinoi; 6061 1
SINCE
VERY FEW PATIENTS HAVING BRU-
c d b i i p m t with a sditary +anary nodule, this report of the fourth cast documented by culture seans in ordcr. Neither the suio of Davis, Pcabcdy and Kak' nor the recent Vetcrana Adminiatration-Army" d e s of solitary pulmonary nodules S i brucellosis as an ctidogic factor. UMRT T.H.A., a 50-yar-old whitefuma, waa found to have a 1.5 cm. roliuy nodule of the posterior segment of the right upperlobe m roaugcn armirutim of the chat in April, 1956 (Fig. 1). CASE
--*
*?mtheS*Sm*cv~ &~ + d 4 or). University School d M e h .
"
?mu= 1: Density U I d d right 6ihh rib The &on hu increased in *.e.
He refused hospitalization. In September, 1961, the diimeta was noted to be 3.5 c m (Fig. 2). On hospital admirion, he was asymptomatic acept for chmniccough. He was a heavy smoker. He had traveledwidely in the a u t h e ~ n nUnited Stata, South and CentralAmerica, and had had contact with chickens, h e , and cows on his fann. Physical armination and routine labonmy work were unrrmutrble. The hLmphanin *in tea was strongly @tive, while the intermediate PPD, mccidioidin and blaatomyein akin t a u were negative. Both sputum lad bronchial cultum for routine bacteria, m k l e baciUi and fungi were negative. Cytologic a u d i a were aomul. Bmodtorow revaled only chronic bronchitis. Hi vital A h c i t y was 55 cent of predicted normal. No Igllutiaatim titen were done at that
&
time.
pateriorly, April, 1956.
222
? m u u 2:
September, 1961.
vdP*
49
No. 2
SOUTAEY PULM:ONARY NODULE
1666
The patient underwent thoncotomy with wedge sive. G m ' believe that thue is a lack of resection of the nodule on September 21, 1961. awarrnar of pulmonary bruecllosir e v ~ n The preoperative din+ was histopham&, but the pathologic diagnosis pmved by d ~ r e among rhasc specializing in pulmonary d h case. Martin and d t a Uwrite that in was Bnrcrlla mu. This was c o n h e d by thr Communicable D b Cmtcr in Atlanta, Gearthcii wrpcriencc, the lungs alt thc fihh
Bie
Pathology: Gross: The man war hemispherical, m a u u r i q 2 5 cm. in its largest diameter. The cut surface &owed coacmvic calcified layers and acentnl area of nrnorit Microscopic: The laion mcaled a c m t n l area of mcrort with hyalinization, arbon pigment and small deposits of calcium. 'Ihir ama was nhnrply demarcated fmm the adjacent lung by a r u m m e of fibmw h u e within which wm lymphocytes. small numbers of epithelioid cells, and occasinnal giant celh of the Luyh.ns type (Fig. 3). Periodic acid-Schi5, Ziehl-Neelm, Gram. Gomori. andG i m m stains did not reveal any organism. A culture of the granulotnatow lesion rwcaled Bnrcrlla mu. On follow-up examination in Much, 1965, the chat x-ray film was normal, febrile agglutinins were negative, and the bmcdla akin tea was pob itive. The patient suted at this time that prior to his h i r e s he had slaughtered swine,had a t m inadequately cooked port saungq and had worted for a d a i i where he had drunk large quantitn of raw milk.
CUSSIO ION
man common site of localitcd brudlmis. Bogan,' Martin," Laffwty and F'hinips,' Haden and Kyger,' Bcatty,' SpinlqUSpunt and McBrydc,* Grew,' Johnsim,' Math-
ur," Hanise and Harvey' have d a c n i
pleurisy, bronchitis, hilar adenopathy, diffuse fibrosis, bnmchopneumonia and pcribronchial infiltration in brucellosis. Hadcn and Kygcf report one patient with multiple pulmonary noddu and two othm with a solitary noduk, but offer no bacteriologic confirmation of the nature of thac lesions. Lafferty and Phillip* report a patient who had "mall, dense, well cimumuibcd bmnchpneumonic areas" progrrsing to 6brmis. Positive agglutination tests were reported, but there were no positive eulturcs. The only well documented ears we have found in the literahuc am thm reported by Weed, Sloss and CkgatU who repo~t t h e patients whose chest rantgcncgmma
Sia Mamton's work in 1859, David Bruce's in 1886, and H u g h in 1897, vduminous literature on bruccUo& has accumulated. However, emphasis on the pul-
monary manifestations haa not been exten-
FIOUUE3:
The y r u h
of h a p l y cir-
cumscribed hyline .aIIuLr mueri.l nvmvaded by 8 nrmrw zone of lymphHemaand eodn, X4.6.
F I O 4: ~ Th upper *It maL tbc .ccllulu mueri.l. Within th numw rn of lymphcqtes there arc mnl giant ah of the L.ntyp. Hemauqb and eodn, X 135.
224
WEBB
ASD T H O R O U G H M A X
revealed a discrete pulmonary lesion. Bacteriologic studies of the excised tissue showed bmcella.
THERAPY Following excision, no antibiotic therapy was administered to our patient. He was s)mptom-free 36 months later. Martin and co-worken'%lieve that following surgical excision, antibiotic therapy should be individualized, but they usually recommend therapy. Two of Weed and cdlaboraton"' patientc did not receive antibiotic therapy and svmptoms did not recur. KEFE~
I B E A ~ Y0. , A,: $'M_.~ anif~
.
.
D rhc ~ Y IChest Y IoI
AND KYOER,E. R.: "Pulmonary Manifestations of Brucellosis," Clrcclnnd Cltn. Quart., 13:?20, 1946. 6 HARRIS,H. J . : "BrucellosL. Diagnosis Diffcr. Y. ential Diagnosis and Treatment." ~ u l i h'. Acod. M c d . , 19:631. 1943. i HAXVEY, W. .4.: "Pulmonary Bruccllorb," Ann. Inr. M e d . , ?8:768. 1948. 8 J o ~ u s o s ,R. M.: "Pneumonia in Undulant Fever. Report of Three Cases," A m . 1. M c d . Sci., 189:483, 1935. 9 LAFFERTY, R. H. Ah.D PHILLIPS,C. C.: "PuImonary Changes in Patienu Suffering from Malta Fever," Southern M c d . 1 , 30:595, 1937 10 M ~ a n s W. , J., S c ~ ~ a o e A., a , ct al.: "Brucel. loris," Pror. Mayo Clin., 35:717. 1960. I1 M*mca, T. N.: "Brucellosis Simulating a Respiratory Illners. A Rcpon of Elcvcn Cases." I n d h n I. M c d . Sri., 14:610, 1960. I? SPIXX. W. W.: T h e Natvrr of BrucrllorL, Cniv. Yinn. Prer. Minneapolis. Minnesota. 1956. 13 SPRVST.D H. ASD McBamr, A,: "Morbid Anatomir Changer in Cases of Bmcella Infection in Man." Arch. Path., ?I :?17, 1936 I t STEELE,J. 0 . : T h r Solitary Pulmonary Hodulr, Charles C. Thomm. Spring6eld, 111.. 1964. L. .4. %LOSS, P. T. AXD ct..&o~TT 15 WEED, 0. T.: "Chronic Localized Pulmonary ~ r u c e l : loris." I A M A . 161 : 1044. 1956.
5 H A D E ~R., L.
1966 .4CCP ESSAY CONTEST 'Members are requested to bring the 1966 Essay Contcrt of the .American College of Chest Physicians to the attention of undergraduate medical students. n h o may write on any subject in the field of chert diseavs (cardiovauular nr pulmonary). Follouing are the ruler for the contest: I ) Complete an application form in dupllhave original by the dean of ,nediral rhool, and return original copy at to the ,[ College of Chert Physicians ? ) Five copies of the manuscript, typewritten in English (double spaced) must be submitted to the .4merican College of Chert Physicians in Chicago not later than March 15. 1966. 3 ) ~h~ length for ?500-4500 uordr ruggertcd. 4 ) The only means of identification of the author shall be a motto or other device on the title page. .4 sealed envelope bearing the same motto on the outride and enclosing the name and addre% of the author mrut accompany the
essay. iMotto may be a word or brief phrase which has a significant meaning to the author ) The first prnze will be $500; second prize will be $300: third prize will be $200. Each -.inner bill also receive a certificate of merit. A trophy. inscribed with the name of the fin1 prize winner and the name of his school will hC awarded Ihe The binning contributions will be selected hy a committee of chest rpecialirtl and will be announced at the 32nd Annual M e e e t i n ~of the American College of Chest Physicians to be held in Chicago, Illinois, June 23-27, 1966. All manuscripts become the property of the American Colllege of Chest Physicians and may be considered for publication ~n the College journal. It is serted that avplicanu study the format of %e College Journal, DLcnrrr of the Chert, to guide them in preparing the essay. A copy will be wnt on q u e s t . For further information and application forms, write the executive officer of the College I I? East Chestnut Street. Chicago, lllinoi; 6061 1