Acute pulmonary embolism and multiple pulmonary nodules mimicking metastatic disease

A 62-year-old patient with a history of traumatic splenectomy after a paragliding accident and chronic hepatitis C presented to the emergency department with worsening dyspnoea and unintended weight loss of 8 kg in 2 months. He was a lifelong non-smoker and consumes alcohol on rare occasions. He also reported recent travels to Asia and South America for business affairs. On clinical examination, the patient was normotensive with a respiratory rate of 25/min. Lung auscultation and the remainder of the physical examination were uneventful. Laboratory parameters showed increased inflammatory parameters (leucocyte count 14.7 g/L, C reactive protein 87 mg/L), absolute eosinophilia (4.73 g/L) and elevated IgE levels (5170 kU/L). A CT scan revealed acute segmental pulmonary embolism and multiple irregular pulmonary nodules (figure 1A). A bronchoscopy showed no airway abnormalities such as inflammation or tumour protrusion; however, bronchoalveolar lavage revealed eosinophilia. Figure 1 (A) CT thorax showing multiple irregular pulmonaly nodules. (B) H&E staining: multifocal echinococcal cysts and granulomas forming an interface with adjacent alveolar tissue. (C) H&E staining: detail showing cyst wall and pallisading histiocytes. (D) EM2 antigen staining: identifying echinococcus multilocularis. The radiological appearance mimicked metastatic disease. With multiple nodules, unintentional weight loss and a history of chronic hepatitis C, metastatic disease from hepatocellular carcinoma or progressive lung carcinoma was suspected. Furthermore, the initial workup showed a partly calcified liver lesion in the right lobe measuring 9×10 cm. A subsequent sonogram showed mild liver enlargement with homogenous parenchyma and an inhomogeneous, round liver lesion in segments V–VII. The corresponding CT showed a cystic lesion with scattered calcifications in the wall. With an extensive tropical travel history, common parasites as well as zoonotic diseases and fungal infection were included in the differential diagnoses. At the time of initial workup, a parasitic disease was included in the differential. …