An Unexpected Endobronchial Mass Appearing During Bronchoscopy Helmut J.F. Salzer, MD, MPH, Christiane Kuempers, MD, Helen Pasternack, MD, Jan Heyckendorf, MD, Ralf Bialek, MD, Emanuel Palade, MD, Lukas Hundack, MD, Barbara Kalsdorf, MD, Christoph Lange, MD  CHEST  Volume 154, Issue 1, Pages e13-e21 (July 2018) DOI: 10.1016/j.chest.2018.03.043 Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 1 Posteroanterior and lateral chest radiograph showing a focal pleural thickening (just below the level of the left scapula on the posteroanterior view) with curvilinear densities in the left apex and a dense lesion in the lateral left mid lung. In general, the lungs appear hyperinflated, with diminished volume of the left lung. In both lungs, diffuse, poorly defined nodules throughout the right upper lobe are present. CHEST 2018 154, e13-e21DOI: (10.1016/j.chest.2018.03.043) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 2 A, Axial CT scan of the chest showing a large, thick-walled cavity with an intracavitary mass in the left upper lobe with thickened pleura. B, Mediastinal window of A. C, Axial CT scan of the chest a few slices below A and B showing a nodular density in the left upper lobe and cystic changes with pleural thickening posteriorly on the left. D, Mediastinal window of (C). See Video 1. CHEST 2018 154, e13-e21DOI: (10.1016/j.chest.2018.03.043) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 3 A, Coronal reconstruction of the CT scan showing a large intracavitary mass in the left upper lobe with contact to the endobronchial lumen. In the lateral left mid-lung is a small cavitary lesion. In general, the left lung appears hyperinflated, with diminished volume of the left lung. B, Mediastinal window of the CT scan. CHEST 2018 154, e13-e21DOI: (10.1016/j.chest.2018.03.043) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 4 Bronchoscopy showing an irregular brown/yellowish mass obstructing the endobronchial lumen of the left upper lobe (segment 1/2). CHEST 2018 154, e13-e21DOI: (10.1016/j.chest.2018.03.043) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 5 Microscopy (×100 magnification) of centrifuged BAL cells stained with Hemacolor showing branching (45°) septate fungal hyphae. CHEST 2018 154, e13-e21DOI: (10.1016/j.chest.2018.03.043) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 6 A, Histology from resected upper left lobe under low power showing fungal hyphae (*) within fibrotic tissue (§) with a dense inflammatory infiltrate. Neighboring normal lung parenchyma (3) with sections of bronchioles (2) and a vessel (1) showing no hyphal invasion (hematoxylin and eosin [H&E], original magnification ×20. B, Higher magnification showing fungal hyphae (*) surrounded by inflammatory cells (§) (H&E, original magnification ×400). C, Zoomed perspective showing 45° fungal hyphae (arrow) in H&E-stained tissue. D, Gomori-silver staining ×400. E, PAS staining ×400 showing fungal hyphae (*) surrounded by inflammatory cells. CHEST 2018 154, e13-e21DOI: (10.1016/j.chest.2018.03.043) Copyright © 2018 American College of Chest Physicians Terms and Conditions