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BAC Lunchtime May 2025 Slide Club Summary

Case 1: Allergic Bronchopulmonary Aspergillosis (ABPA) in HIV-Positive Patient

Presenter: Dr Tony Maddox (West Hertfordshire Teaching Hospitals NHS Trust)
Clinical Summary:

  • Patient: 53-year-old male, HIV-positive, well-controlled on HAART
  • Presentation: Fluffy chest X-ray abnormalities; bronchoalveolar lavage (BAL) performed
  • Cytology Findings:
    • Highly cellular BAL with abundant mucus and foamy macrophages
    • Eosinophils prominent (23% of total cell count)
    • Presence of Charcot-Leyden crystals
    • A single fungal hyphal structure consistent with Aspergillus (septate, acute angle branching)
  • Microbiology:
    • Culture: Aspergillus fumigatus
    • PCR: Negative for Pneumocystis jirovecii
  • Serology:
    • Serum IgE: Elevated (2779 IU/mL)
    • Aspergillus-specific IgE: Significantly raised (47 IU/mL)
  • Diagnosis: Allergic Bronchopulmonary Aspergillosis (ABPA)
  • Lesson:  Despite being HIV-positive, the patient did not have a typical opportunistic infection (e.g., Pneumocystis) and demonstrated an allergic response typical of atopic individuals, highlighting the importance of approaching every case with an open mind and a thorough evaluation of the morphological evidence.

Case 2: Confirmed Pneumocystis Pneumonia

Contrast Case by Dr Maddox to show the morphological appearances of a more “typical” case for this history:

  • Patient: HIV-positive male, mid-30s
  • BAL Findings:
    • Foamy, sponge-like casts
    • Grocott stain confirmed presence of Pneumocystis jirovecii organisms

Case 3: Parathyroid Adenoma Masquerading as Cancer

Presenter: Dr Suzannah Hazeldine (Royal Cornwall Hospitals NHS Trust)
Clinical Summary:

  • Patient: 75-year-old female with known cancer above and below the diaphragm
  • Presentation: Cystic mediastinal lymph node sampled via EBUS
  • Cytology Findings:
    • Tightly clustered cells with well-defined cytoplasm, anisonucleosis, stippled chromatin
    • Dual cell populations resembling neuroendocrine differentiation
  • Immunohistochemistry:
    • Positive: synaptophysin diffusely positive, CK7 focal
    • Negative: PAX8, P40, TTF-1
  • Further Imaging: CT noted unusual mediastinal nodule extending to thyroid
  • Additional Workup:
    • Clinical context: Hypercalcemia
    • SPECT scan confirmed a right parathyroid adenoma
  • Final Diagnosis: Sampling of parathyroid epithelium; adenoma unrelated to patient’s known malignancy
  • Lesson: Highlights the diagnostic value of integrating cytology, immuno, clinical context, and radiology.

Key Takeaways:

  • Maintain broad differentials—even in immunocompromised patients.
  • Cytological details can reveal unsuspected diagnoses like ABPA or parathyroid adenoma.
  • Preserving traditional techniques (e.g., Grocott staining) complements molecular diagnostics and ensures rare or unexpected findings are not missed.