Solitary pulmonary nodule caused by phycomycosis in a patient without obvious predisposing factors.

A 52-year-old man, living in a rural area near Okayama, was admitted to hospital for assessment of a pulmonary shadow found at annual chest radiography. He had been a farmer for 21 years and then a public worker for 10 years. He had smoked one packet of cigarettes daily for 30 years but was otherwise well and free from symptoms. Physical examination disclosed no abnormality apart from a circumscribed area of leucoderma on the right leg. There was no clubbing or lymphadenopathy and examination of the cardiovascular and respiratory systems was normal. The urine was normal. The white cell count was 5,9X109/1 with 11 % eosinophils. The ESR was 1 mm per hour. The PPD skin test was positive. Vital capacity and FEV1 were close to normal. The sputum grew Staph aureus and Candida albicans on culture but repeated examinations for acid-fast bacilli and malignant cells were all negative. A PA radiograph of the chest (fig 1) showed enlargement of the right hilum. Lateral tomograms of the enlarged hilum showed a notch sign with spicula formation and obstruction of the related bronchus; bronchography suggested a subsegmental defect of the anterior bronchus of the right upper lobe. At bronchoscopy the bronchus was found to be narrQwed without obstruction. Because of the strong suspicion of bronchial carcinoma, thoracotomy and right upper lobectomy was performed on 5 June 1978. The operation specimen showed a large nodular lesion in the anterior segment of the right upper lobe, with narrowing of the proximal segmental bronchus. Microscopically (fig 2), the nodule was shown to be a conglomeration