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INTRODUCTION:A lung nodule in an elderly patient almost always raises concern for lung cancer, irrespective of risk factors. While lung cancer remains foremost in the clinicians mind, a thorough occupational history may provide clues implicating a different diagnosis of more uncommon etiologies of lung nodule, such as in our case. CASE PRESENTATION:A 74 year old male with a history of hypertension and prostate cancer in remission presented to his primary care physician with 3 months of dry cough and chest pain. He had no smoking history. Vital signs showed a blood pressure of 170/93 mmHg, with other vital signs within normal limits. Physical examination and laboratory analysis was unrevealing. A chest radiograph showed a 2.9 centimeter (cm) left lower lobe nodule. Computerized tomography scan (CT) of the chest demonstrated a lobular left lower lobe lung nodule measuring 3x2x2 cm with smooth margins. Fluorodeoxyglucose (FDG)positron emission tomography (PET) scan failed to reveal any other avid regions. A robotic left lower lobe wedge resection was performed, revealing a cystic membranous spherical lesion that spilled fluid when incised. Frozen section pathology showed a hydatid cyst containing innumerable Echinococcus granulosus organisms. He was started on albendazole therapy. It was later discovered that the patient was in the Army and deployed to rural southern Vietnam for 5 months in his youth, where he was working in farms and with wild animals, swimming through dirty water and drinking contaminated water. When back in the United States, he did cross country trips, riding mules in Utah. He also lived in Hawaii for 3 years with a dog. Echinococcus serology was negative. Repeat CT scan showed no other hydatid lesions and no other liver lesions. The patient completed 1 month total of albendazole and has recovered.DISCUSSION: Only a minority of lung involvement in E. granulosus infection coincides with liver cysts (20-40%). The lower lobes of the lung are commonly involved (60%). Patients may be asymptomatic, have cough, hemoptysis or even anaphylaxis (1). Differentiating an unruptured cyst from other pulmonary pathology such as malignancy, can be difficult radiographically. One Turkish study reports 7 patients in a 4 year span who had surgical removal of a presumed malignancy but were found to have a hydatid cyst (2), and can be a common occurrence in endemic areas. Chest imaging usually reveals a homogenous wellcircumscribed lesion with smooth lobulated margins. If the bronchus is eroded, air is introduced into the cyst and may appear as a crescent of air (crescent sign) (3). CONCLUSIONS:Obtaining an extensive travel and exposure history may substantially alter the differential diagnosis of such lesions, and assist in diagnostic and management considerations.

Introduction/Objective Acute hemorrhagic leukoencephalitis (Weston-Hurst syndrome) is a rare, fulminant inflammatory hemorrhagic demyelination of the brain white matter, and it is considered to be the most severe form of acute disseminated encephalomyelitis (ADEM). Herein we describe a case of 6-year-old boy presenting with elevated intracranial pressure and uncal herniation. Brain MRI showed a large right temporoparietal T2 hyperintense lesion with edema, abnormal perivascular enhancement and midline shift. Emergent decompressive craniotomy with brain biopsy was performed. Results H&E sections of the brain lesion revealed neutrophilic small vessel vasculitis with extravasation of blood and fibrin. Predominantly in a perivascular distribution were infiltrates of neutrophils and in areas foamy macrophages. Additionally, the white matter was studded with hemorrhages of varying size. Sections stained with Luxol Fast Blue for myelin and with a neurofilament immunostain for axons were compared to reveal selective perivascular loss of myelin with relative sparing of axons. Conclusion The constellation of acute hemorrhages, neutrophilic infiltration and selective loss of myelin with relative sparing of axons is characteristic of this exceptional, hyperacute variant of acute disseminated encephalomyelitis. Histomorphologic diagnosis is characteristic and may be crucial for timely decision for treatment of this often fatal disease.