Migratory Pulmonary Infiltrates Mimicking Malignancy, Tuberculosis, and Sarcoidosis in an Apparently Immunocompetent Adult: A Case of Tissue-Proven Invasive Fungal Disease Due to a Non-marneffeiPenicillium Species.

Non-marneffei Penicillium species are ubiquitous molds usually dismissed as contaminants in respiratory cultures; invasive disease is rare and may mimic malignancy, tuberculosis, or sarcoidosis. A 39-year-old apparently immunocompetent man with asthma, a smoking history, and tuberculosis exposure presented with chronic cough, fever, night sweats, and weight loss. Chest computed tomography (CT) showed right lower-lobe subpleural consolidation, bilateral nodules, and mediastinal lymphadenopathy. Sputum and bronchoalveolar lavage (BAL) studies for tuberculosis were repeatedly negative; CT-guided lung biopsy showed a non-necrotizing granuloma, suggesting sarcoidosis. Five months later, the original lesions had regressed, and new contralateral pleural-based nodules appeared, establishing a migratory pattern. Repeat BAL grew a Penicillium species, a second recovery after an earlier isolate was dismissed as contamination. Surgical mediastinal lymph-node biopsy showed necrotizing granulomatous inflammation containing PAS- and GMS-positive septate hyphae, establishing proven invasive fungal disease, and fungal culture of the same tissue grew a Penicillium species; HIV and hepatitis serologies were negative. Liposomal amphotericin B followed by oral voriconazole produced near-complete radiological resolution. Attribution to Penicillium rests on recovery of the mold from the surgical tissue itself; identification nevertheless remained at genus level, because molecular identification, susceptibility testing, and fungal biomarkers were unavailable, and invasion of lung parenchyma was never demonstrated histologically. Migratory infiltrates should prompt reconsideration of fixed diagnoses; repeated mold recovery with tissue-invasive hyphae and treatment response warrants reassessment rather than dismissal as contamination.