대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 576 Date 2008-11-10

  • Courtesy of Jinwon Kim, MD, Kyung-Nyeo Jeon, MD. / Gyeongsang National University Hospital, Korea.
  • Age/Sex 57 / F
  • Chief ComplaintCough for 40 days / Acute myeloid leukemia
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Invasive aspergillosis of large airway
Radiologic Findings
On chest CT scans, there shows a focal, eccentric wall thickening and luminal narrowing of left main bronchus. A central low attenuation area in the nodular thickening is noted. Concentric luminal narrowing of left lower lobar bronchus with peribronchial thickening is also seen. Parenchymal involvement was not seen.

On bronchoscopic examination, nodular mucosal thickening and a protruding mass covered with whitish exudate were seen in left main bronchus. The histologic examination of the biopsy specimens demonstrated aspergillus hyphae invading respiratory epithelium with necrosis.
Brief Review
Aspergillus infection can result in a wide spectrum of pulmonary abnormalities. The histologic, clinical, and radiologic manifestations of pulmonary aspergillosis are influenced by the number and virulence of the organisms and by the patient뭩 immune response.

In the large airway, aspergillosis may manifest as saprophytic colonization, tracheobronchitis, ulcerative tracheobronchitis with or without pseudomembrane formation, and necrotizing (invasive) aspergillosis.

A condition known as necrotizing bronchial aspergillosis is characterized histologically by invasion of bronchial mucosa with aspergillus. The predisposing factors and associated diseases are leukemia, organ transplantation, solid tumor, AIDS, COPD and prolonged antibiotics or corticosteroid administration.

Characteristic CT findings are smooth or irregular or nodular bronchial luminal narrowing and peribronchial thickening with or without distal atelectasis. CT findings are nonspecific and need to be distinguished from other fungal infection such as mucormycosis and tuberculosis in immunocompromised patients.

The diagnosis is usually established using bronchoscopic, mycologic, and histologic examination.

Bronchoscopic findings are varying degrees of mucosal erythema and edema, with ulcerative lesions and occasionally exophytic nodules or plaque-like lesions.
References
1. Ducreux D, Chevallier P, Perrin C, et al. Pseudomembranous aspergillus bronchitis in a double-lung transplanted patient: unusual radiographic and CT features. Eur Radiol. 2000;10:1547-1549.
2. Franquet T, Serrano F, Gim?ez A, Rodr?uez-Arias JM, Puzo C. Necrotizing Aspergillosis of large airways: CT findings in eight patients. J Comput Assist Tomogr. 2002;26:342-5.
3. Logan PM, Primack SL, Miller RR, and Muller NL. Invasive aspergillosis of the airways: radiographic, CT, and pathologic findings Radiology 1994; 193: 383
4. Vail CM and Chiles C. Invasive pulmonary aspergillosis: radiologic evidence of tracheal involvement. Radiology 1987; 165: 745.
Keywords
Airway, Infection, Fungal infection, Immunocompromised,

No. of Applicants : 74

▶ Correct Answer : 16/74,  21.6%
  • - CHRU lille , France manuel toledano
  • - China Medical University,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - Gimpo Woori Hospital , Korea (South) Son Youl Lee
  • - Catholic medical center , Korea (South) Hyejung Park
  • - Kashan University of Medical Sciences, kashan , Iran Ebrahim Razi
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Seoul National University Hospital , Korea (South) Kwang Nam Jin
  • - Soonchunhyang university Bucheon hospital , Korea (South) Minhee Lee
  • - Armed Forces Chun-Cheon Hospital , Korea (South) ChaeHun Lim
  • - Kasturba Medical College Manipal , India Paresh Desai
  • - Dongguk University International Hospital , Korea (South) Hee Seok Choi
  • - kims,narkatpally , India k bhaskar
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
▶ Correct Answer as Differential Diagnosis : 12/74,  16.2%
  • - Chungnam National University hospital , Korea (South) Kyoung Jin Oh
  • - hospital Sao Paulo , Brazil israel missrie
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - IRSA LA ROCHELLE FRANCE , France jean-luc BIGOT
  • - Private Clinic , Bahamas Trupti Dabholkar
  • - National Taiwan University Hospital , Taiwan Chin-Chung Shu
  • - Yonsei University college of medicine Severance hospital , Korea (South) Hua Sun Kim
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
▶ Semi-Correct Answer : 5/74,  6.8%
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - Asian Heart Institute, Nirman Hitech & Apollo clinic, Mumbai , India Jeshil Shah
  • - Lilavati Hospital & Research Centre , India Mahavir Swami
  • - SPS APOLLO HOSPITALS , India LOVKESH MITTAL
  • - tantia general hospital , India gurpreet singh
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