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Weekly Chest CasesArchive of Old Cases

Case No : 643 Date 2010-02-22

  • Courtesy of Yun Hyeon Kim , Song Choi, Hyun Ju Seon, Jun Hyung Hong / Chonnam National Univeristy Hospital
  • Age/Sex 56 / M
  • Chief ComplaintC/C: Cough, sputum, right chest pain (D: 20 days) P/H: Medication due to arthritis (D: several years)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7
  • Figure 8
  • Figure 9

Diagnosis With Brief Discussion

Diagnosis
Angioinvasive and Airway-invasive Aspergillosis
Radiologic Findings
Chest radiogram (Fig. 1) and chest CT (Fig. 2) show a cavitary lesion with air-fluid level, mottled air densities, and air bronchogram in apical segment of RUL with surrounding halo ground glass attenuation. Also multiple peribronchovascular consolidations and ill-defined centrilobular nodules with branching linear opacities is noted in BULs, RML and RLL.
Follow up radiogram (Fig. 3) and chest CT lung window setting (Fig. 4) after 2 weeks show aggravated peribronchial consolidations and GGOs with air-bronchogram associated with cavitary lesion in RUL.
Bronchoscopic biopsy was done and pathologic diagnosis was invasive aspergillosis. The diagnosis is angioinvasive aspergillosis combined with airway invasive aspergillosis.
Brief Review
Aspergillus infection may manifest in clinically and radiologically distinct patterns: aspergilloma, allergic bronchopulmonary aspergillosis, semi-invasive aspergillosis, airway invasive aspergillosis, and angioinvasive aspergillosis. 60% of fungal pneumonias in immunocompromised patients are caused by Aspergillus. Aspergillus infection may also occur in normal host following massive inhalation, known as primary aspergillosis.
Angioinvasive aspergiollosis is caused by hyphal invasion of blood vessels resulting in infarction and necrosis. Clinically, it is characterized by a hemorrhagic bronchopneumonia with fever, cough, dyspnea, and chest pain. CT typically shows nodules or masses may be surrounded by a halo of ground glass attenuation (CT halo sign). The halo sign is caused by hemorrhage surrounding the nodule or mass of necrotic fungal infected lung tissue. After 2~3 weeks, crescentic and eventual circumferential cavitation may be seen (air crescent sign). It may evolve to aspergilloma.
Airway-invasive aspergillosis is less common than angioinvasive aspergillosis. It is characterized by the presence of Aspergillus deep to the airway basement membrane. It causes a spectrum of diseases, including acute tracheobronchitis, bronchiolitis, and bronchopneumonia. Centrilobular nodules, tree-in-bud opacities, and peribronchial consolidations can be seen at HRCT. Invasive tracheobronchial aspergillosis is associated with ulcerations of trachea and central bronchi, and can cause atelectasis and consolidation.
References
1. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Greene RE, et al. Clin Infect Dis. 44(3):373-9, 2007
Keywords
Lung, Infection, Fungal infection,

No. of Applicants : 106

▶ Correct Answer : 27/106,  25.5%
  • - Osaka University , Japan Osamu Honda
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - McGill University , Canada Ben Smith
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun JunYeh
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - seoul national university hospital , Korea (South) Ijin Joo
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - Yonsei University College of Medicine , Korea (South) Young Joo Suh
  • - CHU Nancy , France kollen marie
  • - DRPGMC TANDA (H.P.) , India Maneesh Verma
  • - Song-do Hospital , Korea (South) Ji-young Yun
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) Sang Lee
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - Dong-A university hospital , Korea (South) Sang-yun LEE
  • - Uzunkopru Devlet Hastanesi , Turkey Armagan Sarac
  • - Assam Medical College , India Karunakaran M
  • - Kwang Myung Sungae Hospital , Korea (South) Jiyong Rhee
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Hopital du Sacr� Coeur , Canada Abraham Bohadana
  • - IRSA rochefort , France Viviane Pages
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - NASA SCANS , India RAKESH BHATIA
  • - Saga University , Japan Ryoko Egashira
▶ Correct Answer as Differential Diagnosis : 29/106,  27.4%
  • - radiologist, aditya imaging centre , India vivek patel
  • - CHU Nancy , France, Metropolitan Guillaume LUX
  • - Dong-A university hospital , Korea (South) Woo-jeong Kim
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - NTUH , Taiwan Kuei-pin Chung
  • - McGill , Canada Sean Carr
  • - Hospital Mae de Deus , Brazil Rodrigo Bello
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - care hospital , India Chary D
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - SMG-SNU boramae medical center , Korea (South) Kwang Nam Jin
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CHU Grenoble , France Fabrice Bing
  • - Seoul national university hospital , Korea (South) A Jung Chu
  • - CHRU lille , France manuel toledano
  • - Doctors Hospital , Bahamas muneesh sharma
  • - Hospital Doce de Octubre , Spain Constanza Li�bana
  • - Mallinckrodt Institute of Radiology , United States Travis Henry
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - EKH-Berlin , Germany Michael Weber
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - IRSA , France jean-luc BIGOT
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Sacr�-Coeur , Canada Andrea Ojanguren
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Trakya University School of Medicine , Turkey Umut Ugur
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Chungnam national university hospital , Korea (South) Jeoung Eun Lee
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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