대한흉부영상의학회 Weekly Chest Cases

Case No : 735 Date 2011-11-28

Courtesy of Ju Won Lee, MD., Kyung-Hee Lee, MD. / Inha University Hospital
Age/Sex 32 / M
Chief Complaintdyspnea during 3 days underlying type 1diabetes and DM nephropathy

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Figure 1

Diagnosis With Brief Discussion

Diagnosis: Tracheobronchial mucormycosis
Radiologic Findings: Fig 1-3. Mediastinal window setting of the chest CT scans show diffuse nodular wall thickening with luminal narrowing of trachea, both main bronchi and bronchus intermedius. Increased infiltration surrounding tracheobronchial tree was also noted. Fig 4. Axial CT scan shows lymph node enlargement in right interlobar nodal station. Fig 5. Lung window setting of the chest CT scan shows dense consolidation in right middle lobe, nodular lesions in right lower lobe and patchy ground-glass opacity in left lower lobe. Fig 6. Chest PA shows ill-defined consolidations in both lower lung zones.
Subsequent bronchoscopic exam showed diffuse narrowing and cobblestone appearance with whitish plaque in whole bilateral bronchi. Bronchoscopic biopsy revealed extensive necrosis with fungal hyphae, favor Mucormycosis.
Brief Review: Mucormycosis is an opportunistic infection that is usually associated with an immunocompromised state. Tracheobronchial mucormycosis is a distinct clinical form of mucormycosis that may involve the central airways with subsequent airway narrowing or obstruction. This entity shows a striking predilection for diabetic patients.
Histologically, mucormycosis is characterized by tissue invasion with nonseptate broad hyphae with right-angle branching, and a propensity for invasion through blood vessel walls.
Endobronchial involvement is a rare presentation of mucormycosis. Endobronchial mucormycosis has been described in the literature and the lesions have been identified as gray-white mucoid materials that frequently block a major airway. The involved airways are typically edematous and necrotic. In one previous study, CT scans showed luminal narrowing and wall thickening of the mid- or distal trachea and bronchi, variably sized mediastinal lymph nodes, nonspecific pulmonary opacities, and a large lung abscess. There were intramural air collections within the thickened bronchial wall, nonenhancing low attenuation thickening of the bronchial wall, and bronchonodal fistula.
References: 1. Mucormycosis of the central airways: CT findings in three patients. Kim KH, Choi YW, Jeon SC, Shin DH, Jung JI, Seo HS, Hahm CK. J Thorac Imaging. 1999 Jul;14(3):210-4.
2. Pulmonary mucormycosis presenting as an endobronchial lesion. Husari AW, Jensen WA, Kirsch CM, Campagna AC, Kagawa FT, Hamed KA, Azzi RL, Stevens DA. Chest. 1994 Dec;106(6):1889-91.
Keywords: airway, infection, fungal,

No. of Applicants : 83

▶ Correct Answer : 10/83, 12.0%

- UWO , Canada S Lee
- Dong-A University Hospital , Korea (South) Ji-yeon Han
- MUHC , Canada Nesreen Abourokbah
- Japanese Red Cross Society Himeji Hospital , Japan Yuichiro Kanie
- All India Institute of medical sciences , India Justin Moses
- CHU NANCY , France, Metropolitan LEGOU Francois
- Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
- Mallinckrodt Institute of Radiology , United States Naganathan Mani
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Private sector , Greece Vasilios Tzilas

▶ Correct Answer as Differential Diagnosis : 9/83, 10.8%

- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Fukuyama daiichi Hospital , Japan Mototsugu Saeki
- China Medical University ,Taiwan,R.O.C. , Taiwan Jun JunYeh
- Chungnam National University hospital , Korea (South) sunkyoung you
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- HSC , Brazil Diogo Pinheiro
- IRSA , France jean-luc BIGOT
- All India Institute of Medical Sciences , India Ashish Gupta

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 735 Date 2011-11-28

Discussion

No. of Applicants : 83