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Weekly Chest CasesArchive of Old Cases

Case No : 889 Date 2014-11-10

  • Courtesy of Kyeho Lee / Dankook University Hospital
  • Age/Sex 57 / F
  • Chief ComplaintMild fever, Hx of concurrent chemoradiotherapy due to tongue cancer.
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7

Diagnosis With Brief Discussion

Diagnosis
Angioinvasive Aspergillosis
Radiologic Findings
Initial chest PA (Fig. 1) shows no abnormal increased opacity lesions in both lungs, however chest CT lung window setting (Fig. 2) show small round GGA nodular lesion in right upper lobe.
Follow up CT (Fig. 3) after 7 weeks show increased size of previous right upper lobe GGA lesion with newly appeared mottled air density.
Follow up chest PA (Fig. 4) and chest CT (Fig. 5) after 1 week aggravated right upper lobe consolidation with irregular cavity formation and surrounding ground glass attenuated halo.
CT guided transthoracic needle aspiration biopsy was performed. H&E and GMS stains revealed acute inflammation with fungal organism and hyphae, consistent with aspergillosis.
Follow up chest PA (Fig. 6) and chest CT (Fig. 7) performed 4 weeks after initiation of treatment show thin walled cavitated nodule with air-crescent formation.
Brief Review
The invasive form of pulmonary aspergillosis occurs frequently in immunocompromised patients and angioinvasive aspergillosis is the most common form. Histologically angioinvasive aspergillosis is characterized by invasion and occlusion of small to medium-sized pulmonary arteries by fungal hyphae, with formation of coagulative necrosis, alveolar hemorrahge or hemorrhagic infarcts. Clinical manifestations are non-specific, but typical symtoms include cough, fever and dyspnea.
Typical CT findings are nodules surrounded by a halo of ground glass attenuation or pleura based, wedge shaped consolidations. The halo sign is characterized as aspergillosis infected lung nodule with infarction and coagulative necrosis surrounded by alveolar hemorrhage. Eventually cavitation may occur and separation of central necrotic lung from surrounding lung parenchyma forming an air crescent can be observed.
The halo sign has been identified as an early indicator of invasive aspergillosis. Although non-pathognomonic and identified in a number of other conditions, the CT halo sign is highly suggestive of angioinvasive aspergillosis when detected in immunocompromised patients. The air crescent sign appears lately in the phase of infection resolution, coinciding with the improvement of neutropenia. The air crescent sign is observed in a later stage of disease, typically 2-3 weeks after initiation of treatment and reported as an indication of good prognosis.
References
1.Franquet T, Muller N, Gimenez A et al. Spectrum of Pulmonary Aspergillosis: Histologic, Clinical, and Radiologic Findings. Radiographics 2001;21:825-837
Keywords
Lung, Infection, Fungal infection,

No. of Applicants : 78

▶ Correct Answer : 38/78,  48.7%
  • - university of montreal , Canada Andrei Gorgos I
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - University of British Columbia , Canada Amr Ajlan
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Asan Medical Center , Korea (South) Jooae Choe
  • - CHU Poitiers , France Yannick DE LA TORRE
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - Otsu Red Cross Hospital , Japan Hirotsugu Nakai
  • - 異⑸ , Korea (South) Yunhee Jang
  • - SNUH , Korea (South) Eui Jin Hwang
  • - Inha university hospital , Korea (South) Eugene Kim
  • - HUEC , Brazil Diogo Pinheiro
  • - McGill University Health Center , Canada Alexandre Semionov
  • - The University of Tokyo Hospital , Japan Toshihiro Furuta
  • - king abdulaziz medical city -NGHA , Saudi Arabia MOHAMMED THABET
  • - Kanto Rosai Hospital , Japan tomoko sako
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - stanley medical college , India yazhini v
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Intermed Hospital , Mongolia Khulan Khurelsukh
  • - Samsung medical center , Korea (South) Hyun Su Kim
  • - CHU POITIERS , France SZTARK Guillaume
  • - Chonnam national university hospital , Korea (South) Gunsoo Kim
  • - VHS medical center , Korea (South) Seong hee Jeon
  • - Wuhan Union Hospital , China Qiguang Cheng
  • - Government Medical College, Nagpur, India , India Krishna Prasad Bellam
  • - IRSA La Rochelle , France Denis Chabassiere
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - NIMS, HYDERABAD , India ashish sarode
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Gifu Central Hospital , Japan Haruo Watanabe
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - Hopital Bichat , France, Metropolitan Pauline Pradere
  • - Freelance Resident in Reunion Island , Reunion Fabien HO
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - Medicheck health care , Korea (South) Chae Lim
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
▶ Correct Answer as Differential Diagnosis : 25/78,  32.1%
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - Avrasya Hospital , Turkey Murat Ulusoy
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - GRMC , India shailesh gupta
  • - NIMS, HYDERABAD , India bhaskar kakarla
  • - Fortis Hospital , India Vaibhav Singh
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - CHU Poitiers , France CHAN paul
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - CNUH , Korea (South) Noh Hoon
  • - Chonnam national university hospital , Korea (South) Wongi Jeong
  • - Chungbuk national university , Korea (South) Yong Kim
  • - Seoul National University Gangnam Center , Korea (South) Hua Sun Kim
  • - National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
  • - Fortis hospital , Mohali , India Shaleen Rana
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
  • - Imagerie Sainte-Therese Fribourg , Switzerland Louis Locatelli
  • - NASA SCANS , India RAKESH BHATIA
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
▶ Semi-Correct Answer : 8/78,  10.3%
  • - GHICL , France manuel toledano
  • - �stanbul , Turkey Ayhan Yilmaz
  • - Northern Yokohama Showa university , Japan Kota Watanabe
  • - stanley medical college , India vanitha gnanasoundran
  • - Columbia Asia Hospitals , India Hirennappa udnur
  • - 異⑸ , China ZHANG YING
  • - Teikyo University Mizonokuchi Hospital , Japan Noriko Kobayashi
  • - Ondokuz Mayis University , Turkey Cetin Celenk
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