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Weekly Chest CasesImaging Conference Cases

Case No : 2

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  • Age/Sex 43 / M
  • Case Title Cough and blood-tinged sputum in a patient with acute lymphocytic leukemia.
  • Figure 1
  • Figure 2

Diagnosis With Brief Discussion

Courtesy
S
Imaging Findings
PA chest shows ill-defined consolidation in right upper lobe and multiple small patchy opacity in other lung fields.

Contrast enhanced chest CT shows enhancing consolidation with air bronchogram and central lucency in right upper lobe.

Small enhancing nodules are also seen in other lung fields.

On lung window CT scan, areas of ground glass opacity surround the consolidation (halo sign), which is considered alveolar hemorrhage.

Other multiple nodules are surrounded by the halo, too.
Discussion
Invasive pulmonary aspergillosis is a frequent serious complication in immunocompromised patients.

Conditions that predispose patients to it include acute leukemia with neutropenia, use of corticosteroids and other immunosuppressive agents, organ transplantation, and lymphoreticular or hematologic malignancy.

The increasing number of patients with myelosuppression parallels the increasing frequency (14-23%) of invasive pulmonary aspergillosis and the high rate of mortality due to the disease.

Infection begins when aerosolized spores are inhaled into the distal airways and air spaces.

In the absence of an effective host immune response, the spores mature into hyphae that can invade the pulmonary arteries. This results in pulmonary arterial thrombosis, hemorrhage, and lung necrosis.

Early diagnosis of invasive pulmonary aspegillosis important, since early trial of amphotericin B therapy has been reported to improve survival rates.


Chest CT is useful in early recognition of invasive pulmonary aspergillosis.

Nodules surrounded by ground-glass attenuation or segmental areas of consolidation plus ground glass attenuation have been known as early findings of invasive pulmonary aspegillosis.

This finding is non-specific and can be seen in neutropenic patients with mucormycosis, organizing pneumonia, or pulmonary hemorrhage.

Cavitation in the nodules or masses occurs in 40% of affected patients and often has a distinctive radiographic appearance, the air-crescent sign.

This finding is characterized by an intracavitary mass composed of invasive pulmonary aspergillosis, occurs after granulocyte recovery, and usually indicates a good prognosis.

Pleural effusion is uncommon, and adenopathy is rare.
Reference
1. Won HJ, Lee KS, Cheon J-E, Hwang JH, Kim TS, Lee HG, Han J. Invasive pulmonary aspergillosis: prediction at thin-section CT in patients with neutropenia-a prospective study. Radiology 1998; 208: 777-782.
2. Connolly JE, McAdams HP, Erasmus JJ, Rosado de Christenson ML. Opportunistic fungal pneumonia. J Thora Imag 1999; 14: 51-62.
Keywords
Lung, Infection, Fungal infection,
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