대한흉부영상의학회 Weekly Chest Cases

Case No : 512 Date 2007-08-20

Courtesy of Yoon Kyung Kim, MD. / Ewha Womans University, Mokdong hospital, Seoul, Korea.
Age/Sex 46 / M
Chief ComplaintAbnormality on chest radiograph Past history; Ewing sarcoma in left maxilla

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Diagnosis With Brief Discussion

Diagnosis: Pulmonary cryptococcosis
Radiologic Findings: Chest radiograph shows nodular opacity in left lower lung zone. CT scan obtained at level of inferior pulmonary vein show a cavitary nodule with surrounding ground-glass opacity at peripheral portion of left lower lobe. Wedge resection of the nodule revealed chronic granulomatous inflammation. Special stain revealed Cryptococcus.
Brief Review: Cryptococcus neoformans is a ubiquitous fungus found worldwide, particularly in soil contaminated by pigeon droppings. Cryptococcal infection usually results from inhalation of organisms; dependent on host immune status, the infection may remain isolated to the lungs or undergo hematogenous spread to involve the CNS, bones, and skin. Pulmonary cryptococcosis occurs rarely in immunocompetent individuals. Defects in cellular immune function predispose to infection, with susceptible patient groups including those with HIV infection, lymphoma, leukemia, malignancy, and drug-induced immunosuppression. The most common manifestation of pulmonary cryptococcosis on CT was pulmonary nodules. Nodules were typically 5-20 mm in diameter, smoothly marginated, either solitary or multiple in number, and associated with other parenchymal findings such as masses and consolidation. Cavitation in nodules and masses has been previously described as a radiographic feature particularly in immunosuppressed patients.
Ground-glass opacities adjacent to or surrounding nodules in an appearance consistent with the CT halo sign were present in 40% of patients presenting with a nodular pattern of disease. The CT halo sign was first used by Kuhlman et al. to describe the CT appearance of hemorrhagic nodules due to invasive aspergillosis; subsequently, this sign has been shown to occur in association with hemorrhagic nodules of varying causes as well as some nonhemorrhagic infections such as coccidioidomycosis and actinomycosis. In patients with pulmonary cryptococcosis and the CT halo sign, histologic correlation showed the ground-glass opacities to represent granulomatous inflammation.
The radiologic manifestations of pulmonary cryptococcosis are thought to be affected by the patient's level of immunosuppression. Prior radiographic and CT studies of cryptococcal pneumonia in AIDS patients have shown that in contrast to the nodular patterns most common in the HIV-seronegative population, interstitial-type patterns predominate in HIV-seropositive patients.
References: Zinck SE, Leung AN, Frost M, Berry GJ, Muller NL. Pulmonary cryptococcosis: CT and pathologic findings. J Comput Assist Tomogr 2002; 26:330-334.
Keywords: Lung, Infection, Fungal infection,

No. of Applicants : 55

▶ Correct Answer : 11/55, 20.0%

- E-Da hospital, Taiwan Yu-Feng Wei
- Makay Memorial Hospital, Taipei, Taiwan Sheng-Yao Yu
- Osaka University, Japan Osamu Honda
- Dept. of Radiology, Seoul National University Hospital, Korea Kwang Nam Jin
- Asan Medical Center, Korea Eun Jin Chae
- St. Mary's Hospital, The Catholic University of Korea, Korea Yun Ju Lee
- Gimpo woori hospital, Korea Son Youl Lee
- Aditya Imaging centre, Sayajigunj, Vadodara, Gujarat, India Vivek Patel
- Changi General Hospital, Singapore Angeline Poh
- Rio Kenbi Clinic, Japan Shigeki Misumi
- Ultracare Coimbatore, India Debabrata Das

▶ Correct Answer as Differential Diagnosis : 13/55, 23.6%

- Dept. of radiology, Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
- Charliesome
- Sinsegye Rad Clinic, Daegu, Korea Kim Gi Beom
- Annecy hospital, France Gilles Genin
- Regional Imaging Riverina, Australia Rashid Hashmi
- Annemasse, Polyclinique De Savoie, France Gay-Depassier Philippe
- CHU Grenoble , France Pierre Yves Savoye
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee
- IRSA, La Rochelle, France Denis Chabassiere
- Hospital Sotiria, Athens, Greece Vasilios Tzilas
- Yongsan Hospital, College of Medicine Chung-Ang University, Korea Jae Seung Seo
- Max Hospital, New Delhi, India Vickrant Malhotra
- China Medical University Hospital, Taiwan Jun-Jun Yeh

▶ Semi-Correct Answer : 23/55, 41.8%

- Ma Diagnositc Center, Guntur, India Sunil Almale
- Kandula Achala
- Pune, India Rahul Deshmukh
- Marein Hospital, Hamm, Germany Davis Chiramel
- Anonymous University of Pennsylvania, USA Jones Lisa
- Dept. of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India Ram Prakash Galwa
- Roman Suleymanov
- CHRU Lille hopital calmette, France Toledano Manuel
- Ibra hospital, sultant Oman Shaker Omera
- Samsung medical center, Sungkyunkwan university, Korea Young A Bae
- Asan medical center, Korea Dae Yun Kim
- Pohang Naval Hospital, Korea Jinoo Kim
- Yongsan Hospital, College of Medicine Chung-Ang Universtiy, Korea Chang Keun Sung
- EKH-Berlin, Germany Michael Weber
- ICL, Saint Etienne, France Olivier Moussatoff
- Nirman Hi-Tech Diagnostic Centre, Mumbai, India Minal Seth
- Soonchunhyang University Hospital, Chunan, Korea Sang Hyun Park
- Nassau, Bahamas Trupti Dabholkar
- Armidale Radiology, Australia Saurabh Khandelwal
- Pittwater Radiology, Australia Julie Arora
- All India Institute of Medical Sciences, Delhi, India Ashish Gupta
- Jackson Memorial Hospital, Miami, FL, USA N.B.S. Mani
- CHU Grenoble, France Bing Fabrice

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 512 Date 2007-08-20

Discussion

No. of Applicants : 55