대한흉부영상의학회 Weekly Chest Cases

Case No : 518 Date 2007-10-01

Courtesy of Hyun-Ju Seon, MD. / Chonnam National University College of Medicine, Korea.
Age/Sex 67 / M
Chief ComplaintFever, myalgia, nausea and vomiting for 3 days He had been diagnosed as liver cirrhosis and HCC and treated in 7 years ago

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6

Diagnosis With Brief Discussion

Diagnosis: Leptospirosis with diffuse alveolar hemorrhage
Radiologic Findings: He was troubled with fever, myalgia, nausea and vomiting for 3 days. The symptom was aggravated in spite of treatment in a private clinic. At the time of admission, he complained tenderness and skin rash in his lower extremities and laboratory exam revealed elevated LFT and RFT.
One day after admission, the symptom of sudden onset massive hemoptysis developed. At the day, follow up chest AP showed diffuse parenchymal infiltrations in both lungs and titer for leptospira antibody was also elevated (1:1280)
Fig 1. Initial chest radiograph shows borderline cardiomegaly without definite abnormal parenchymal opacities in both lungs.
Fig 2. One day later, follow up chest radiograph shows diffuse bilateral parenchymal filtrations in both lungs and slightly increased cardiac size.
Fig 3. Eight days later after treatment, follow up chest radiograph shows marked improvement of previous diffuse lung infiltrations.
Fig 4-6. HRCT scans show bilateral patchy and geographic areas of ground glass opacities, some confluent consolidations, and fine reticulations in both lungs.
Brief Review: Leptospirosis is a zoonotic diseases caused by Leptospira interrogans in rodent and wild animals. Human disease is acquired by contact with urine or tissues of an infected animal or through contaminated water or soil. Systemic infection of leptospirosis shows variable clinical symptoms and signs from indolent and fatal manifestation with multi-organ failure.
Leptospirosis can be complicated by ARDS, which needs the treatment of underlying disease and adequate supportive care with artificial mechanical ventilation.
The main causes of the disease, we believe, are heavy rain and water flooding during the summer, which leads to wide propagation of Leptospira.
Leptospirosis can occur as two clinical manifestations:
1) a self-limiting anicteric systemic illness, which occurs in 85-90 % of the disease, and 2) a septicemic leptospirosis, 10-15 % of patients.
Systemic leptospirosis is characterized by abrupt onset of chills, fever, headache, and myalgia. Anorexia, nausea, vomiting, and abdominal pain can occur occasionally.
Weil's disease, icteric leptospirosis, is the severest form of the disease and characterized by the presence of impaired renal and hepatic function, multi-organ internal hemorrhage, vascular collapse, and severe alteration in consciousness.
Pneumonia occurs in one fifth to two thirds of patients with leptospirosis. Im et al. reviewed the chest radiographic findings in 37 patients of 58 serologically proven leptospirosis, who had the positive radiographic findings, with pathologic correlation by experimental study. Three radiographic patterns were evident: (1) 21 (57%) of the 37 patients had small nodular densities, (2) six (16%) had large confluent areas of consolidation, and (3) 10 (27%) had diffuse, ill-defined, ground-glass density. Serial radiographs showed a tendency for the nodular pattern to be followed by confluent consolidation and/or ground-glass opacity, as this case. Abnormalities were bilateral, nonlobar in all cases, and had a marked tendency toward peripheral predominance. The pulmonary abnormalities were due to petecheal hemorrhage, which progressed to large confluent areas of hemorrhage on experimental study. Hilar and mediastinal adenopathy does not appear to be a feature.
References: 1. Fraser and Pare's Diagnosis of diseases of the chest. 4th ed. 776-777.
2. Im JG, Yeon KM, Han MC, et al. Leptospirosis of the lung: radiographic findings in 58 patients. AJR 1989 152;955.
Keywords: Lung, Infection, Bacterial infection,

No. of Applicants : 53

▶ Correct Answer : 8/53, 15.1%

- Dept. of radiology, Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
- Gimpo Woori Hospital, Korea Son Youl Lee
- Armed Forces ChunCheon Hospital (AFCC), Korea Chae Hun Lim
- IRSA La Rochelle, France Jean-Luc BIGOT
- Samsung medical center, Korea Young A Bae
- IRSA, La Rochelle, France Denis Chabassiere
- Jackson Memorial Hospital, Florida, USA N.B.S.Mani
- China Medical University Hospital, Taiwan Jun-Jun Yeh

▶ Correct Answer as Differential Diagnosis : 5/53, 9.4%

- Pune, India Rahul Deshmukh
- CHRU Lille hopital calmette, France Toledano Manuel
- Homs National Hospital, Homs - Syria Rami Abou Zalaf
- Severance hospital, Korea Koo Hye Ryoung
- Mackay Memorial Hospital, Taipei, Taiwan Chia-Fu Tsai

▶ Semi-Correct Answer : 37/53, 69.8%

- Nirman Hitech centre, Malald, Apollo Clinic, Kandivali, Mumbai, India Jeshil R. Shah
- Marein Hospital, Hamm, Germany Davis Chiramel
- Registrar in Radiology, UHL NHS Trust, UK. A. Donuru
- Bollineni superspeciality hospital nellore india jignesh dubal
- Ondokuz Mayis University, Samsun Turkey Cetin Celenk
- E-Da hospital, Taiwan Yu-Feng Wei
- Postgraduate institute of medical sciences , Chandigarh, India Pushpender Gupta
- Ruby Hall Clinic, Pune, India John Joseph
- Shiga University of Medical, Japan. Norihisa Nitta
- Armidale Radiology, Australia Saurabh Khandelwal
- Pittwater Radiology, Australia Julie Arora
- Clinic 1, Moscow, Russia Lepikhina Dasha
- Nirman Hitech CT MR centre & Apollo clinic, Mumbai, India Jeshil Shah
- Osaka University, Japan Osamu Honda
- Sinsegye Rad Clinic, Daegu, Korea Kim Gi Beom
- EKH-Berlin, Germany Michael Weber
- Jiangsu Province Official Hospital, Nanjing, Jiangsu Province, China Dong Sheng Jin
- Regional Imaging Riverina, Australia Rashid Hashmi
- Pravara medical college, loni, India. Sushant Bhadane
- Hospital Sotiria, Athens, Greece Vasilios Tzilas
- Trakya University Edirne Turkey Armagan Sarac
- Dept. of radiology, Assam medicalcollege, Assam, India Karunakaran M
- Trakya University School of Medicine, Turkey Mustafa Kemal Demir
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee
- Diagnostic Radiology, Yongdong Severance Hospital, Korea Kim Dae Jung
- Annemasse, Polyclinique De Savoie, France Gay-Depassier Philippe
- Annecy hospital, France Gilles Genin
- Hospital Sotiria Athens Greece Delaveri kaith
- Vital imaging centre, Mumbai, India Ganesh Agrawal
- Breach Candy Hospital, Mumbai, India Rohan Kashyape
- Ultra Care, Coimbatore, India Debabrata Das
- Dept. of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India Ram Prakash Galwa
- Lilavati Hospital, Mumbai, India Mahavir Swami
- Yongsan Hospital, College of Medicine, Chung-Ang University, Korea Jae Seung Seo
- Nassau, Bahamas Trupti Dabholkar
- Max Hospital, New Delhi, India Vickrant Malhotra
- CHU Grenoble, France Bing Fabrice

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 518 Date 2007-10-01

Discussion

No. of Applicants : 53