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Weekly Chest CasesArchive of Old Cases

Case No : 578 Date 2008-11-24

  • Courtesy of Choong Hee Shin, MD, Sang Hyun Paik, MD, Jai Soung Park, MD. / Soonchunhyang University Hospital, Bucheon, Korea.
  • Age/Sex 65 / M
  • Chief ComplaintCough / Onset) 15 days ago
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Fig 1.

Diagnosis With Brief Discussion

Diagnosis
Chronic Necrotizing Aspergillosis
Radiologic Findings
Fig 1. Chest PA and lateral shows numerous irregular shaped nodular increased opacities with cavitation.
Fig 2. Lung window setting of the chest CT scan shows consolidative lesions with inner low density, nodules and multiple cavitary lesions in entire both lungs.
Fig 3. Lung window and mediastinal window setting of the chest CT shows aggravation of multiple cavitary lesion and consolidative lesions in both lungs. There are multiple enlarged LNs at mediastinal and both hilar nodal stations.

Aspergillus species grow from percutaneous transthoracic needle biopsy at consolidation of LLL.
Brief Review
This type is the chronic granulomatous form of aspergillosis, arising in the setting of mild immunologic compromise and being a progressive form of localized disease. This unusual form of pulmonary aspergillosis resembles clinically a number of other chronic pulmonary diseases including tuberculosis, actinomycosis, histoplasmosis (1).

The patients are usually middle-aged and have poor nutrition due to alcoholism, diabetes mellitus, chronic granulomatous disease or connective tissue disorders. Pulmonary abnormalities resulting in lowered defense mechanisms of the lung such as fibrotic area of mycobacterial infection, chronic obstructive lung disease, previous surgery, radiation therapy, pulmonary infarction or pneumoconiosis may be associated (2).

Clinical symptoms include cough, sputum, fever, weight loss, and hemoptysis, usually persisting at least for a few months. This time course is different from that of invasive aspergillosis (IPA) in which the rate of progression depends on the degree of immunosuppression of host (usually two or three weeks).

Gefter et al (3) reviewed radiographic findings of semi-invasive pulmonary aspergillosis in five patients. They appeared as consolidation or progressing cystic infiltrate subsequently forming a thick-walled cavity and aspergilloma with upper lobe predominance. And pleural thickening was frequently seen.

According to Kim et al (4) in a review of six cases of semi-invasive aspergillosis, the CT findings of the disease were diverse ranging from findings of bronchopneumonia to cavitary consolidation containing an aspergilloma. Main feature distinguishing chronic necrotizing pulmonary aspergillosis from aspergilloma is the presence of obvious tissue invasion and destruction in the former. Whereas, pulmonary aspergilloma usually forms within preexisting cavity without tissue invasion. Pathologically, the findings of angioinvasion are lacking which are characteristic in IPA.

Treatment option depends on the clinical status of the patients; from observation in asymptomatic patients to antifungal therapy or surgical resection in patients with hemoptysis or progressing disease.
References
1. SY Kim, KS Lee, J Han, JG Kim, TS Kim, SW Choo, SJ Kim. Semiinvasive Pulmonary Aspergillosis CT and Pathologic Findings in Six Patients, AJR 2000; 174:795-798
2. Binder RE, Faling LJ, Pugatch RD, Mahasaen C, Snider GL. Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity. Medicine 1982; 61:109-124
3. Gefter WB, Weingrad TR, Epstein DM, Ochs RH, Miller WT. "Semiinvasive" pulmonary aspergillosis: A new look at the spectrum of Aspergillus infections of the lung. Radiology 1981; 140:313-321
4.Cheon J-E, Im J-G, Kim MY, Lee JS, Choi GM, Yeon KM. Thoracic actinomycosis: CT findings. Radiology 1998; 209:229-233
Keywords
Lung, Infection, Fungal infection,

No. of Applicants : 83

▶ Correct Answer : 19/83,  22.9%
  • - China Medical University,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - The Armed Forces HamPyeong Hospital , Korea (South) Bae Geun Oh
  • - Marien Hospital, Hamm , Germany Davis Chiramel
  • - Samsung Medical Center , Korea (South) Eun Kim
  • - Korea university anam hospital , Korea (South) SONG GYU
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - Trakya medical university, , Turkey belma kmazaslan
  • - Soonchunhyang university Bucheon hospital , Korea (South) Minhee Lee
  • - Asian Heart Institute, Nirman Hitech & Apollo clinic , India Jeshil Shah
  • - kims,narkatpally , India k bhaskar
  • - Cheongshim international medical center , Korea (South) Hae Jum Yang
  • - Gimpo Woori Hospital , Korea (South) Son Youl Lee
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Armed Forces Chun-Cheon Hospital , Korea (South) ChaeHun Lim
  • - All India Institute of medical sciences , India Justin Moses
  • - All India Institute of Medical Sciences , India Ashish Gupta
▶ Correct Answer as Differential Diagnosis : 25/83,  30.1%
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - hospital Sao Paulo , Brazil israel missrie
  • - Seoul National University Hospital , Korea (South) Kwang Nam Jin
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Ruby Hall Clinic , India john joseph
  • - MD PG Resident, PIMS,LONI, MAHARASHTRA, INDIA , India Sushant Bhadane
  • - Arora Neuro Centre,Ludhiana , India Devendra Kumar
  • - UZ Gent , Belgium robert gosselin
  • - chp st martin , France Mariotte benoit
  • - john h stroger hsp , United States dheeraj reddy gopireddy
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - jiangsu province hospital , China yuan doctor
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - National Taiwan University Hospital , Taiwan Chin-Chung Shu
  • - BOLLINENI HOSPITAL NELLORE , India jignesh dubal
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - Saga University , Japan Ryoko Egashira
  • - IRSA LA ROCHELLE FRANCE , France jean-luc BIGOT
  • - Trakya University School of Medicine , Turkey Umut Ugur
  • - CHU Grenoble , France Fabrice Bing
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
▶ Semi-Correct Answer : 36/83,  43.4%
  • - Samsung Medical Center , Korea (South) Dae Kun Oh
  • - OSWAL CANCER HOSP. , India VISHAL GARG
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - KMC,Manipal , India satish maddukuri
  • - Chungnam National University hospital , Korea (South) Kyoung Jin Oh
  • - Kasturba Medical College Manipal , India Paresh Desai
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
  • - suwon well space clinic , Korea (South) kim .cheolyoung
  • - POPOVO HOSPITAL , Bulgaria VLADISLAV RUSINOV
  • - Osaka University , Japan Osamu Honda
  • - Ruby Hall Clinic , India sudarshan rawat
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - EKH-Berlin , Germany Michael Weber
  • - Hospital Clinico Universidad de Chile , Chile Rojas Andres
  • - Taichung Veterans General Hospital, Radiology department , Taiwan SI-WA CHAN
  • - E-DA Hospital / I-Shou University , Taiwan Yu-Feng Wei
  • - McGill University Health Center , Canada Alexandre Semionov
  • - seoul national university hospital , Korea (South) Ijin Joo
  • - CHRU Lille , France Benjamin Damarey
  • - KHD , Turkey Tay Bakar
  • - partner, aditya imaging centre , India vivek patel
  • - Mackay Memorial Hospital , Taiwan Shen ShengYeh
  • - Apollo Hospital. , India Sandip R Shah
  • - McGill University Health Centre , Canada Amr Ajlan
  • - Retd. Prof Thoracic Surgery B.J.MEDIDCAL COLLEGE Punr India , India Bankim Amin
  • - ROHINI Scans (P) Ltd. , India UMAPATHI MAHESH
  • - radiology department ANNECY , France gilles GENIN
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - xi , China qiu zhang
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - SPS APOLLO HOSPITALS , India LOVKESH MITTAL
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Dongguk University International Hospital , Korea (South) Hee Seok Choi
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