대한흉부영상의학회 Weekly Chest Cases

Case No : 1159 Date 2020-01-20

Courtesy of Ju Gang Nam / Seoul National University Hospital
Age/Sex 59 / F
Chief ComplaintIntermittent cough (duration : 1-2 months)

Figure 1
Figure 2
Figure 3
Figure 4

Diagnosis With Brief Discussion

Diagnosis: Subacute Invasive Pulmonary Aspergillosis
Radiologic Findings: Fig 1-3. CT scan demonstrates consolidative mass with internal low-attenuation and peripheral ground-glass opacities at right upper lobe.
Fig 4. 2 years ago, there was a well-defined soft tissue density inside a cavitary mass at right upper lobe, showing air-meniscus sign.
Brief Review: Aspergillus is a saprophytic conidial mold commonly inhaled from the environment, illness from which depending on the patients’ immune state and underlying lung pathology. There are three broad categories of pulmonary aspergillosis: allergic bronchopulmonary aspergillosis (ABPA), chronic pulmonary aspergillosis (CPA) and invasive pulmonary aspergillosis (IPA) (Figure). Which category may develop depends largely on the underlying host characteristics and the interaction between the fungus and the host. Subacute invasive aspergillosis, formerly known as chronic necrotizing pulmonary aspergillosis, is a locally destructive lung disease which tends to manifest in mildly immunocompromised patients and progresses more rapidly, over 1-3 months. While subacute invasive aspergillosis is commonly grouped under chronic pulmonary aspergillosis (CPA), it is diagnosed and treated similarly to IPA. Fever, weight loss and night sweats, usually absent in patients with simple aspergilloma and aspergillus nodules, are common in subacute invasive aspergillosis. Inflammatory makers such as the erythrocyte sedimentation rate (ESR) and the high-sensitivity C-reactive protein (hrCRP) are also likely to be elevated. Sputum culture may also grow Aspergillus.
On CT image, It may be difficult to distinguish subacute invasive aspergillosis from otherwise CPA. Radiologic features of CPA are often a combination of both the Aspergillus infection and the underlying lung condition. They can range from new or pre-existing expanding cavities of variable wall thickness to pericavitary infiltrates, adjacent bronchiectasis, pleural thickening and effusions. New cavities result from central necrosis of consolidations. The cavity-wall is usually thicker in chronic cavitary pulmonary aspergillosis and thinner in simple aspergilloma and subacute invasive aspergillosis. On biopsy, the presence of tissue invasion distinguishes subacute invasive aspergillosis from other forms of CPA. Oral itraconazole, given at a dose of 200 mg twice daily, with therapeutic drug level monitoring, is the initial drug of choice.
Please refer to: KSTR Imaging Conference 2002 Spring Case 10,
References: 1. Kanj A, Abdallah N, Soubani AO. The spectrum of pulmonary aspergillosis. Respiratory medicine 2018.
Please refer to
Keywords: lung, aspergillosis, chronic pulmonary aspergillosis, semi invasive aspergillosis, chronic necrotizing pulmonary aspergillosis,

No. of Applicants : 63

▶ Correct Answer : 41/63, 65.1%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- TWMU Medical Center East , Japan MASAFUMI KAIUME
- McGill , Canada ADRIANA SOFIA MORALES
- , Korea (South) HYEYOUNG CHOI
- Gifu University Hospital , Japan TOMOHIRO ANDO
- Lille , France BENOIST CAPON
- NIMS, HYDERABAD , India BHASKAR K
- Kyeongpook National University Hospital , Korea (South) CHANGGUN KIM
- , Korea (South) CHOHEE KIM
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
- St. Lukes International Hospital , Japan DAISUKE YAMADA
- , Korea (South) JIN YOUNG LEE
- Oita University, Faculty of Medicine , Japan Fumito Okada
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Gifu University Hospital , Japan Yo Kaneko
- Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
- The University of Tokyo Hospital , Japan RYO KUROKAWA
- Kyeongpook National University Hospital , Korea (South) MIRAN KIM
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Ajou University Hospital , Korea (South) HYERIN KIM
- Seoul National University Hospital , Korea (South) SE WOO KIM
- Chonbuk National University Hospital , Korea (South) KUM JU CHAE
- Seoul Veterans Hospital , Korea (South) JANG SEONG WON
- TB centre kasaragod. , India rikhy krishnan
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- Nishida Hospital , Japan SHOJI OKUDA
- University of Tsukuba Hospital , Japan SODAI HOSHIAI
- , Japan SOTA MASUOKA
- Toranomon Hospital , Japan KAORU SUMIDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
- , Japan KAZUMA TERAUCHI
- Private sector , Greece VASILIOS TZILAS
- , Korea (South) JIHYUN KIM
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Ajou University Hospital , Korea (South) YONG HO JANG
- Asan Medical Center , Korea (South) HYEMIN AHN

▶ Correct Answer as Differential Diagnosis : 13/63, 20.6%

- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- Mayo Clinic , United States AKITOSHI INOUE
- McGill University Health Center , Canada Alexandre Semionov
- Other , Korea (South) SEONGSU KANG
- The Jikei university , Japan TAKU GOMI
- Fujieda Municipal General Hospital , Japan HAYATO NOZAWA
- National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
- Hallym University Dongtan Medical Center , Korea (South) MINSU KIM
- Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
- , India SHYJUMON GEORGE
- , Japan YUMI MAEHARA
- Hamamatsu University Hospital , Japan YUKI HAYASHI
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Semi-Correct Answer : 6/63, 9.5%

- Ondokuz Mayis University , Turkey CETIN CELENK
- university of montreal , Canada Andrei Bogdan Gorgos I
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Seoul National University Hospital , Korea (South) JI HEE KANG
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
- Holy Family Hopsital , India RAJESH GOTHI

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1159 Date 2020-01-20

Discussion

No. of Applicants : 63