대한흉부영상의학회 Weekly Chest Cases

Case No : 1190 Date 2020-08-11

Courtesy of Hye Young Kwon, Sung Shine Shim, Woocheol Kwon / Ewha Womans University Seoul Hospital
Age/Sex 68 / M
Chief Complainthemoptysis, cough (2 days)

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initial chest X-ray

Diagnosis With Brief Discussion

Diagnosis: Subacute invasive pulmonary aspergillosis
Radiologic Findings: Figure 1. Multiple small nodules are noted in both lungs with cavitary consolidation in right apex.
Figure 2-3. An approximately 4.5cm-sized thick walled cavity with adjacent fibrotic bands is seen in right upper lobe with randomly distributed multiple small nodules in both upper lobes.
Figure 4. On chest X-ray after 1 year, there is increasing cavitary consolidation in RULZ while other findings remain constant.
Figure 5-8. Chest CT scans after 1 year show substantially thickened wall of the cavity with unchanged multiple nodules in both upper lobes.

The patient had a history of tuberculosis and pneumoconiosis. Aspergillus fumigatus was detected in culture by PCNA, and a definitive diagnosis of subacute invasive pulmonary aspergillosis was made.
Brief Review: Subacute invasive pulmonary aspergillosis (SIPA) is a rapidly progressive fungal infection lasting fewer than three months and arising from pre‐existing lung lesions, generally affects moderately immunocompromised patients. Previously known as chronic necrotizing aspergillosis or semi-invasive aspergillosis, it is a subacute to chronic, localized, and indolent form of invasive aspergillosis.

Development of chronic cavitary pulmonary aspergillosis (CCPA) occurs over several months, with the condition commonly relapsing, even after surgery. Over time, if untreated, these cavities enlarge and coalesce, and fungal balls may appear or disappear. The development from CCPA to SIPA is caused by cavity expansion and is found among patients with impaired immunity. SIPA is the progressive enlargement of a single (preexisting) cavity, usually with a thin wall, either progressing slowly over months or rapidly in weeks. The rapidity of installation seems closer to that of invasive forms of aspergillosis in the non-immunocompromised context.

Oral itraconazole is the initial drug of choice and considerably superior to standard supportive therapy, with a relatively safe proﬁle even if administered over several months. Voriconazole is a second-line oral therapy that can be used when adverse eﬀects or failure of therapy occur with itraconazole. Although duration of therapy is variable, a minimum of 6 months is generally recommended. A recently published paper suggested extended antifungal treatment therapy for 12 months for demonstrable clinical improvement. Asymptomatic patients can also be safely observed without antifungal therapy and reassessed every 3–6 months.
Please refer to
References: 1. Barac A, Kosmidis C, Alastruey-Izquierdo A, et al. Chronic pulmonary aspergillosis update: A year in review. Med Mycol. 2019 Apr 1;57(Supplement_2):S104-S109
2. Kanj A, Abdallah N, Soubani AO. The spectrum of pulmonary aspergillosis. Respir Med. 2018 Aug;141:121-131
3. Denning DW, Cadranel J, Beigelman-Aubry C, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J. 2016 Jan;47(1):45-68.
Keywords: lung, chronic pulmonary aspergillosis, subacute invasive pulmonary aspergillosis,

No. of Applicants : 61

▶ Correct Answer : 11/61, 18.0%

- Tiger Gate Hospital , Japan SHIN-ICHI CHO
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Osaka City General Hospital , Japan SHU MATSUSHITA
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
- Fortis hospital , Mohali , India SHALEEN RANA
- Toranomon Hospital , Japan KAORU SUMIDA
- , Japan KAZUMA TERAUCHI
- Private sector , Greece VASILIOS TZILAS
- Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 12/61, 19.7%

- Mayo Clinic , United States AKITOSHI INOUE
- CH de la Cote Basque , France PAUL ARDILOUZE
- Hamamatsu University Hospital , Japan HAYATO NOZAWA
- , Japan YASUSHI AOYAGI
- Gifu University Hospital , Japan Yo Kaneko
- Mayo Clinic , Japan HIROAKI TAKAHASHI
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
- Suita Tokushukai Hospital , Japan JUNKO OCHI
- Nishida Hospital , Japan SHOJI OKUDA
- National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
- , Japan YUMI MAEHARA
- Hamamatsu University Hospital , Japan YUKI HAYASHI

▶ Semi-Correct Answer : 12/61, 19.7%

- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- Ondokuz Mayis University , Turkey CETIN CELENK
- Scans world , India PHILSON JOSEPH MUKKADA
- Seoul Medical Center , Korea (South) HYUK GI HONG
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
- The University of Tokyo Hospital , Japan RYO KUROKAWA
- Asan Medical Center , Korea (South) JIHOON KIM
- Other , Korea (South) KYU-CHONG LEE
- Post graduate , India SHASHI KUMAR ANBAZHAGAN
- University of Tsukuba Hospital , Japan SODAI HOSHIAI

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1190 Date 2020-08-11

Discussion

No. of Applicants : 61