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Weekly Chest CasesArchive of Old Cases

Case No : 1406 Date 2024-09-30

  • Courtesy of Dabee Lee, Kye Ho Lee / Dankook University Hospital
  • Age/Sex 60 / M
  • Chief ComplaintSputum, Alcoholic LC, s/p DDLT
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Pseudomembranous Tracheobronchitis d/t Aspergillus infection
Radiologic Findings
Fig. 1. Chest AP image shows mild tracheal luminal narrowing and diffuse peribronchial cuffing.
Fig. 2-3. CT scans with mediastinal window setting shows diffuse circumferential tracheobronchial wall thickening with multifocal ulcerative change, irregular endoluminal nodular or linear lesions.
Brief Review
Bronchoscopy shows severe mucosal inflammation and edematous change with pseudomembranous changes including white plaques in the entire trachea, both main and lobar bronchi. Aspergillus antigen was positive and culture from bronchoalveolar lavage fluid confirmed Aspergillus species.

• Pseudomembranous tracheobronchitis infections ; Corynebacterium, Aspergillus, Streptococcus, Bacillus cereus, Staphylococcus, and RSV…

• Predisposing conditions for invasive pulmonary aspergillosis : leukemia, HIV/AIDS, recipients of hematopoietic stem cell, transplant or solid organ transplantation, graft versus host disease, receiving antineoplastic treatment or chronic systemic high-dose corticosteroids, chronic granulomatous diseases, some immunocompetent patients (long-term endotracheal intubation, co-infection with influenza).

• Tracheobronchial aspergillosis (5% of invasive pulmonary aspergillosis)

1) Aspergillus tracheobronchitis
2) Ulcerative Aspergillus tracheobronchitis
3) Pseudomembranous Aspergillus tracheobronchitis
- Extensive invasion of entire tracheobronchial tree covered by grayish plaque-like membrane
- Highest mortality rate
- Intraluminal proliferation of Aspergillus hyphae on mucosa -> bronchial/tracheal inflammation with mucus production -> ulceration of surface epithelium d/t submucosal pyogranulomatous inflammation -> fungal hyphae, purulent exudate, mucus, necrotic tissue forms plaque-like pseudomembrane or nodular plaques
- Bronchoesophageal fistulation or broncho-arterial fistulation, which can cause fatal hemorrhage

• CT findings
- Tracheal or bronchial wall thickening (main finding) : nodular or circumferential
- Multifocal endoluminal nodular lesions
- Enhancement of the tracheobronchial tree
-> Dx is confirmed by pseudomembrane (fibrin, leukocytes, overlying bacteria) on bronchoscopy.
References
1. Cho JS, Kim JJ, Jeong SY, Lee YS, Kim M, Park SJ, Koh MJ. J Korean Soc Radiol. 2022 May;83(3):737-743
Keywords

No. of Applicants : 60

▶ Correct Answer : 20/60,  33.3%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Oita university , Japan AYUMI KAMEI
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - University of Yamanashi , Japan HIROYUKI MORISAKA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - University of Yamanashi , Japan HIROAKI WATANABE
  • - Other , Korea (South) CHAEHUN LIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - GHICL , France MANUEL TOLEDANO
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - , Japan YUMI MAEHARA
  • - Toyota Kosei Hospital , Japan YUKI HAYASHI
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 4/60,  6.7%
  • - Kyoto University , Japan AKIHIKO SAKATA
  • - Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
  • - Centre Hospitalier Regional de Lanaudiere , Canada MATTHIEU STORME
  • - Fukuoka university , Japan KEISUKE SATO
▶ Semi-Correct Answer : 2/60,  3.3%
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
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