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Weekly Chest CasesArchive of Old Cases

Case No : 83 Date 1999-05-29

  • Courtesy of Jae-Woo Song, MD / Seoul City Boramae Hospital, Seoul, Korea
  • Age/Sex 23 / F
  • Chief Complaintpersistent fever for one week during chemotherapy for known acute lymphocytic leukemia
  • Figure 1
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Chest PA1 (july 3)

Diagnosis With Brief Discussion

Diagnosis
Invasive Aspergillosis
Radiologic Findings
PA chest radiograph shows a mass-like consolidation in the right lower lobe. Follow-up chest radiograph, obtained 5 days after, shows cavity formation with air-crescent in upper portion of the RLL lesion. CT scans show a mass-like air space consolidation with internal necrotic low attenuation in the right lower lobe. Note the ground glass opacity around the mass-like consolidation.
Brief Review
Invasive aspergillosis is the most common opportunistic pulmonary fungal infection, followed by candidiasis and mucormycosis. Major risk factors for invasive aspergillosis include severe or prolonged neutropenia (absolute neutrophil count < 500), prolonged corticosteroid therapy, graft-versus-host disease after allogenic BMT, and late-stage AIDS. Infection begins when aerosolized spores are inhaled into the distal airways and air spaces. In the absence of an effective host immune response, the spores mature into hyphae that can invade the pulmonary arteries. This results in pulmonary arterial thrombosis, hemorrhage, lung necrosis, and systemic dissemination. affected patients report nonspecific symptoms of fever, cough, and dyspnea. symptoms suggestive of pulmonary embolism can also occur. The diagnosis of invasive aspergillosis is difficult because the organism can normally colonize the upper airway. Thus, although single positive sputum cultures are considered unreliable for diagnosis, repeatedly positive cultures in a patient with fever and neutropenia suggest the diagnosis. As many of these patients are thrombocytopenic, invasive diagnostic procedures such as percutaneous or transbronchial biopsy may be precluded. Cultures of bronchoalveolar lavage fluid are positive in 30% to 68% of infected patients. Mortality rates from infection are high (50% to 70%), and patient outcomes depend on the early institution of antifungal therapy, the severity of the underlying disease, and the speed of granulocyte recovery. Invasive pulmonary aspergillosis characteristically manifests on radiographs as multiple, ill-defined 1 to 3 cm peripheral nodules that gradually coalesce into larger masses or areas of consolidation. An early computed tomography finding, best seen with thin collimation, is a rim of ground glass opacity surrounding the nodules (CT halo sign). This finding is nonspecific and has also been described in patients with tuberculosis, mucormycosis, and Wegener granulomatosis. In the appropriate clinical setting, however, the CT halo sign is highly suggestive of fungal infection, usually aspergillosis. Cavitation in the nodules or masses occurs in 40% of affected patients and often has a distinctive radiographic appearance, the air-crescent sign. This finding is characterized by an intracavitary mass composed of invasive pulmonary aspergillosis, occurs after granulocyte recovery, and usually indicates a good prognosis. Lobar or diffuse pulmonary consolidation are common, less specific findings. Pleural effusion is uncommon, and adenopathy is rare. Chest wall or mediastinal invasion can occur, and systemic dissemination to the central nervous system, kidney, and gastrointestinal tract occurs in 25% to 50% of patients.
References
1. Thompson BH, Stanford W, Galvin JR, Kurihara Y. Varied radiologic appearances of pulmonary aspergillosis. Radiographics 1995;15:1273-1284
2. Connolly JE, McAdams HP, Erasmus JJ, Rosado de Christenson ML. Opportunistic fungal pneumonia. J Thor Imag 1999;14:51-62
Keywords
Lung, Infection, Fungal infection,

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