대한흉부영상의학회 Weekly Chest Cases

Case No : 441 Date 2006-04-10

Courtesy of Hyun Ju Lee, MD. / Seoul National University Hospital, Seoul, Korea
Age/Sex 61 / F
Chief ComplaintAML, neutropenic fever

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Diagnosis With Brief Discussion

Diagnosis: Angio- and Airway-Invasive Aspergillosis
Radiologic Findings: Chest radiograph shows air space consolidation in right upper lobe and both middle lung zones. Chest CT shows consolidation with surrounding ground-glass halo in right lung and patchy consolidation in left lung. Bronchial wall thickening and luminal narrowing are seen in the right upper lobar bronchus and bronchus intermedius.

This patients diagnosed as AML, M2 in eight years ago. Fungal sinusitis and invasive pulmonary aspergillosis were identified in 7 years ago. The consolidation and bronchial wall thickening were wax and wane. Bronchial luminal narrowing might be caused by recurrent bronchial inflammation.
Brief Review: The invasive pulmonary aspergillosis is an acute fungal infection of the lungs that is characterized by hyphal invasion and destruction of normal lung tissue. Invasive pulmonary aspergillosis affects patients with prolonged neutropenia due to AIDS or with hematologic malignancies and those who have undergone organ transplantation. Invasive pulmonary aspergillosis usually occurs in patients with advanced AIDS and a CD4 cell count of less than 50/mm3. Clinical manifestations of Invasive pulmonary aspergillosis include cough, chest pain, and hemoptysis.

Angioinvasive aspergillosis is characterized at histologic analysis by the invasion and occlusion of small to medium-sized pulmonary arteries by fungal hyphae. This leads to the formation of necrotic hemorrhagic nodules or pleura-based, wedge-shaped hemorrhagic infarcts. Radiographic evaluation, although nonspecific, may reveal poorly defined pulmonary nodules or air-space consolidation early in the disease process. Thick-walled cavitary lesions represent a late finding. At high-resolution CT, the term halo sign is applied to a masslike lung consolidation or nodule surrounded by ground-glass attenuation, corresponding to hemorrhagic necrosis.

Airway-invasive aspergillosis is characterized at histologic analysis by the presence of Aspergillus organisms deep to the airway basement membrane. Clinical manifestations include acute tracheobronchitis, bronchiolitis, and bronchopneumonia. Patients with acute tracheobronchitis usually have normal radiologic findings. Occasionally, tracheal or bronchial wall thickening may be seen. Bronchiolitis is characterized at high-resolution CT by the presence of centrilobular nodules and branching linear or nodular areas of increased attenuation having a "tree-in-bud" appearance. Tracheobronchitis with severe inflammation of the airways that is associated with ulcerations and plaque formation. This may lead to airway obstruction and secondary atelectasis.

Bronchoalveolar lavage often suggests the diagnosis but has a low diagnostic yield. Similarly, sputum cultures are positive in only 12% of HIV-infected patients with invasive pulmonary aspergillosis. Definitive diagnosis often requires lung biopsy, but patients may be too ill to undergo this invasive procedure. Amphotericin B remains the treatment of choice.
References: Franquet T, Muller NL, Gimenez A, Guembe P, de La Torre J, Bague S. Spectrum of pulmonary aspergillosis: histologic, clinical, and radiologic findings. Radiographics. 2001;21:825-837
Keywords: Lung, Airway, Infection, Fungal infection,

No. of Applicants : 37

▶ Correct Answer : 19/37, 51.4%

- Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
- Hopital Calmette CHRU, Lille, France Toledano Manuel
- National Taiwan University Hospital, Taiwan Yu-Feng Wei
- MYH, Indore, India Sonali Jain
- Cabinet de Radiologie Guiton, La Rochelle, France Jean-Luc Bigot
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee
- Pusan National Univeristy Hospital, Korea Kun-Il Kim
- EKH Berlin, Germany Michael Weber
- Annecy Hospital, France Gilles Genin
- Diskapi Yildirim Beyazit Hospital, Ankara, Turkey Meric Tuzun
- Radiologie Guiton, La Rochelle, France Denis Chabassiere
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Sam Anyang Hospital, Korea Jae Seung Seo
- Yonsei University Shinchon Severance Hospital, Korea Chung Yong Eun
- Yonsei University Shinchon Severance Hospital, Korea Hye-Jeong Lee
- China Medical University Hospital,Taiwan Jun-Jun Yeh
- Pgimer, Chandigarh, India Ashish Gupta
- Apollo FirstMed Hospital, Chennai, India R G Gopinath
- Ultra Care, Coimbatore, India Debabrata Das

▶ Correct Answer as Differential Diagnosis : 6/37, 16.2%

- Mackay Memorial Hospital, Taipei, Taiwan Tsai Chia-Fu
- Seoul National University Hospital, Seoul, Korea Chang-Hoon Lee
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Annecy Hospital, France Bing Fabrice
- Max Hospital, New Delhi, India Vickrant Malhotra
- Pgimer, Chandigarh, India Ram Prakash Galwa

▶ Semi-Correct Answer : 5/37, 13.5%

- Consultant Radiologist, Vizag, India S Pipavath
- Kashan Shahid Beheshti Hospital, Kashan, Iran Ebrahim Razi
- Nirman Hi-tech Diagnostic Center. Mumbai, India Minal Seth
- Seoul National University Hospital, Seoul, Korea Se -Yeong Chung
- Seoul National University Hospital, Seoul, Korea Young Soon Yoon

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 441 Date 2006-04-10

Discussion

No. of Applicants : 37