CH4

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CH4
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INTRODUCTION

• Pulmonary aspergillosis is a hot topic.
• These infections are not unusual, especially in
  the context of chronic obstructive pulmonary and
  immune depressed about.
• The diagnosis can be strongly evoked in front of
  several radiological imaging.
• CT is more sensitive than plain films in the
  detection of occult or small lesion and more
  accurate in delineating the extent of disease and
  number of aspergillomas.
• Confident diagnosis is difficult, it is based on
  cytological and histological.

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OBJECTIVES

• Show the interest of the scanner in the
  diagnosis of pulmonary aspergillosis.
• Show radiological aspects of different forms.
• Underpin suggestive radiological aspects.

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BACKGROUND

• Pulmonary aspergillosis is a mycotic infection
  caused most of the times by Aspergillus
  Fumigatus, an ubiquitous soil fungus acquired by
  inhaling its spores.
• When we talk about aspergillosis we are referring
  to a spectrum of radiologic and clinical
  manifestations that depend directly of the
  immunological state of the patient and the
  virulence of the organism.
• We can distinguish 4 types of pulmonary
  aspergillosis.
• Aspergilloma (saprophytic aspergillosis)
• Allergic bronchopulmonary aspergillosis (ABPA)
• Semi-invasive or chronic necrotizing
  aspergillosis
• Invasive aspergillosis (which can be divided
  into airway invasive and angioinvasive forms).

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MATERIALS AND METHODS

• A retrospective study involving 30 patients
  collected for department of radiology and lung
  diseases over 3 years.
• Median age is 41 years (22- 67 years).
• Chest CT scan was performed without injection of
  contrast and fine reformatted reconstructions in
  all patients. Bell in front of a picture, another
  acquisition in the prone position was performed.
  Histological confirmation was performed in all
  patients.

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RESULTS
Various underlying lung diseases
COPD chronic obstructive pulmonary disease
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RESULTS

• radiographic and CT findings were abnormal in all
  patients.
• A preoperative diagnosis of aspergilloma
  considering
• Their radiological examination in 20 cases.
• Radiological examination and isolation of
  Aspergillus fumigatus, in the bronchial aspirate
  in 2 cases.
• A postoperative diagnosis of aspergilloma in 8
  cases.

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RESULTS

• The spectrum of CT finding were
• Aspergilloma with air crescent sign in 7
  cases.
• Bronchectasis in 4 cases.
• Chronic consolidation in 15 cases.
• Multiples nodules with progressive cavitation 18
  cases.
• Hydropneumothorax in 2 cases.
• Abcess in 1 case.
• Lung destruction in 3 cases.

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Supine
a
a
Prone
b
b
Saprophytic aspergillom. Supine (a)and prone (b)
MDCT scans with lung windows show a gravity
dependent intracavitary mass
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C
D
C axial CT shows Aspergilloma in 55 years old
women identified air crescent upper lobe
associated to a segmental area of consolidation
surrounded by areas of ground-glass attenuation
A
D axial CT shows a consolidation in the right
lower lobe with a central area of Cavitation, the
diagnosis of aspergilloma was considered, post
opératory diagnosis was lung carcinoma.
A Sagittal view shown two right upper lobe
aspergillomas associated with bronchiectasis
B Bronchoscopic image shows elevated whitish
nodular lesions in the trachea consistent with
endobronchial growth of Aspergillus
B
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RESULTS

• Aspergilloma
• Aspergillus infection in immunocompetent host.
• The most common underlying causes Tuberculosis,
  Sarcoidosis, Emphysema, Bronchiectasis,
  Pneumoconiosis, Fibrotic lung disease, Neoplasm,
  Pulmonary infarction, Bronchogenic cyst,
  Pulmonary sequestration and Pneumatoceles
  secondary to Pneumocystis jirovecii pneumonia.
• single, or multiples ones and it occurs
  predominantly in the upper lobes.
• Clinical manifestation of aspergilloma is
  hemoptysis.

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RESULTS

• Aspergilloma
• Chest radiographs and CT scans show
• A lung cavity containing a solid rounded mass
  which is separated from the wall by a rim of air.
  This feature is called the "air crescent"sign.
• Another common feature is the thickening of the
  cavity wall and the adjacent pleura.
• This fungus ball may be mobile.
• The differential diagnosis
• Hematoma.
• Neoplasm.
• Abscess, Hydatid cyst.
• Wegener granulomatosis.

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Chest radiography
Postero anterior radiographs chest shows Upper
lobe opacity surrounded by air crescent fungus
ball within a cavity.
CT


a
c
b
Chest CT  a  axial  b  coronal shows a
fungus ball within cavity air cresecent
Surrounded this cavity, the Chest CT shows also
bronchiesctasis   associated and
multiples basal centrilobular nodules   .
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RESULTS

• Allergic bronchopulmonary aspergillosis (ABPA)
• Characterized by the presence of fleeting dense
  plugs of mucus, hyphaes and eosinophils in lung
  parenchyma due to deposition of immune complexes
  and inflammatory cells within the segmental and
  subsegmental bronchi.
• ABPA represents a hypersensitivity reaction to
  Aspergillus occurring almost exclusively in
  long-standing bronchial asthma patients and
  occasionally as a complication of cystic fibrosis.

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RESULTS

• Allergic bronchopulmonary aspergillosis (ABPA)
• Clinically wheezing, cough and fever.
• Eosinophilia and elevated serum IgE levels are
  typically found and they can suggest the
  diagnosis.
• Initial radiologic manifestations
• Transitory pulmonary opacities (deposition of
  immune complexes and inflammatory cells in the
  alveoli).
• An irreversible damage occurs to the bronchi with
  dilatation, wall thickening and mucus plugging.
• CT findings tubular or saccular finger-in-glove
  areas of increased opacity in a bronchial
  distribution representing mucus plugging within
  bronchiectasis, predominantly involving the upper
  lobes.

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RESULTS

• Allergic bronchopulmonary aspergillosis (ABPA)
• The diagnosis is made by a combination of
  criteria
• Episodic asthma exacerbations.
• Transient or fixed pulmonary infiltrates.
• Central bronchiectasis.
• Peripheral blood eosinophilia.
• Elevated serum IgE levels.
• Positive Aspergillus precipitins.

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Fig B High-resolution CT showing central
bronchiectasis in ABPA. The patient has had a
previous left upper lobectomy for
severe bronchiectasis.
B
Fig C High-resolution CT in the same patient as
in Fig A, showing peribronchial thickening and
apparent nodular opacities in the lower lobes due
to bronchiectasis with mucoid impaction.
A
Fig A A pulmonary artery chest radiograph
showing branching finger-in-glove tubular
opacities in the left lower lobe
(retrocardiac) due to mucus plugging of ectatic
bronchi in ABPA
C
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RESULTS

• Chronic necrotizing pulmonary aspergillosis
  (CNPA) or semi-invasive aspergillosis
• Local and more indolent form of invasive
  pulmonary aspergillosis.
• Patients with a chronic disease that predispose
  them to infection.
• Histologically Presence of tissue necrosis and
  granulomatous inflammation similar to that seen
  in reactivated tuberculosis.

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RESULTS

• Chronic necrotizing pulmonary aspergillosis
  (CNPA) or semi-invasive aspergillosis
• Clinically Chronic productive cough or with
  hemoptysis, which varies from severe to trivial.
• Radiologically
• chronic consolidation.
• Multiples nodules with progressive cavitation in
  one or both upper lobes.
• Non-specific, most commonly mimicking
  those of mycobacterial infection.
• lesions are more peripheral, associate pleural
  thickening and mayprogress to form a
  bronchopleural fistula.

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B
A
Fig A Posteroanterior chest radiograph shows
area of air-space consolidation in the right
upper lobe
C
MDCT scan show a focal areas of consolidation
and nodules surrounded by an halo of ground-glass
attenuation fig B one month after MDCT scan
shows the evolution of the lesion which have
increased in size and show a central area of
cavitation Fig C and D. .
D
The diagnostic of CNPA is made after positive
sputum culture for Aspergillus.
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RESULTS

• Invasive pulmonary aspergillosis (IPA)
• Mortality of up to 85.
• Occurs in severe immunocompromised patients,
  especially in those with neutropenia due to
  hematologic malignancies, chemotherapy or
  immunosuppressive therapy.
• Depending on the route of spread we can discern
  two kinds of invasive aspergillosis
• Angioinvasive.
• Airway invasive.
• which can even coexist in the same patient.
  However,
• this is just a histological and etiopathogenical
  distinction as, in the clinical practice, this is
  not relevant for therapy.

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RESULTS

• Invasive pulmonary aspergillosis (IPA)
• Angioinvasive aspergillosis
• Is histologically characterized by invasion of
  small to medium-sized vessels by fungal hyphae.
  This results in thrombus formation and vascular
  occlusion with the consequent tissue necrosis and
  systemic dissemination.
• CT scans shows
• Early IPA Small nodules and/or small
  pleuralbased,wedge-shaped consolidations with a
  surrounding halo of ground-glass attenuation
  (halo sign). The halo sign represents alveolar
  hemorrhage.
• As the disease progresses the nodules may
  cavitate, the necrotic parenchyma detaches from
  the adjacent lung forming an air crescent similar
  to that seen in aspergilloma.

In the right clinical context, nodules
or consolidations surrounded by a ground-glass
halo, progressing to cavitation or air crescent
formation are considered typical of angio
invasive aspergillosis .
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RESULTS

• Invasive pulmonary aspergillosis (IPA)
• Invasive aspergillosis of the airways
• 14-34 of cases of invasive aspergillosis.
• Includes bronchitis and bronchiolitis,
  bronchopneumonia and lobar pneumonia without
  evidence of vascular invasion.
• Surrounding the involved airway there is often a
  variably sized zone of hemorrhage and/or
  organizing pneumonia.

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RESULTS

• Invasive pulmonary aspergillosis (IPA)
• Invasive aspergillosis of the airways
• In the majority of cases, radiographic findings
  of invasive aspergillosis of the airways appear
  as
• Patchy peribronchial consolidation.
• Centrilobular nodules.
• Areas of tree-in-bud pattern.

These features are non-specific and are
indistinguishable from those of bronchopneumonia
caused by other microorganisms.
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RESULTS

• Invasive pulmonary aspergillosis (IPA)
• Invasive aspergillosis of the airways
• This uncommon manifestation affects almost
  exclusively lung transplant recipients and AIDS
  patients.
• Patients experience cough, dyspnea and hemoptysis
  but they can also be asymptomatic.
• CT scans are usually normal sometimes a
  non-specific tracheal wall thickening is the only
  evident finding.
• Bronchoscopy and fungal culture of the sputum
  proportionate a definitive diagnosis.

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IPA in a patient with cervix carcinoma and severe
neutropenia (20 neutrophils/mm3) after
chemotherapy. MDCT scan demonstrates bilateral
multiple ill-defined nodules with peripheral
ground-glass attenuation (a-b) and a segmental
area of consolidation in the posterior segment of
the middle lobe also surrounded by areas of
ground-glass attenuation  .
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CONCLUSION
Computed tomography has become a key
consideration in the diagnosis of pulmonary
aspergillosis and this in front of suggestive
radiological aspects. It also determines the
therapeutic.
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