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 ID: 784815
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Slide1
CH4
Slide2Pulmonary
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.
INTRODUCTION
Slide3Show the interest of the scanner in the diagnosis of pulmonary
aspergillosis
.
Show radiological aspects of different forms.
Underpin suggestive radiological aspects.
OBJECTIVES:
Slide4BACKGROUND
Pulmonary aspergillosis is a mycotic infection caused most of the times by A
spergillus 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).
Slide5MATERIALS 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.
Slide6Various underlying lung diseases
:
RESULTS:
COPD: chronic obstructive pulmonary disease
Slide7RESULTS:
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.
Slide8RESULTS:
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.
Slide9Prone
Supine
Saprophytic
aspergillom
. Supine (a)and prone (b) MDCT scans with lung windows show a gravity dependent
intracavitary
mass
a
b
a
b
Slide10C
A
B: Bronchoscopic image shows elevated whitish nodular lesions in the trachea consistent with endobronchial growth of Aspergillus
B
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.
D
A: Sagittal view shown two right upper lobe
aspergillomas
associated with bronchiectasis
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
Slide11RESULTS:
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.
Slide12RESULTS:
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
.
Slide13Chest radiography:
CT:
Postero
anterior radiographs chest shows Upper lobe opacity surrounded by air crescent
:
fungus
ball
within
a
cavity
.
a
b
c
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 «
^
».
*
^
Slide14RESULTS:
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
.
Slide15RESULTS:
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.
Slide16RESULTS:
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.
Slide17Fig 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
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.
Fig B: High-resolution CT showing central bronchiectasis in ABPA.
The patient has had a previous left upper lobectomy for severebronchiectasis.
A
B
C
Slide18RESULTS:
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.
Slide19RESULTS:
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.
Slide20A
B
C
D
Fig A: Posteroanterior chest radiograph shows area
of air-space consolidation in the right upper lobe
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”. .
The diagnostic of CNPA
is
made after
positive
sputum
culture for
Aspergillus
.
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.
Slide22RESULTS:
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
.
Slide23RESULTS:
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
.
Slide24RESULTS:
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
.
Slide25RESULTS:
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.
Slide26IPA 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
« .
Slide27CONCLUSION:
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.
Slide28Bibliography
:
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Pulmonary aspergillosis; a spectrum of CT findings. ECR 2012: 1-22.
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The protean radiological appearances of pulmonary
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