CME INDIA Case Presentation by Dr. Sudhir Kumar, MD, DNB DM (Pulmonology). Medical Director at Ramakrishna Chest Hospital, a super speciality centre for chest diseases and respiratory critical care, Patna (Bihar-India). Former Associate Professor and Head of the Department of Chest Diseases at the Indira Gandhi Institute of Medical Sciences in Patna.

CME INDIA Case Study

How Presented?

• 34 yr. male with history of Cold cough and dyspnea on exertion since childhood. ATT for six months, for cough six years back. Presently cough and DOE increased for last ten days.

CXR done: This x-ray is first yet to be reported in literature (All contents are restricted to reuse without permission)

• Xray shows definite evidence of bronchiectasis on right side with doubtful signs of bronchiectasis on left lung along with branching high density thick linear toothpaste shadow in right hilum suggesting mucous impacted in dilated bronchi.

What to suspect now?

• With this history and Xray findings ABPA is suspected. But that is not my point. This x-ray is first yet to be reported in literature showing HAM (High-attenuation mucus) or HDMI (High density mucus impaction).

HAM-A well-recognised and described sign of HRCT LUNGS

This x-ray is first yet to be reported in literature showing HAM

• Usual described radiographic features in the first chest x-ray in cases of ABPA
  • Normal
  • Transient consolidation
  • Nodular
  • Nonhomogeneous opacities
  • Tram lines
  • Toothpaste/finger in glove opacities
  • Fleeting opacities
  • Permanent lines and ring shadows
  • Bronchiectasis
  • Extensive fibrosis
  • HRCT chest findings in ABPA
  • Central bronchiectasis, extensive, usually involving 3 or more lobes
  • Mucus-plugging, usually hypodense,HAM seen up to 20% of patients
  • Atelectasis
  • Area of consolidation
  • Mosaic attenuation due to air trapping

Total IgE was raised in this case

High-resolution computed tomography (HRCT)

• HRCT was done only to prove HAM as per current criterion. Otherwise diagnosis was confirmed. It was also done to prove my suggestion of adding this finding on plain radiography as an alternative to HRCT criteria in select few.

Spirometry of the case

• Not a mandatory criterion for ABPA or Asthma

Highlight of the case

• HAM is not a described and recognised sign in plain chest radiography. It’s a well-recognised and described sign of HRCT LUNGS.
• Therefore, I propose that if a plain chest radiography shows bilateral bronchiectasis and HAM with other criteria satisfying for ABPA, then poor patient should be spared from HRCT criterion for diagnosis of ABPA-CB-HAM (Allergic bronchopulmonary aspergillosis-Central Bronchiectasis-High-attention mucus).
• HAM is missed mostly on plain chest radiography.

CME INDIA Learning Points

• Allergic bronchopulmonary aspergillosis (ABPA) is a well-known pulmonary disorder. It is characterised by a hypersensitivity reaction to Aspergillus spp, involving type I (IgE-mediated) and type III (IgG-mediated) immunologic responses.
• ABPA most commonly encountered in adults before the age of 40 years, with longstanding asthma, that is the most important contributing factor.
• Patients generally experience symptoms of recurrent asthma exacerbations (wheezing, cough and dyspnoea).
• The established major criteria for the diagnosis of ABPA:
  • History of asthma.
  • Immediate skin reactivity to Aspergillus.
  • Elevated total serum IgE (>1000 ng/ml).
  • Elevated ige or igg to Aspergillus.
  • Central bronchiectasis (CB).
• The diagnosis is frequently missed on chest radiographs, since it is normal in almost half of the cases. CT is preferable for its higher sensitivity and specificity.
• The radiological findings consist:
  • Central bronchiectasis (cystic or varicose).
  • Mucoid impaction of underlying bronchiectasis airway.
  • On imaging, it corresponds to tubular branching opacities extending from the hilum with the appearance of “finger in glove,” that may be associated with air-fluid levels in dilated bronchi.
  • Pulmonary collapse may be seen as a consequence of endobronchial mucoid impaction.
• Hyperattenuating mucus on CT scans has been reported as a diagnostic criterion for ABPA – It corresponds as an attenuation superior to 70 Hounsfield Unit (denser than the para-spinal muscles). It is currently attributed to the fungal metabolism by calcium salts and metals (iron and manganese) and desiccated mucus.
• HAM-The occurrence of high attenuation mucoid impaction in ABPA. It was first described by Goyal et al in 1992. Currently, the presence of hyperdense mucus is considered a characteristic, if not a pathognomonic, finding in ABPA. HAM is a specific feature and confirms ABPA as the root cause for bronchiectasis the presence of HAM represents immunological severity and also indicates higher chances of relapse.
• The presence of hyperdense mucous plugging impaction has been shown as a 100% specific criterion of ABPA. It may be considered pathognomonic.

CME INDIA Tail Piece

What is being shown in this CXR?

• Classical “finger in glove sign” – An opacity with lobulated contours in the right mid zone (para-hilar).
• C T correlation – Large cystic and varicose bronchiectasis, almost all distributed centrally in the right upper lobe occluded by mucoid impaction, resulting in bronchocele with the typical “finger in glove” – sign (Mucous plugs of  high density, greater than the soft tissue attenuation).

References

1. Agarwal R, Khan A, Garg M, Aggarwal AN, Gupta D. Chest radiographic and computed tomographic manifestations in allergic bronchopulmonary aspergillosis. World J Radiol 2012; 4(4): 141-150 [PMID: 22590668 DOI: 10.4329/wjr.v4.i4.141]
2. Agarwal R. High attenuation mucoid impaction in allergic bronchopulmonary aspergillosis. World J Radiol 2010; 2(1): 41-43 [PMID: 21160739 DOI: 10.4329/wjr.v2.i1.41]
3. Agarwal R. High attenuation mucoid impaction in allergic bronchopulmonary aspergillosis. World J Radiol 2010; 2(1): 41-43 [PMID: 21160739 DOI: 10.4329/wjr.v2.i1.41]
4. Uma Debi, Muniraju Maralakunte, Lokesh Singh, Mandeep Kumar Garg, Vikas Bhatia, Gita Devi, Anindita Sinha. Revisiting HRCT Features of ABPA. Archives of Clinical and Medical Case Reports 4 (2020): 520-526
5. Prasad Panse, Maxwell Smith, Kristopher Cummings, Eric Jensen, Michael Gotway, Clinton Jokerst,The many faces of pulmonary aspergillosis: Imaging findings with pathologic correlation,Radiology of Infectious Diseases,Volume 3, Issue 4,2016,Pages 192-200,ISSN 23526211,https://doi.org/10.1016/j.jrid.2016.10.002.(https://www.sciencedirect.com/science/article/pii/S2352621116300821)
6. https://www.eurorad.org/case/16497

Discover CME INDIA:

• Explore CME INDIA Repository
• Examine CME INDIA Case Study
• Read History Today in Medicine
• Register for Future CMEs

Get CME INDIA Highlights

Curated articles in your inbox.

SUBSCRIBE!

You have Successfully Subscribed!