CME INDIA Case Presentation by Dr. Nishith Kumar (Pulmonary Medicine), FAPSR, Consultant Respiratory Medicine & Interventional Pulmonology, Orchid Medical Centre, Ranchi.
CME INDIA Case Study
History
- 60yr/Female, uncontrolled T2DM with Cough, Fatigue, mild fever x 2 weeks.
- COVID-Negative.
- What the chest X-ray and CT scan suggests?
CT Scan of Thorax
CT Scan Thorax Report:
CME INDIA Discussion
Dr. Himalaya Jha, CMO, CGHS, Ranchi:
- Uncontrolled Diabetes.
- Thick Wall Multiple cavities.
- Old age.
- TLC of WBC – Neutropenia? ESR? Lymphadenopathy?
- Mass Within cavity.
D/D
- Pulmonary Tuberculosis.
- Mucor mycosis.
- Squamous cell carcinoma.
- Pulmonary emboli? (But there is no history of Breathlessness)
Investigations Required:
TLC and DLC – Neutropenia
- History of Cytotoxic therapy
- Any immunosupressant use .
- Rhino cerebral involvement,more in mucormycosis.
- Positive fungal culture and Microscopic examination.
- Positive Galactomannan, more in IPA than mucormycosis.
- BAL Galactomannan
- CT Thorax and CT PNS with Brain
Additional – Sputum for AFB, CBNAAT, Blood Sugar.
Dr. Harish Moorjani, Hudson, USA:
- If not tuberculosis or MOTT, then actinomycosis, fusobacterium or Pepto streptococcus.
- Aetiology of acute lung abscesses can be determined by appropriate cultures.
Dr. Nishith Kumar, Ranchi:
Now Checkout the Bronchoscopy findings:
Partially obstructed lower lobe segmental opening with greyish white mucoid material which is adhered to endobronchial mucosa
Endobronchial Biopsy-Turned out to be a case of Mucormycosis.
Dr. N. K. Singh:
- How treated?
Dr. Nishith Kumar, Ranchi:
- IV Liposomal Amphotericin B + Posaconazole + glycaemic control.
Clinical Pearls
- If you look at the radiology, the feature is suggestive of bird’s nest sign which refers to the appearance created by a reverse halo sign with associated irregular and intersecting areas of stranding or irregular lines within the area of ground glass opacity.
- Bird’s nest sign is suggestive of invasive pulmonary fungal infection (e.g., Angio invasive aspergillus or Mucor mycosis) in susceptible patient populations.
CME INDIA Learning Points
The reverse halo and bird’s nest signs may also be seen in:
| Cryptogenic organizing pneumonia |
| Bacterial pneumonia |
| Paracoccidioidomycosis |
| Tuberculosis, sarcoidosis |
| Wegener granulomatosis |
| Pulmonary infarction |
Mucormycosis vs Aspergillosis
How to distinguish mucormycosis from aspergillosis?
Considering that voriconazole is not effective against mucormycosis, we must distinguish between mucormycosis and aspergilolosis.
Features favoring mucormycosis over aspergillus infection in a neutropenic patient
| Bird’s nest sign |
| >10 pulmonary nodules |
| Pleural effusion |
| Concomitant sinusitis and development of infection despite voriconazole prophylaxis |
CME INDIA Tail Piece
At a glance, Classic Signs and Patterns in Pulmonary Infection:
| Consolidation and Air Bronchogram Sign | With fever and cough, this sign suggests the diagnosis of pneumonia. |
| Silhouette Sign | This sign usually seen when the interface between the lungs and the heart, mediastinum, chest wall, and diaphragm occurs. Eg. – Consolidation. |
| Tree-in-Bud Sign | The tree-in-bud sign is an imaging manifestation of various infections caused by bacteria, fungi, parasites, and viruses. |
| Bulging Fissure Sign | Classically associated with right upper lobe consolidation It is due to Klebsiella pneumoniae or any form of pneumonia can manifest the bulging fissure sign. Also, frequently seen in patients with pneumococcal pneumonia. |
| Feeding Vessel Sign | Apart from Septic emboli, it could be seen in other conditions, like metastasis, arteriovenous fistula, and pulmonary vasculitis |
| Inhomogeneous Enhancement Sign and Cavitation | CT detection of inhomogeneous enhancement and cavitation suggests the presence of necrotizing infection. |
| Air-Fluid Level Sign | In a patient with pneumonia, detection of an air-fluid level on chest radiographs or CT images suggests the presence of a lung abscess or empyema with bronchopleural fistula. |
| Split-Pleura Sign | Consider Empyema. |
| Halo Sign | CT finding of a peripheral rim of ground-glass opacity surrounding a pulmonary nodule or mass. If detected in a febrile patient with neutropenia, this sign is highly suggestive of angio-invasive Aspergillus infection. |
| Air Crescent Sign of Angioinvasive Aspergillus Infection | It is the CT finding of a crescentic collection of air that separates a nodule or mass from the wall of a surrounding cavity. |
| Air Crescent or Monad Sign of Mycetoma | The air crescent sign of mycetoma is also referred to as the Monad sign. It is seen in an immunocompetent host with pre-existing cystic or cavitary lung disease, usually from tuberculosis or sarcoidosis |
| Finger-in-Glove Sign | The finger-in-glove sign is the chest radiographic finding of tubular and branching tubular opacities. It appears to emanate from the hila, said to resemble gloved fingers. The finding is classically associated with allergic bronchopulmonary aspergillosis (ABPA). |
| Crazy-Paving Sign | It is the CT finding of a combination of ground-glass opacity and smooth interlobular septal thickening that resembles a masonry pattern used in walkways. It is a characteristic CT pattern detect- ed in patients with pulmonary alveolar proteinosis. |
| Grape-Skin Sign | It is the radiographic or CT finding of a very thin-walled cavitary le- sion that develops in lung parenchyma previously affected by consolidation or lung granulomas that have undergone central ca- seous necrosis. |
| Reverse Halo and Bird’s Nest Signs | The reverse halo sign is the CT finding of peripheral consolidation surrounding a central area of ground-glass opacity. When associated irregular and intersecting areas of stranding or irregular lines may be present within the area of ground-glass opacity, it could be evident as the bird’s nest sign. It suggests Invasive fungal infection. |
| Meniscus, Cumbo, and Water Lily sign | Signs of Echinococcal Infection. |
| Burrow Sign of Paragonimiasis | Paragonimiasis is a zoonotic parasitic infection caused by lung flukes. |
References:
- Mucormycosis in a 40-year-old woman with diabetic ketoacidosis Lauren Thomas et al., CMAJ, 2020
- Mucormycosis presenting with dental pain and palatal ulcer in a patient with chronic myelomonocytic leukaemia: case report and literature review Ourania Nicolatou‐Galitis et al., JMMCR, 2015
- https://radiopaedia.org/articles/birds-nest-sign-lungs
- https://www.ajronline.org/doi/pdf/10.2214/AJR.13.11463
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