CME INDIA Case Presentation by Dr. Nishith Kumar (Pulmonary Medicine), FAPSR, Consultant Respiratory Medicine & Interventional Pulmonology, Orchid Medical Centre, Ranchi.

CME INDIA Case Study


  • 60yr/Female, uncontrolled T2DM with Cough, Fatigue, mild fever x 2 weeks.
  • COVID-Negative.
  • What the chest X-ray and CT scan suggests?
The Reverse Halo and Bird’s Nest Signs in Radiology Are Not Specific

CT Scan of Thorax

The Reverse Halo and Bird’s Nest Signs in Radiology Are Not Specific

CT Scan Thorax Report:

The Reverse Halo and Bird’s Nest Signs in Radiology Are Not Specific

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.


  • 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.

The Reverse Halo and Bird’s Nest Signs in Radiology Are Not Specific

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
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 SignThis sign usually seen when the interface between the lungs and the heart, mediastinum, chest wall, and diaphragm occurs. Eg. – Consolidation.
Tree-in-Bud SignThe tree-in-bud sign is an imaging manifestation of various infections caused by bacteria, fungi, parasites, and viruses.
Bulging Fissure SignClassically 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 SignApart from Septic emboli, it could be seen in other conditions, like metastasis, arteriovenous fistula, and pulmonary vasculitis
Inhomogeneous Enhancement Sign and CavitationCT detection of inhomogeneous enhancement and cavitation suggests the presence of necrotizing infection.
Air-Fluid Level SignIn 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 SignConsider Empyema.
Halo SignCT 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 InfectionIt 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 MycetomaThe 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 SignThe 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 SignIt 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 SignsThe 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 ParagonimiasisParagonimiasis is a zoonotic parasitic infection caused by lung flukes.


  1. Mucormycosis in a 40-year-old woman with diabetic ketoacidosis Lauren Thomas et al., CMAJ, 2020
  2. 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

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