Case 12
History
41-year-old male status post renal transplant.
PA chest radiograph shows multiple poorly defined
nodules, more numerous on the right.
Follow-up chest film two weeks later shows increasing
size and number of cavitating nodules with thick walls
(1 cm).
Diagnosis
Cavitary Aspergillus.
Findings
Aspergillus Fumigatus, a rare cause of primary pneumonia in the general population, plays a major role in the immunocompromised group. The pulmonary Aspergilloses are a spectrum of diseases ranging from bronchopulmonary Aspergillosis in the hyperimmune host (asthmatics) through pulmonary mycetoma formation in lung cavities of patients with normal immune status, or invasive pulmonary Aspergillosis in the immunocompromised host. The latter is pathologically characterized by mycotic vascular invasion, thrombosis, and infarction, leading to necrosis and cavitation. The seeding to the lung can occur from innoculation via the airway, which is usually a more localized form resembling bronchopneumonia, or from the blood stream, which gives a more disseminated pattern.
Radiographically it can present initially with single or multiple areas of rounded pneumonia. Cavitation is common. The earliest sign of cavitation can be seen anywhere between seven to 28 days from the initial presentation and is often referred to as the “air crescent sign,” which is a lucent, semi-lunar defect within the nodules or area of rounded pneumonia. Disseminated invasive Aspergillosis can arise denovo or be a complication of the localized form of bronchopneumonia.
Patients clinically present with fever, dyspnea, and nonproductive cough. Pleuritic chest pain, sinus tenderness, epistaxis, and nasal discharge often are useful clues to the diagnosis. Hemoptysis is a rare complication, but is seen at a stage with cavitary formation.
