Date: 21 January 2014
The chest is distorted by a deformity of the back and ribs.
Copyright: n/a
Notes:
This patient’s X-ray is complex. The chest is distorted by a deformity of the back and ribs. Substantial metalwork following a spinal fusion is in place to support the vertebral column and part of this overlies the heart and part of it crosses the left lung. The patient also has a portacath device in-situ over the right lung, which allows i.v. antibiotics to be given. A needle is in-situ inside the portacath device. An external drainage tube is currently in-situ in a large air cavity and left upper thorax. This cavity contains mostly air but there is some fluid with the fluid level at its base. Underneath this large pyopneumothorax is a normal component of left lower lobe. The heart is very substantially moved to the right of the lung because of a previous right lower lobe resection. There is no evidence of aspergillosis on this x-ray as it stands.
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5 sputum samples were positive for A. niger, a bronchoscopy was normal and culture and microscopy were negative. Rx voriconazole, 200mg bd was given. An excellent clinical response was seen.
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The patient was a 37-year old man in whom P.carinii pneumonia developed in August 1987, followed by esophageal candidiasis and upper gastrointestinal bleeding in September. Chronic perineal herpes led to the formation of rectourethral fistula and multiple episodes of urosepsis, for which he was given long-term ciprofloxacin therapy to suppress bacterial colonization of the bladder. He discontinued heavy alcohol use in September 1987 and smoked marijuana occasionally.On April 23 1989, the patient was admitted to the hospital with a two-month history of increasing dry cough with shortness of breath. He reported transient fever (temperature to 41°C). He was admitted with leukopenia, with his neutrophil count falling to 16 x 106/l on the second hospital day. A chest film showed bilateral fluffy lower-lobe infiltrates (this image). Zidovudine was discontinued. The patient had a rapidly downhill course despite intravenous treatment with trimethioprim-sulfamethoxazole. A bronchoscopy on the sixth hospital day revealed what appeared to be a foreign body in the left lower-lobe bronchus. It was removed, together with much necrotic, mucoid debris. On microscopic examination, the “foreign body” was necrotic, containing large numbers of hyphae and conidia in a manner typical of an aspegilloma or fungal cast. The culture grew A.fumigatus.
Clinical and radiologic improvement followed bronchoscopy, and itraconazole therapy was begun because of the concern about invasive aspergillosis in the setting of marked neutropenia. The patient tolerated the medication well at a dose of 200 mg twice daily, and the chest film became normal over the subsequent six weeks, after which itraconazole was discontinued. A sputum specimen cultured for fungus four weeks after the start of therapy was negative. After the initial improvement with itraconazole, the patient had recurrent urosepsis, associated with dehydration and marked confusion. Nine weeks after the discontinuation of itraconazole, he died of progressive dementia complicated by recurrent pneumonia and sepsis. There was no postmortem examination.
This patient was described (pt 11) and this chest radiograph reproduced in Denning DW, Follansbee S, Scolaro M, Norris S, Edelstein D, Stevens DA. Pulmonary Aspergillosis in the Acquired Immunodeficiency Syndrome. N Engl J Med 1991; 324: 654-662.
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Image A. This 25 year old woman was previously well and presented with a pneumonia of uncertain aetiology. She has infiltrates in right upper-lobe and left middle and lower zones. The diagnosis was later made of chronic invasive pulmonary aspergillosis by bronchoscopy . Subsequently she was diagnosed with adult-onset chronic granulomatous disease with neutrophil function assays.
Image B. CT scan of the thorax just below the carina, showing almost complete opacification of the right lung and marked nodular shadowing around the hilum of the left lung.
Image C. Progression of pulmonary infiltrates are seen seven weeks later, despite administration of amphotericin B.
Image D. CT scan of the thorax above the carina showing near complete opacification of the right lung and multiple discrete nodular shadows in the left lung.
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02/10/09 X -ray shows improvement in appearances from initial presentation with complete chest radiographic resolution by 07/11/2008
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Subacute IPA in rhematoid nodules of the lung. in a patient with rheumatoid arthritis. Histology sections stained with H&E
