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Imaging of thoracic aspergillosis
Prof. G FERRETTI CHU GRENOBLE
HANOI, NOV 2015
Aspergillus diseases
• Aspergillus species (A fumigatus) • saprophyAc, aerobic fungus that develops on dead or decaying organic maNer and produces airborne spores that can be inhaled by man
• Four presentaAons according to clinical presentaAon and state of immunity ü Hypersensi0vity reac0on (ABPA) ü Aspergilloma ü Semi-‐invasive (chronic necro0zing) aspergillosis ü Invasive aspergillosis Angioinvasive vs. Airway-‐invasive
Godet C Respira0on 2014;88:162-‐174
1-‐ Allergic bronchopulmonary
aspergillosis (ABPA) Secondary to anAgens released by Aspergillus fumigatus that colonizes the tracheobronchial tree Pathogenesis : Aspergillus-‐specific IgE-‐mediated Type I hypersensiAvity reacAon / specific IgG-‐mediated Type III hypersensiAvity reacAons Progressive disease with
– recurrent exacerbaAons – bronchiectaAc changes – end-‐stage fibrosis
• Under diagnosed disease • Early diagnosis and treatment prevents its progression and alleviate its
clinical manifesta0ons. • High resolu0on CT of the chest has emerged as a promising inves0ga0on
for its diagnosis. DW Denning, Clin Transl Allergy. 2014
Clinical presentaAon
• Common contribuAng factor: – asthma (the most frequent) – cysAc fibrosis – other underlying bronchiectaAc diseases
• ABPA occurs in 0.25%-‐11% of paAents with asthma Novey JS. Epidemiology of allergic bronchopulmonary aspergillosis. Immunol Allergy Clin North Am.
1998;18:641-‐53.
• Poorly controlled asthma, hemoptysis, weight loss and fever.
Morgan J, Med Mycol, 2005
ABPA Central bronchiectasis with predilecAon for
upper and middle lobes (78%)
ABPA with recent exacerba>on
70 yo man ABPA recent exacerbaAon Tree in buds Dense mucocele which is specific for ABPA
56 yo man, COPD, asthma, acute exacerbation
10
Imaging presentaAon • Diagnosis of APBA is frequently missed on chest X ray which is normal in almost 50% of the cases
Agarwal R, et al. Pictorial essay: Allergic bronchopulmonary aspergillosis. Indian J Radiol Imaging. 2011 Oct-‐Dec; 21(4): 242–52.
• HRCT May be normal (23%) • Abnormal HRCT scan
– Central bronchiectasis with predilecAon for upper and middle lobes (78%)
– Centrilobular nodules with or without linear opaciAes (tree in bud paNern): 86%
– Mucoceles: 59% – High-‐aSenua0on mucus: 36% of cases calcium salts and metals (iron and manganese) or desiccated mucus
2-‐Aspergilloma or Saprophy0c aspergillosis
• Aspergillus infecAon without Assue invasion • leads to conglomeraAon of fungal hyphae admixed with mucus and cellular debris within a preexistent pulmonary cavity or ectaAc bronchus
• ComplicaAon of Tuberculosis / sarcoidosis IV / bronchectasis / pneumatocele
• The most common symptom is hemoptysis • The source of bleeding: bronchial arteries or anastomoAc communicaAons between pulmonary and bronchial arteries associated with the aspergilloma.
History of tuberculosis
HIV+ paAent History of aspergilloma since 2005
Early aspergilloma Pleural thickening
Imaging Aspergilloma
• CXR / CT – ovoid or round opacity located within a lung cavity – localized pleural thickening best appreciated on CT – crescent of air around the mycetoma: separaAon of the fungal mass from its surrounding cavity wall
– posi0onal changes of the intra-‐cavitary mass during imaging may indicate its mobility within the cavity.
Stage IV sarcoidosis Occurrence of hemoptysis
Aspergilloma Bronchial artery
embolisation
3-‐ Chronic Pulmonary Aspergillosis: significa0on
Due to existence of overlapping clinico-‐radiologic phenotypes that may follow variable courses, the term ‘CPA’ may be used to encompass:
ü simple aspergilloma ü CCPA (chronic cavitary pulmonary aspergillosis) ü CFPA (chronic fibrosing pulmonary Aspergillosis) ü CNPA (chronic necroAsing pulmonary aspergillosis) being classified as a sub-‐acute form of IPA
Affects individuals with non-‐systemic or mildly systemic immunodepression or altered pulmonary integrity due to underlying disease. All paAents share the clinical presentaAon: weight loss, fa0gue and chronic cough, +/-‐ chest pain and hemoptysis lung parenchyma alteraAons results mostly from the lung immune/inflammatory response against Aspergillus spp. rather than from direct invasion by the fungi CPA generally requires long-‐term an0fungal treatment . High morbidity and mortality.
Chronic pulmonary aspergillosis (CPA)
Franquet T Radiographics 2001; 21: 825–837.
35 yo man sere pneumonia in 2014. absence of cavity but progressive destrucAon of the LUL
Dg: CPA
CPA in a 50-‐year-‐old paAent. A large cavity filled with a typical fungus ball surrounded by an air crescent is seen in a partly collapsed lel upper lobe. The pleura are thickened and the remaining lel lung shows distorAon features.
Role of CT Scan Imaging in CPA Diagnosis • CT provides useful informaAon regarding 1/ the characterisAcs, 2/ distribuAon
3/extent of features Kim SY AJR 2000; 174: 795–798.
Franquet T Radiographics 2001; 21: 825–837. • CT findings of CPA are non-‐specific and can be encountered in TB,
ac0nomyosis and lung carcinoma.
• In a proper clinical seZng, the diagnosis of CPA can be suggested on CT – unilateral or bilateral areas of consolida0on, frequently with one or several cavita0ons containing fungus balls in about 50% of cases (most frequent)
– thickening of the walls of cavitaAon and pleura – areas of consolidaAon or of ground glass aNenuaAon in the surroundings.
– pulmonary nodules of varying sizes may be present (tree-‐in-‐bud sign)
– LocalizaAon: upper lobes, that frequently appears collapsed
Soubani AO, Chest 2002; 121: 1988–1999.
Chronic pulmonary consolida0on in the right upper lobe Pa0ents with COPD, diabetes and alcoholism Diagnos0c: trans thoracic biopsy and then surgery
CPA
75 yo woman chronic lung parenchyma consolida0on with cavita0ons Severe altera0on of general state Diabetes mellitus
Mucormycosis
15 10 2012
28 02 2012 Lung adenocarcinoma
Differen0al diagnosis
• Differen0al diagnosis – TB, non-‐TB mycobacterial infecAon, histoplasmosis coccidiomycosis…
– lung cancer, rheumatoid arthriAs, sarcoidosis • Before considering the treatment of probable CPA and in the absence of absolute diagnos0c criteria for CPA, it seems necessary to eliminate the diagnosis of lung cancer or other associated infecAons by any means (repeated biology, bronchoscopy, CT)
Denning DW Clin Infect Dis 2003; 37(suppl 3): S265–S280.
Role of bronchial embolisa0on
• Hemoptysis is the cause of death in up to 26% of paAents with condiAons including aspergilloma and complex aspergilloma/CPA
• BAE achieves immediate control of hemoptysis in 91.6% of aspergilloma paAents within 24 h
• Any paAent with even minimal hemoptysis should be promptly invesAgated by CTA + BAE
Stevens DA Clin Infect Dis 2000; 30: 696–709.
4-‐ Invasive aspergillosis • affects mainly the lungs • is an important cause of mortality and morbidity in paAents with – hematologic malignancies (prolonged neutropenia) (<25%) – recipients of allogeneic hematopoieAc stem cell transplants (<10%) – prolonged use of corAcosteroids and/or T-‐cell immunosuppressants
• The diagnosis is difficult to make: – Assue specimen (rarely obtained) – associa0on of a host factor, lung CT findings, and microbiologic findings either direct tests (such as direct microscopy or culture) or indirect tests (such as galactomannan an0gen [GM] or β-‐D glucan)
CT scanning: a cornerstone • nodule with a halo sign: highly suggesAve of IPA in
neutropenic pa0ents Caillot D et al. J Clin Oncol. 2001;19(1):253-‐ 259.
• liNle is known about CT scan features in non-‐neutropenic pa0ents: up to 40% of paAents with IPA do not present with a nodule with a halo sign.
Greene R. Med Mycol. 2005;43(supl 1): S147-‐S154.
• 2 different pa7erns of IPA
– angioinvasive pulmonary aspergillosis is characterized by vascular invasion by Aspergillus and a nodule with a halo sign
– airway-‐invasive aspergillosis is characterized by the destrucAon of the bronchiolar wall by Aspergillus and centrilobular micronodules and tree-‐in-‐bud opaciAes (14% to 34% of cases of IPA)
Franquet T et al. J Comput Assist Tomogr. 2004;28(1):10-‐16.
• Angioinvasive. Histology of a nodule with a halo sign demonstrates occlusion of arteries by plugs of hyphae and the subsequent development of infected pulmonary infarcts: poor mycologic diagnos0c yield
angioinvasive bronchoinvasive
• Bronchoinvasive. Histologic examinaAon of airway-‐invasive aspergillosis shows colonies of Aspergillus invading through bronchiolar walls together with peribronchiolar inflammaAon: high performance of mycologic examina0on
Franquet T et al. J Comput Assist Tomogr. 2004;28(1):10-‐16.
halo sign strongly suggests angioinvasive aspergillosis when it occurs in a patient with neutropenia who is receiving cytotoxic therapy and broad-spectrum antibiotic, but non specific (candidiasis, CMV, Kaposi sarcoma)
55 yo man – acute leukemia under chemotherapy. Chest pain and liNle fever
Follow-up CT scan in the same patient with angioinvasive aspergillosis
à J15
à J30
Clinical InfecAous Diseases 2011;52(9):1144–1155
16 10 2013
22 10 2013
Bronchoinvasive Aspergillosis • 3 types
Ø obstrucAve, Ø ulceraAve Ø Pseudomembranous
• co-‐exisAng presentaAon++
• Neutropenia and systemic immunosuppression are major risk factors
• increasing frequency among lung transplant recipients and paAents with chronic auto immundiseases, acquired immune deficiency syndrome (AIDS) and malignancy
• 62 yo man • Recent faAgue weigh loss anorexia • Fever • Cough • acute respiratory distress… ICU
Aspergillus tracheobronchiAs
• Symptoms may be non-‐specific including cough in the majority, dyspnoea, blood-‐stained sputum, night sweats, fever and wheeze which may be asymmetric.
• Radiographic findings include endo-‐bronchial sol Assue thickening, obstrucAon and tracheobronchial stenosis leading to segmental or subsegmental lobar collapse
• Bronchoscopic examinaAon and mucosal biopsy is essenAal for accurate diagnosis. Macroscopic findings include luminal obstrucAon, mucosal ulceraAon and exudaAve pseudomembranes adherent to the underlying mucosa while microscopic demonstraAon of fungal elements is both sensiAve and specific for Aspergillus tracheobronchiAs and allows a confident diagnosis to be made
Conclusion • Imaging plays an important role in aspergillus related diseases
• Always remember that imaging is dependent on clinical presenta0on and state of immunity o Hypersensi0vity reac0on (ABPA) o Aspergilloma o Semi-‐invasive (chronic necro0zing) aspergillosis o Airway-‐invasive aspergillosis o Angioinvasive aspergillosis
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