IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES Air Crescent Sign Not Caused by Fungal or Tuberculous Infection Jung Yueh Chen and Yu Feng Wei Division of Chest Medicine, Department of Internal Medicine, E-DA Hospital and I-Shou University, Kaohsiung, Taiwan, Republic of China
A 53-year-old man presented with intermittent right-side chest pain and productive cough for 2 years. Initial chest computed tomography (CT) revealed a 3.5-cm heterogenous density mass in the right upper lung and small nodules in the right lower lung, with mediastinal mass and nodules (Figure 1). A bronchoscopic lavage culture was negative, and pathology by CT-guided biopsy only revealed granulomatous inflammation with necrosis. A tissue culture was also negative for tuberculosis or fungus. However, chest CT 1.5 years later showed a lobulated hypodense mass in the right upper lung with new internal cavitation and multiple satellite nodules in the right upper and right lower lung areas (Figure 2). Pulmonary tuberculosis was suspected. Antituberculous agents including isoniazid, rifampicin, ethambutol, and pyrazinamide were administered for 3 weeks but with no effect. A sputum stain was negative for acid-fast bacilli. A low-grade fever was noted at this time. A bacteria culture from a bronchoscopic sample revealed Burkholderia pseudomallei. Oral doxycycline and sulfamethoxazole-trimethoprim were then administered. A follow-up CT scan demonstrated improvement (Figure 3), and his fever, cough, and chest pain also subsided. Melioidosis is an endemic disease in southeast Asia and northern Australia (1). It is caused by the soil-associated bacteria Burkholderia pseudomallei. The severity of disease ranges from chronic disease to fulminant sepsis (2), and chest radiographic findings vary widely. Typical image findings in chronic melioidosis include patterns of pulmonary nodules, cavities, or infiltrates with fibrotic change, which may mimic tuberculous or fungal infections (3). n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Currie BJ, Dance DA, Cheng AC. The global distribution of Burkholderia pseudomallei and melioidosis: an update. Trans R Soc Trop Med Hyg 2008;102:S1–S4.
2. White NJ. Melioidosis. Lancet 2003;361:1715–1722. 3. Burivong W, Wu X, Saenkote W, Stern EJ. Thoracic radiologic manifestations of melioidosis. Curr Probl Diagn Radiol 2012;41: 199–209.
Am J Respir Crit Care Med Vol 190, Iss 3, pp e10–e11, Aug 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201309-1698IM Internet address: www.atsjournals.org
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American Journal of Respiratory and Critical Care Medicine Volume 190 Number 3 | August 1 2014
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 1. Chest computed tomography (CT) revealed a 3.5-cm heterogenous density mass in the right upper lung and small nodules in the right lower lung (A, C, and D, white arrows), with upper paratracheal, bilateral pulmonary hilar and subcarinal low density cystic mass and nodules (B, white arrows). A = anterior; L = left.
Figure 2. Lobulated hypodense mass in the right upper lung with new internal cavitation and multiple satellite nodules in the right upper and right lower lung areas (white arrow). A = anterior; L = left.
Figure 3. Regression of the right lung consolidation and a reduction in the size of the cavitary mass (white arrow). A = anterior; L = left.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
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A 53-year-old man presented with intermittent right-side chest pain and productive cough for 2 years. Initial chest computed tomography (CT) revealed a 3.5-cm heterogenous density mass in the right upper lung and small nodules in the right lower lung, with mediastinal mass and nodules (Figure 1). A bronchoscopic lavage culture was negative, and pathology by CT-guided biopsy only revealed granulomatous inflammation with necrosis. A tissue culture was also negative for tuberculosis or fungus. However, chest CT 1.5 years later showed a lobulated hypodense mass in the right upper lung with new internal cavitation and multiple satellite nodules in the right upper and right lower lung areas (Figure 2). Pulmonary tuberculosis was suspected. Antituberculous agents including isoniazid, rifampicin, ethambutol, and pyrazinamide were administered for 3 weeks but with no effect. A sputum stain was negative for acid-fast bacilli. A low-grade fever was noted at this time. A bacteria culture from a bronchoscopic sample revealed Burkholderia pseudomallei. Oral doxycycline and sulfamethoxazole-trimethoprim were then administered. A follow-up CT scan demonstrated improvement (Figure 3), and his fever, cough, and chest pain also subsided. Melioidosis is an endemic disease in southeast Asia and northern Australia (1). It is caused by the soil-associated bacteria Burkholderia pseudomallei. The severity of disease ranges from chronic disease to fulminant sepsis (2), and chest radiographic findings vary widely. Typical image findings in chronic melioidosis include patterns of pulmonary nodules, cavities, or infiltrates with fibrotic change, which may mimic tuberculous or fungal infections (3). n Author disclosures are available with the text of this article at www.atsjournals.org.
References 1. Currie BJ, Dance DA, Cheng AC. The global distribution of Burkholderia pseudomallei and melioidosis: an update. Trans R Soc Trop Med Hyg 2008;102:S1–S4.
2. White NJ. Melioidosis. Lancet 2003;361:1715–1722. 3. Burivong W, Wu X, Saenkote W, Stern EJ. Thoracic radiologic manifestations of melioidosis. Curr Probl Diagn Radiol 2012;41: 199–209.
Am J Respir Crit Care Med Vol 190, Iss 3, pp e10–e11, Aug 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201309-1698IM Internet address: www.atsjournals.org
e10
American Journal of Respiratory and Critical Care Medicine Volume 190 Number 3 | August 1 2014
IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES
Figure 1. Chest computed tomography (CT) revealed a 3.5-cm heterogenous density mass in the right upper lung and small nodules in the right lower lung (A, C, and D, white arrows), with upper paratracheal, bilateral pulmonary hilar and subcarinal low density cystic mass and nodules (B, white arrows). A = anterior; L = left.
Figure 2. Lobulated hypodense mass in the right upper lung with new internal cavitation and multiple satellite nodules in the right upper and right lower lung areas (white arrow). A = anterior; L = left.
Figure 3. Regression of the right lung consolidation and a reduction in the size of the cavitary mass (white arrow). A = anterior; L = left.
Images in Pulmonary, Critical Care, Sleep Medicine and the Sciences
e11
