to the hypothesis that C albicans can cause ABPM similar to A fumigatus. REFERENCES
1 Hinson KFw, Moon AJ, Plummer NS. Bronchopulmonary aspergillosis: a review and report of eight new cases. Thorax
1952; 73:317-33
2 Sandhu RS, Mehta SK, KhanZU, Singh MM. BoleofAspergillus and Candida species in allergic bronchopulmonary mycoses: a comparative study. Scand J Respir Dis 1979; 60:235-42 3 Akiyama K, Mathison DA, Riker JB, Greenberger PA, Patterson R. Allergic bronchopulmonary candidiasis. Chest 1984; 85:699700 4 Lee TM, Greenberger PA, Oh S, Patterson R, Roberts M, Liotta JL. Allergic bronchopulmonary candidiasis: case report and suggested diagnostic criteria. J Allergy Clin Immunol 1987;
80:816-20 5 Scadding JG. The bronchi in allergic aspergillosis. Scand J Respir Dis 1967; 48:372-77 6 Mintzer RA, Rogers LF, Kruglik GD, Rosenberg M, Neinian HL, Patterson R. The spectrum of radiologic findings in ABPA. Radiology 1978; 127:301-07 7 McCarthy OS, Pepys J. Allergic bronchopulmonary aspergillosis. Clin Immunol Clin Allergy 1971; 1:415-32 8 Patterson R, Greenberger PA, Halwig MJ, Liotta JL, Roberts M. Allergic bronchopulmonary aspergillosis: natural history and classification of early disease by serologic and roentgenographic studies. Arch Intern Med 1986; 146:916-18 9 Schwartz JH, Citron KM, Chester EH, et al. A comparison of sensitization to Aspergillus antigens among asthmatics in Cleveland and London. J Allergy Clin Immunol 1978; 62:9-14 10 Patterson R, Greenberg PA, Ricketti AJ, Roberts M. A radio immunoassay index for allergic bronchopulmonary aspergillosis. Ann Intern Med 1983; 99:18-22 11 Lee TM, Greenberger PA, Patterson R, Roberts M, Liotta JL. Stage V (fibrotic) ABPA. Arch Intern Med 1987; 147:319-23 12 Patterson R, Greenberger PA, Radin RC, Roberts M. Allergic bronchopulmonary aspergillosis: staging as an aid to management. Ann Intern Med 1982; 96:286-91 13 Greenberger PA, Patterson R. Allergic bronchopulmonary aspergillosis and the evaluation of the patient with asthma. J Allergy Clin Immunol 1988; 81:646-50 14 Greenberger PA. Allergic bronchopulmonary aspergillosis and fungoses. Clin Chest Med 1988; 9:599-608
Legionella Pneumonia Presenting as a Bulging Fissure on Chest Roentgenogram* Robin S. Wcas, M.D.;t lruoor V. Kuzmowych, M.D.;* and Samuel V. Spagnolo, M.D., F.C.C.P.§
We report a case of Legionella pneumonia presenting as a bulging interlobar &ssure on the lateral chest roentgenogram. This microorganism should be added to the list of *From the Pulmonary Diseases Section, Medical Service, Veterans ~inistration Medical Center, and the Division of Pulmonary Diseases and Allergy, George Washington University School of Medicine and Health Sciences, Washington, D.C. tFellow in Pulmonary Diseases; Clinical Instructor of Medicine. µssociate Professor of Medicine. §Professor of Medicine. Reprint requests: Dr. Spagnolo, 2150 ltnnsyloonia Avenue Nw. Wlahington, DC 20037 ''
etiologic agents producing a bulging &ssure on chest roentgenogram. (Chat 1991; 100:S61-68)
I I its discovery, pneumophlla bas become Sincerecognized as a common cause of both communityDFA=direct immunoftuorescent antibody
Legionella
acquired and nosocomial pneumonia.• Ninety percent of the patients with this infection exhibit some type of roentgenographic abnormality that can range from an alveolar, patchy, ill-defined density to a cliffuse, bilateral, lower lobe consolidation. 1 This case of Legionella pneumonia is unusual because our patient presented with a bulging interlobar &ssure on the lateral chest roentgenogram. To our knowledge, such a radiologic &nding has not been previously reported with this disease. CASE REPORT
A 39-year-old man presented to the hospital complaining of a cough, headache, and chills of three days' duration. The patient was in good health without any chronic medical problems until about 72 hours prior to hospital admission when he noted the onset of a dry cough, chills, without associated rigors, and a headache. The headache was without photophobia, nuchal rigidity, loss of consciousness, or vomiting. Twenty-fuur hours prior to seeking medical attention, the patient developed a vague, nonradiating, left upper quadrant discomfort not associated with diarrhea, nausea, or vomiting. There was no history of diabetes, hypertension, seizure disorder, or tuberculosis. He participated in intravenous drug abuse as an adolescent. No other risk factors for human immunodeficiency virus (HIV) infection were obtained. Social history was significant for tobacco use, about one pack per day for the past nine years, and alcohol use, about a sU:-pack of beer per day with some increase in this amount on weekends. The patient relocated to the Washington, DC, area from Nevada in the past year. He was employed as a garage supervisor and had no known toxic occupational exposure. Physical examination at the time of hospital admission revealed the man to be alert and in no acute distress. The oral temperature was 40"C. The respiratory rate was 28 per minute. Dentition was poor. Lung examination revealed rhonchi over the left anterior hemithorax. The white blood cell count was 20,000/cu mm with 83 percent neutrophils, 4 percent bands, 11 percent lymphocytes, and 2 percent monocytes. Sputum Gram stains showed numerous white blood cells, some Gram-positive cocci, and a few Gram-negative bacilli. Posteroanterior chest roentgenogram revealed a dense left upper lobe infiltrate, air bronchograms, and a blunted left costophrenic angle. A bulging long fissure was present on the lateral projection (Fig 1). Intravenous penicillin and cefuroxime were started at the time of hospital admission. The antibiotic regimen was changed to vancomycin, piperacillin, and tobramycin on the third day because of persistent fever. The patient's symptoms and gas exchange continued to deteriorate. He was intubated and transferred to the intensiw care unit. Erythromycin, 1 g IV every six hours, was added to his regimen. Fiberoptic bronchoscopy with lavage was performed. The bronchoalveolar lavage fluid was Legionella direct immunofluorescent antibody (DFA) positive. Culture of the lavage fluid grew ugfonella pneumophila. Initial Leglonella titer was 1:256. Serum HIV antibody was negative. All antibiotic therapy was discontinued except for erythromycin. The patient's hospital course was complicated by pneumomediastinum, pneumopericardium, a small left pneumothorax, and CHEST I 100 I 2 I AUGUST, 1991
517
FIGURE la (left). Posteroanterior chest roentgenogram from day of hospital admission showing dense left upper lobe infiltrate, air bronchograms, and a blunted left costophrenic angle. b (right). Corresponding lateral projection demonstrating a bulging long fissure (arrows). generalized subcutaneous emphysema secondary to mechanical ventilation with positive-end expiratory pressure. Renal failure and a disseminated intravascular coagulopathy also developed. After three weeks of erythromycin therapy, the patient was successfully extubated. The coagulapathy cleared and renal function returned after repeated hemodialyses. He subsequently left the hospital. Follow-up chest roentgenograms showed complete resolution of all infiltrates and effusions. DISCUSSION
The displacement of an interlobar fissure in a direction away from an involved lobe on chest roentgenogram, ie, a bulging fissure, is a sign of volume expansion of that lobe. Fraser et al3 list three possible mechanisms for this phenomenon. The volume increase of a lobe of the lung may be due to the very rapid accumulation of copious amounts of purulent exudate in that lobe, air trapping via a check-valve mechanism in a communicating airway distending an abscess cavity within the lobe, and mass effect resulting in the displacement of an interlobar fissure by a lesion occupying a large enough volume and/or being contiguous with that fissure. Historically, a bulging fissure was first described in chest roentgenograms of patients with Klebsiella pneumonia. •Indeed, this pulmonary infection is initially characterized by a tendency to produce voluminous amounts of inffammatory exudate that may well, at least in part, explain the swollen or bulging appearance of the affected lobe. However, Klebsiella pneumonia is also characterized by the rapid massive destruction of lung parenchyma, liquefaction necrosis, abscess formation, and the accumulation of large amounts of purulent exudate in the lung.• Thus, it is more likely that all three of the proposed mechanisms of Fraser et al 3 for volume expansion ofan infected lobe are responsible for the pathologic and radiologic findings in this disease, rather than any one particular mechanism. Although the bulging fissure is a common radiologic 588
finding in Klebsiella pneumonia, it is by no means pathognomonic of this infection. It can occasionally be also seen in pulmonary infections due to Streptococcus pneumoniae, Mycobacterium tuberculosis, and Yersinia pestis. 3 Indeed, Fraser et al6 state that pneumonia due to Legionella species can rarely cause lobar expansion. We present a documented case of Legionella pneumophila pneumonia that appeared on chest roentgenogram as a dense left upper lobe infiltrate and a bulging long fissure. Our report confirms the fact that this microorganism should be added to the list of etiologic agents in the differential diagnosis of a bulging fissure on the chest roentgenogram . REFERENCES
l Chow JW. Yu VL. New perspectives on Legionella pneumonia: diagnosis, management and prevention. J Crit Illness 1988; 3:1727 2 Moore EH, Webb WR, Gamsu G, Golden
JA.
Legionnaires'
disease in the renal transplant patient: clinical presentation and radiographic progression. Radiology 1984; 153:589-93 3 Fraser RG, Pare JAP, Pare PD, Fraser RS, Generex GP. Diagnosis of diseases of the chest, 3rd ed. Philadelphia: WB Saunders Co,
1988; 1:578-80 4 Felson 8, Rosenberg LS, Hamburger M. Roentgen findings in acute Friedlanders pneumonia. Radiology 1949; 53:5.59-6.5 5 Ritvo M, Martin F. Clinical and roentgen manifestations of pneumonia due to Bacillus mucosus capsulatus (primary Friedlander's pneumonia). Am J Roentgenol Rad Ther 1949; 62:211-22 6 Fraser RG, Pare JAP, Pare PD, Fraser RS, Genereux GP. Diagnosis of diseases of the chest, 3rd ed. Philadelphia: WB Saunders Co, 1989; 2:865 Leglonella Pneumonia Pl8senting
as Bulging Fls8ue
(l...uc"8, Kuzmowych, Spagnolo}
1 Hinson KFw, Moon AJ, Plummer NS. Bronchopulmonary aspergillosis: a review and report of eight new cases. Thorax
1952; 73:317-33
2 Sandhu RS, Mehta SK, KhanZU, Singh MM. BoleofAspergillus and Candida species in allergic bronchopulmonary mycoses: a comparative study. Scand J Respir Dis 1979; 60:235-42 3 Akiyama K, Mathison DA, Riker JB, Greenberger PA, Patterson R. Allergic bronchopulmonary candidiasis. Chest 1984; 85:699700 4 Lee TM, Greenberger PA, Oh S, Patterson R, Roberts M, Liotta JL. Allergic bronchopulmonary candidiasis: case report and suggested diagnostic criteria. J Allergy Clin Immunol 1987;
80:816-20 5 Scadding JG. The bronchi in allergic aspergillosis. Scand J Respir Dis 1967; 48:372-77 6 Mintzer RA, Rogers LF, Kruglik GD, Rosenberg M, Neinian HL, Patterson R. The spectrum of radiologic findings in ABPA. Radiology 1978; 127:301-07 7 McCarthy OS, Pepys J. Allergic bronchopulmonary aspergillosis. Clin Immunol Clin Allergy 1971; 1:415-32 8 Patterson R, Greenberger PA, Halwig MJ, Liotta JL, Roberts M. Allergic bronchopulmonary aspergillosis: natural history and classification of early disease by serologic and roentgenographic studies. Arch Intern Med 1986; 146:916-18 9 Schwartz JH, Citron KM, Chester EH, et al. A comparison of sensitization to Aspergillus antigens among asthmatics in Cleveland and London. J Allergy Clin Immunol 1978; 62:9-14 10 Patterson R, Greenberg PA, Ricketti AJ, Roberts M. A radio immunoassay index for allergic bronchopulmonary aspergillosis. Ann Intern Med 1983; 99:18-22 11 Lee TM, Greenberger PA, Patterson R, Roberts M, Liotta JL. Stage V (fibrotic) ABPA. Arch Intern Med 1987; 147:319-23 12 Patterson R, Greenberger PA, Radin RC, Roberts M. Allergic bronchopulmonary aspergillosis: staging as an aid to management. Ann Intern Med 1982; 96:286-91 13 Greenberger PA, Patterson R. Allergic bronchopulmonary aspergillosis and the evaluation of the patient with asthma. J Allergy Clin Immunol 1988; 81:646-50 14 Greenberger PA. Allergic bronchopulmonary aspergillosis and fungoses. Clin Chest Med 1988; 9:599-608
Legionella Pneumonia Presenting as a Bulging Fissure on Chest Roentgenogram* Robin S. Wcas, M.D.;t lruoor V. Kuzmowych, M.D.;* and Samuel V. Spagnolo, M.D., F.C.C.P.§
We report a case of Legionella pneumonia presenting as a bulging interlobar &ssure on the lateral chest roentgenogram. This microorganism should be added to the list of *From the Pulmonary Diseases Section, Medical Service, Veterans ~inistration Medical Center, and the Division of Pulmonary Diseases and Allergy, George Washington University School of Medicine and Health Sciences, Washington, D.C. tFellow in Pulmonary Diseases; Clinical Instructor of Medicine. µssociate Professor of Medicine. §Professor of Medicine. Reprint requests: Dr. Spagnolo, 2150 ltnnsyloonia Avenue Nw. Wlahington, DC 20037 ''
etiologic agents producing a bulging &ssure on chest roentgenogram. (Chat 1991; 100:S61-68)
I I its discovery, pneumophlla bas become Sincerecognized as a common cause of both communityDFA=direct immunoftuorescent antibody
Legionella
acquired and nosocomial pneumonia.• Ninety percent of the patients with this infection exhibit some type of roentgenographic abnormality that can range from an alveolar, patchy, ill-defined density to a cliffuse, bilateral, lower lobe consolidation. 1 This case of Legionella pneumonia is unusual because our patient presented with a bulging interlobar &ssure on the lateral chest roentgenogram. To our knowledge, such a radiologic &nding has not been previously reported with this disease. CASE REPORT
A 39-year-old man presented to the hospital complaining of a cough, headache, and chills of three days' duration. The patient was in good health without any chronic medical problems until about 72 hours prior to hospital admission when he noted the onset of a dry cough, chills, without associated rigors, and a headache. The headache was without photophobia, nuchal rigidity, loss of consciousness, or vomiting. Twenty-fuur hours prior to seeking medical attention, the patient developed a vague, nonradiating, left upper quadrant discomfort not associated with diarrhea, nausea, or vomiting. There was no history of diabetes, hypertension, seizure disorder, or tuberculosis. He participated in intravenous drug abuse as an adolescent. No other risk factors for human immunodeficiency virus (HIV) infection were obtained. Social history was significant for tobacco use, about one pack per day for the past nine years, and alcohol use, about a sU:-pack of beer per day with some increase in this amount on weekends. The patient relocated to the Washington, DC, area from Nevada in the past year. He was employed as a garage supervisor and had no known toxic occupational exposure. Physical examination at the time of hospital admission revealed the man to be alert and in no acute distress. The oral temperature was 40"C. The respiratory rate was 28 per minute. Dentition was poor. Lung examination revealed rhonchi over the left anterior hemithorax. The white blood cell count was 20,000/cu mm with 83 percent neutrophils, 4 percent bands, 11 percent lymphocytes, and 2 percent monocytes. Sputum Gram stains showed numerous white blood cells, some Gram-positive cocci, and a few Gram-negative bacilli. Posteroanterior chest roentgenogram revealed a dense left upper lobe infiltrate, air bronchograms, and a blunted left costophrenic angle. A bulging long fissure was present on the lateral projection (Fig 1). Intravenous penicillin and cefuroxime were started at the time of hospital admission. The antibiotic regimen was changed to vancomycin, piperacillin, and tobramycin on the third day because of persistent fever. The patient's symptoms and gas exchange continued to deteriorate. He was intubated and transferred to the intensiw care unit. Erythromycin, 1 g IV every six hours, was added to his regimen. Fiberoptic bronchoscopy with lavage was performed. The bronchoalveolar lavage fluid was Legionella direct immunofluorescent antibody (DFA) positive. Culture of the lavage fluid grew ugfonella pneumophila. Initial Leglonella titer was 1:256. Serum HIV antibody was negative. All antibiotic therapy was discontinued except for erythromycin. The patient's hospital course was complicated by pneumomediastinum, pneumopericardium, a small left pneumothorax, and CHEST I 100 I 2 I AUGUST, 1991
517
FIGURE la (left). Posteroanterior chest roentgenogram from day of hospital admission showing dense left upper lobe infiltrate, air bronchograms, and a blunted left costophrenic angle. b (right). Corresponding lateral projection demonstrating a bulging long fissure (arrows). generalized subcutaneous emphysema secondary to mechanical ventilation with positive-end expiratory pressure. Renal failure and a disseminated intravascular coagulopathy also developed. After three weeks of erythromycin therapy, the patient was successfully extubated. The coagulapathy cleared and renal function returned after repeated hemodialyses. He subsequently left the hospital. Follow-up chest roentgenograms showed complete resolution of all infiltrates and effusions. DISCUSSION
The displacement of an interlobar fissure in a direction away from an involved lobe on chest roentgenogram, ie, a bulging fissure, is a sign of volume expansion of that lobe. Fraser et al3 list three possible mechanisms for this phenomenon. The volume increase of a lobe of the lung may be due to the very rapid accumulation of copious amounts of purulent exudate in that lobe, air trapping via a check-valve mechanism in a communicating airway distending an abscess cavity within the lobe, and mass effect resulting in the displacement of an interlobar fissure by a lesion occupying a large enough volume and/or being contiguous with that fissure. Historically, a bulging fissure was first described in chest roentgenograms of patients with Klebsiella pneumonia. •Indeed, this pulmonary infection is initially characterized by a tendency to produce voluminous amounts of inffammatory exudate that may well, at least in part, explain the swollen or bulging appearance of the affected lobe. However, Klebsiella pneumonia is also characterized by the rapid massive destruction of lung parenchyma, liquefaction necrosis, abscess formation, and the accumulation of large amounts of purulent exudate in the lung.• Thus, it is more likely that all three of the proposed mechanisms of Fraser et al 3 for volume expansion ofan infected lobe are responsible for the pathologic and radiologic findings in this disease, rather than any one particular mechanism. Although the bulging fissure is a common radiologic 588
finding in Klebsiella pneumonia, it is by no means pathognomonic of this infection. It can occasionally be also seen in pulmonary infections due to Streptococcus pneumoniae, Mycobacterium tuberculosis, and Yersinia pestis. 3 Indeed, Fraser et al6 state that pneumonia due to Legionella species can rarely cause lobar expansion. We present a documented case of Legionella pneumophila pneumonia that appeared on chest roentgenogram as a dense left upper lobe infiltrate and a bulging long fissure. Our report confirms the fact that this microorganism should be added to the list of etiologic agents in the differential diagnosis of a bulging fissure on the chest roentgenogram . REFERENCES
l Chow JW. Yu VL. New perspectives on Legionella pneumonia: diagnosis, management and prevention. J Crit Illness 1988; 3:1727 2 Moore EH, Webb WR, Gamsu G, Golden
JA.
Legionnaires'
disease in the renal transplant patient: clinical presentation and radiographic progression. Radiology 1984; 153:589-93 3 Fraser RG, Pare JAP, Pare PD, Fraser RS, Generex GP. Diagnosis of diseases of the chest, 3rd ed. Philadelphia: WB Saunders Co,
1988; 1:578-80 4 Felson 8, Rosenberg LS, Hamburger M. Roentgen findings in acute Friedlanders pneumonia. Radiology 1949; 53:5.59-6.5 5 Ritvo M, Martin F. Clinical and roentgen manifestations of pneumonia due to Bacillus mucosus capsulatus (primary Friedlander's pneumonia). Am J Roentgenol Rad Ther 1949; 62:211-22 6 Fraser RG, Pare JAP, Pare PD, Fraser RS, Genereux GP. Diagnosis of diseases of the chest, 3rd ed. Philadelphia: WB Saunders Co, 1989; 2:865 Leglonella Pneumonia Pl8senting
as Bulging Fls8ue
(l...uc"8, Kuzmowych, Spagnolo}
