PULMONARY FUNGAL INFECTIONS part 2

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PULMONARY FUNGAL INFECTIONS:

PULMONARY FUNGAL INFECTIONS Dr Neelam

FUNGAL INFECTIONS:

FUNGAL INFECTIONS Histoplasmosis Coccidioidomycosis Blastomycosis Cryptococcosis Candidiasis Mucormycosis Aspergillosis

HISTOPLASMOSIS:

HISTOPLASMOSIS Due to inhalation of soil or dust contaminated by bird or bat excreta Rarely cause chest infection except in eastern USA .

Slide5:

Usually subclinical and heals spontaneously leave small calcified pulmonary nodules or calcified hilar or mediastinal lymph nodes

Slide6:

Mediastinal granuloma due to histoplasmosis in a 30-year-old man with chest pain. (a) Posteroanterior chest radiograph shows a calcified right paratracheal mass (arrowhead).

Slide7:

CT scan (mediastinal window) shows the focal paratracheal mass with a low-attenuation center and extensive calcification (arrowhead). Note the mass effect on the trachea (T). A noninvasive, well-encapsulated mass containing viable H capsulatum organisms was found at resection.

Slide8:

Fibrosing mediastinitis associated with histoplasmosis in a 58-year-old man with a 6-month history of cough. (a) Computed tomographic (CT) scan (lung window) shows an infiltrating, soft-tissue right hilar mass extending into the right lower lobe along bronchovascular bundles.

hist:

hist CT scan (mediastinal window) shows the soft-tissue mass (arrowhead) and extensive calcification in the right hilum and subcarinal region.

Slide10:

Left main bronchus stenosis due to fibrosing mediastinitis treated with laser ablation, balloon dilation, and endobronchial stent placement. The patient also had a history of recurrent left lung pneumonia. (a) CT scan (mediastinal window) shows a wire mesh stent in the left main bronchus, calcified adenopathy (arrow) in the aortopulmonary window, and a subcarinal soft-tissue mass (arrowhead). ∗ = esophagus.

Slide11:

Thoracic histoplasmosis. High-resolution CT of the chest confirms chest radiographic findings and nicely shows the tightly formed micronodules in both upper lobes.

Slide12:

Thoracic histoplasmosis. CT image at the lung bases confirms the diffuse nature of the disease (a miliary form of disseminated pulmonary histoplasmosis [DPH]).

Slide13:

Thoracic histoplasmosis. Chest radiograph demonstrates a lobulated soft tissue mass in the right paratracheal region, with an enlarged and dense right hilum, suggesting lymphadenopathy. The radiographic differential diagnosis for these findings includes lung cancer, primary tuberculosis, histoplasmosis in endemic areas, lymphoma, and (less likely) sarcoidosis (owing to the asymmetric nature of nodal enlargement). Further workup revealed that this patient had a sarcoid-type reaction to histoplasmosis.

Slide14:

Thoracic histoplasmosis. Fibrosing mediastinitis is a rare but well-known clinical manifestation of histoplasmosis. Contrast enhanced chest CT at the level of the aortic arch in a patient with histoplasmosis and fibrosing mediastinitis shows an ill-defined soft tissue mass encasing and narrowing the trachea. The superior vena cava is also significantly narrowed (arrowhead).

Slide15:

Progression of these nodules may occur along with hilar enlargement,consolidation,fibrosis and cavitation appearance similar to TB. When massive inhalation of organisms occur CXR shows diffuse small nodular shadows which following resolution may calcify A histoplasmoma may resemble tuberculoma well circumscribed and often calcified

Slide16:

Uncommon late manifestation is fibrosing mediastinitis which cause stenosis of vena cave,oesophagus,trachea.bronchi or central pulmonary vessels.CXR will show a wide mediastinum large hilar shadows with opacities extending into the lungs and Kerley B lines may appear

COCCIDIOIDOMYCOSIS:

COCCIDIOIDOMYCOSIS Endemic disease in parts of south west USA.

Slide18:

60% asymptomatic and the commonest radiographic finding is a nodule which calcify as it heals

Slide19:

Progression of the disease may cause consolidation,cavitation, Lymphadenopathy,pleural effusion.

Slide21:

Coccidioides immitis spherule containing daughter spores.

co:

co Right-lower-lobe nodule secondary to the disease.

c:

c Computed tomography scan shows a calcified nodule in the right lower lobe of an individual who traveled to Arizona 3 years previously. In comparison with tuberculosis, coccidioidomas are less commonly associated with calcification.

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A large, masslike airspace lesion is seen in the right lower lobe. The lesion is secondary to the progressive, infectious form of coccidioidomycosis.

Slide25:

Another case of extensive airspace consolidation resulting from coccidioidomycosis.

Slide26:

Bilateral reticular-nodular infiltrates in a patient with progressive coccidioidomycosis.

Slide27:

Chest radiograph of a patient who winters in Arizona, presenting with symptoms of a cough and fever, as well as an airspace masslike opacity.

Slide28:

Several months later, spontaneous clinical improvement was noted in the patient in the previous image. The infiltrate has now evolved into a well-defined nodule.

Slide29:

Computed tomography scan shows a nodule in the left lower lobe at the level of the left lower bronchus take-off. A percutaneous needle biopsy confirmed coccidioidomycosis.

Slide30:

Nodule in the left upper lobe of a patient who visited Arizona during the winter months. A needle biopsy revealed coccidioidomycosis.

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A close-up view of the chest radiograph in the previous image.

Slide32:

Computed tomography scan shows a nodule and an airspace infiltrate.

Slide33:

A masslike opacity in the superior segment of the left lower lobe is noted in a patient with cough, fever, and chills. Fungal cultures from bronchoalveolar lavage confirmed the diagnosis of coccidioidomycosis.

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Thin-walled coccidioidomycosis cavity, right upper lobe.

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Coccidioidomycosis nodule, left upper lobe

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Thin-walled coccidioidomycosis cavity, right upper lobe.

Slide37:

Coccidioidomycosis. Acute respiratory distress syndrome and large right pneumatocele.

BLASTOMYCOSIS:

BLASTOMYCOSIS Found in south east USA

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Asymptomatic pulmonary nodule

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Progression lead to consolidation,cavitation,lymphadenopathy,miliary disease But fibrosis and calcifications rare

CRYPTOCOCCOSIS:

CRYPTOCOCCOSIS Yeast form of fungus found world wide

Slide42:

Mostly asmptomatic Any radiographic pattern may occur

Slide43:

May present as pleural based mass(torulosis) possibly cavitating may be indistinguishable from lung cancer.

cryptococcosis:

cryptococcosis Transverse CT scan in 46-year-old woman shows several nodules in the lung bases (7-mm-thick section). Most of the nodules have smooth margins.

cryptococcosis:

cryptococcosis Transverse CT scan in 46-year-old woman shows several nodules in the lung bases (7-mm-thick section). Most of the nodules have smooth margins.

crypto:

crypto Transverse CT scan in 46-year-old woman shows several nodules in the lung bases (7-mm-thick section). Most of the nodules have smooth margins

crypto:

crypto Transverse CT scan in 51-year-old woman (7-mm-thick section). (a) Scan obtained at level of the bronchus of the upper lobe in the right lung shows several nodules (thin arrows), one of which is cavitated (thick arrow)

crypto:

crypto Transverse CT scan in 46-year-old woman shows several nodules in the lung bases (7-mm-thick section). Most of the nodules have smooth margins

crypto:

crypto Transverse CT scan in 51-year-old woman (7-mm-thick section). (a) Scan obtained at level of the bronchus of the upper lobe in the right lung shows several nodules (thin arrows), one of which is cavitated (thick arrow)

CANDIDIASIS:

CANDIDIASIS C.albicans normal mouth commensal Cause thrush when conditions favourable Lung infection when it occurs is probably from hematogenous spread

Slide52:

Pulmonary lesion is chronic pneumonia which forms abscess A mycetoma may form in the abscess

Secundary lobules. The centrilobular artery (in blue: oxygen-poor blood) and the terminal bronchiole run in the center. Lymphatics and veins (in red: oxygen-rich blood) run within the interlobular septa:

Secundary lobules. The centrilobular artery (in blue: oxygen-poor blood) and the terminal bronchiole run in the center. Lymphatics and veins (in red: oxygen-rich blood) run within the interlobular septa

Slide54:

Centrilobular area is the central part of the secundary lobule. It is usually the site of diseases, that enter the lung through the airways ( i.e. hypersensitivity pneumonitis, respiratory bronchiolitis, centrilobular emphysema ). Perilymphatic areais the peripheral part of the secundary lobule. It is usually the site of diseases, that are located in the lymphatics of in the interlobular septa ( i.e. sarcoid, lymphangitic carcinomatosis, pulmonary edema). These diseases are usually also located in the central network of lymphatics that surround the bronchovascular bundle.

Slide56:

The distribution of nodules shown on HRCT is the most important factor in making an accurate diagnosis in the nodular pattern. In most cases small nodules can be placed into one of three categories: perilymphatic, centrilobular or random distribution. Random refers to no preference for a specific location in the secondary lobule. Perilymphatic distribution In patients with a perilymphatic distribution, nodules are seen in relation to pleural surfaces, interlobular septa and the peribronchovascular interstitium. Nodules are almost always visible in a subpleural location, particularly in relation to the fissures. Centrilobular distribution In certain diseases, nodules are limited to the centrilobular region. Unlike perilymphatic and random nodules, centrilobular nodules spare the pleural surfaces. The most peripheral nodules are centered 5-10mm from fissures or the pleural surface. Random distribution Nodules are randomly distributed relative to structures of the lung and secondary lobule. Nodules can usually be seen to involve the pleural surfaces and fissures, but lack the subpleural predominance often seen in patients with a perilymphatic distribution.

Slide58:

Tree-in-bud In centrilobular nodules the recognition of 'tree-in-bud' is of value for narrowing the differential diagnosis. Tree-in-bud describes the appearance of an irregular and often nodular branching structure, most easily identified in the lung periphery. It represents dilated and impacted (mucus or pus-filled) centrilobular bronchioles.

Slide61:

Increased lung attenuation is called ground-glass-opacity (GGO) if there is a hazy increase in lung opacity without obscuration of underlying vessels and is called consolidation if the increase in lung opacity obscures the vessels. In both ground glass and consolidation the increase in lung density is the result of replacement of air in the alveoli by fluid, cells or fibrosis. In GGO the density of the intrabronchial air appears darker as the air in the surrounding alveoli. This is called the 'dark bronchus' sign In consolidation, there is exclusively air left intrabronchial. This is called the 'air bronchogram'.

Slide64:

Candida albicans infection in a 28-year-old man with acute myeloid leukemia and hematopoietic stem cell transplant. (a) Transverse thin-section (1-mm collimation, lung window) CT scan of upper lobes shows bilateral multifocal patchy areas of ground-glass opacity and a nodule greater than 1 cm (arrow) with a surrounding halo of ground-glass opacity in the superior segment of the right lower lobe.

Slide65:

Pneumonia due to C albicans in a 25-year-old man with acute myeloid leuke-mia and hematopoietic stem cell transplant.(a) Transverse thin-section (1-mm collimation) CT scan of the right lung shows multiple, scattered, and poorly defined centrilobular nodules of different sizes. Diffuse ground-glass opacity is also visible.

Slide66:

Pneumonia due to C albicans in a 45-year-old man who underwent hematopoietic stem cell transplantation. (a) Transverse thin-section (1-mm collimation) CT scan through the hila demonstrates bilateral well-defined tiny nodules in a random distribution.

Slide67:

Candida pneumonia in a 52-year-old man who underwent hematopoietic stem cell transplantation. (a) Transverse thin-section (1-mm collimation) CT scan at the level of the lower pulmonary veins shows multiple ill-defined bilateral nodules with a surrounding halo of ground-glass opacity.

Slide68:

C albicans bronchopneumonia in a 23-year-old man with neutropenia following hematopoietic stem cell transplantation. Transverse thin-section (1-mm collimation) CT scan of the right lung shows consolidation in the posterior segment of right upper lobe, thickening of bronchiolar walls, and branching distal structures (tree-in-bud pattern) (arrows).

tree in bud:

tree in bud

MUCORMYCOSIS:

MUCORMYCOSIS They cause spreading destructive infection of the face and sinuses in immunocompromised

Slide71:

Lung infection is rapidly progresive,dense,cavitating bronchopneumonia

ASPERGILLOSIS:

ASPERGILLOSIS Widespread in the atmosphere Three categories Aspergilloma Invasive aspergillosis Allergic bronchopulmonary aspergillosis

ASPERGILLOMA:

ASPERGILLOMA Any chronic pulmonary cavity may be colonized by fungus Such cavities are mostly TB,histoplamosis.or sarcoidosis and usually in upper lobes.The fungal hyphae may form a ball or mycetoma which lies free in the cavity.

Slide74:

CXR may show a density surrounded by air within a cavity best shown by CT.By altering the position of patient the ball is seen to be mobile .Mycetomas are associated with development of vascular granulations in cavity wall which may bleed cause hemoptysis,for life threatening hemoptysis if difficult by surgery treated by embolization.

INVASIVE ASPERGILLOSIS:

INVASIVE ASPERGILLOSIS In immunocompromised it cause primary infection May be lobar consolidation,bronchopneumonia or multiple nodules. On HRCT a halo of increase attenuation in the surrounding lung may be seen represents hemorrhagic inflammation Cavitation is common

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS:

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS Patient usually asthmatic Fungus colonize the lobar and segmental bronchi cause type 3 reaction. Patient presents with cough and wheeze ,often expectorate mucus plugs containing fungi

Slide77:

In the acute phase CXR shows patchy consolidation often in the upper zones Mucus plugging causes collapse,mucocles,bronchiectasis. With repeated episodes,fibrosis occur Mycetoma may form

Slide78:

Aspergilloma in a 54-year-old man with a history of tuberculosis. (a) Linear tomogram (magnified view) shows multiple fungus balls within a cavity in the right upper lobe.

Slide79:

Bilateral aspergillomas in a 71-year-old man with residual tuberculosis. Chest computed tomographic (CT) scan (lung window) shows large cavities bilaterally in the upper lobes containing fungus balls of different sizes.

Slide80:

Aspergilloma with the air crescent sign in a 67-year-old woman with residual tuberculosis. Thin-section CT scan (mediastinal window) shows extensive scarring in the upper lobes. A large aspergilloma is seen in the left upper lobe, with a characteristic air crescent between the aspergilloma and the cavity wall. Note the marked pleural thickening surrounding the cavity containing the aspergilloma (arrowheads). Punctate bilateral pleural calcifications are also visible.

Slide81:

Mobile aspergilloma within a pulmonary cystic cavity in a 43-year-old man. Chest CT scans obtained with the patient supine

Slide82:

and prone (b) show a change in the position of the aspergilloma. A fumigatus was discovered at bronchoscopy. (Courtesy of Josep M. Mata, MD, Unidad Diagnóstica de Alta Tecnología, Sabadell, Spain.)

Slide83:

Allergic bronchopulmonary aspergillosis in a 43-year-old asthmatic man. On a CT scan obtained 2 months later, cystic bronchiectasis is clearly depicted.

Slide84:

Semi-invasive aspergillosis in a 68-year-old man with chronic bronchitis and recurrent episodes of mild hemoptysis. (a) Thin-section CT scan (lung window) shows bilateral rounded areas of consolidation with associated cavitation in both upper lobes

Slide85:

Necrotizing bronchial aspergillosis in a 54-year-old man who presented with cough and sputum production. (a) Chest CT scan (mediastinal window) obtained at the level of the carina shows a thickened, narrowed right main bronchus with associated right upper lobe collapse.

Slide86:

Invasive bronchiolar aspergillosis in a patient who had undergone bone marrow transplantation. (a) Thin-section CT scan (lung window) shows peripheral branching structures associated with focal areas of consolidation in the right lower lobe

Slide87:

Bronchopneumonia aspergillosis. (a) Conventional CT scan through the upper lungs shows a segmental area of consolidation in the right upper lobe with visible air bronchogram.

Slide88:

Obstructing bronchopulmonary aspergillosis in a 29-year-old man with AIDS. CT scan shows multiple rounded and tubular areas of increased attenuation in both lower lobes, findings that are consistent with mucus-filled airways. Bronchoscopy revealed that the lumen was packed with inflammatory material.

Slide89:

Angioinvasive aspergillosis in a 42-year-old man with acute myelogenous leukemia. (a) Chest CT scan (lung window) reveals a 2-cm nodular lesion with a wide halo of ground-glass attenuation representing adjacent hemorrhage.

Slide90:

Angioinvasive aspergillosis in a 54-year-old man. (a) Thin-section CT scan (lung window) shows a cavitated nodule with air crescent formation

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Angioinvasive aspergillosis in a 43-year-old woman who had undergone bone marrow transplantation. (a) CT scan shows a peripheral Aspergillus nodule in the right upper lobe.

Slide92:

CT scan obtained 4 weeks later shows cavitation of the nodule with the air crescent sign.

Slide93:

Invasive bronchiolar aspergillosis in a patient who underwent bone marrow transplantation. (a) High-resolution CT scan (lung window) shows peripheral branching structures (arrow) associated with focal areas of consolidation in the right lower lobe

Slide94:

Thin-section CT scan of a 49-year-old cardiac transplant recipient revealing a nodule surrounded by ground-glass attenuation (i.e., CT halo sign) in the right middle lobe.

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