Bronchi
77 year old female with
Asthma and Cough
2. Findings and Diagnosis
ABPA Finger in Glove Sign LLL
77 year old female with history of asthma, allergic bronchopulmonary aspergillosis (ABPA) and COPD
CT in the axial plane of the left lower lobe shows inspissated and bronchiectatic segmental airways to the LLL, magnified in the lower image, (green arrowheads) reminiscent of the finger in glove appearance of ABPA)
Ashley Davidoff TheCommonVein.net
PAGE 2 – FINDINGS
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Finger-in-Glove Opacities and Centrilobular Nodules in ABPA |
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CT scan shows tubular branching opacities (finger-in-glove sign) in the left lower lobe, along with scattered centrilobular nodules and small airway involvement. These findings, in the setting of asthma and cough, are consistent with allergic bronchopulmonary aspergillosis (ABPA).
CT in the axial plane of the left lower lobe shows inspissated and bronchiectatic segmental airways to the LLL, magnified in the lower image, (green arrowheads) reminiscent of the finger in glove appearance of ABPA)
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| Courtesy: Ashley Davidoff MD, TheCommonVein.com (227Lu 135157cL) |
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Clinical Context
Patient with chronic asthma and cough presents for evaluation of persistent pulmonary symptoms.
Radiologic Findings Table
| Observation |
Description |
| Finger-in-glove opacities |
Dilated, mucus-filled bronchi appear as tubular branching densities—classic sign of ABPA |
| Centrilobular nodules |
Ill-defined nodules suggestive of bronchiolar inflammation and small airway involvement |
| Distribution |
Predominantly in the left lower lobe; central and dependent lung zones affected |
| No consolidation or effusion |
Suggests inflammation rather than infection or mass effect |
Differential Diagnosis
Most Likely Diagnosis Table
| Diagnosis |
Rationale |
| ABPA |
Characteristic imaging (mucus plugging, small airway involvement), clinical setting of asthma, chronic cough |
Other Considerations Table (in user-defined diagnostic category order)
| Category |
Diagnosis |
Rationale |
| Infection |
Endobronchial tuberculosis |
Can cause mucus plugging and nodules, but less common in asthmatics without systemic symptoms |
| Neoplasm – Benign |
Bronchial hamartoma |
Rare; lacks mucus impaction pattern |
| Neoplasm – Malignant (Primary) |
Bronchogenic carcinoma |
Typically presents with mass effect, not finger-in-glove pattern |
| Mechanical |
Foreign body aspiration |
Could mimic obstruction but usually localized and acute |
| Iatrogenic |
Post-bronchial intervention |
Can cause mucus impaction, though lacks background asthma and immune features |
Key Points and Pearls Table
| Pearl |
Explanation |
| Finger-in-glove = mucus-filled bronchi |
Pathognomonic appearance when bronchi are dilated and impacted by dense allergic mucus |
| Asthma + bronchial plugging = ABPA? |
Always consider ABPA in asthmatic patients with new mucoid impactions or peripheral nodules |
| CT more sensitive than CXR |
Early or small airway disease may be missed on radiographs |
| Left lower lobe predilection |
Though classically central, ABPA can localize to dependent zones or one lobe initially |
3. Clinical
PAGE 4 – INFO: Broader Clinical and Radiologic Context
Table 1 – Broad Disease Context
| Category |
Details |
| Definition |
ABPA is a hypersensitivity reaction to Aspergillus fumigatus colonizing the airways, typically in patients with asthma or cystic fibrosis. |
| Etiology |
Overactive immune response (Type I and III hypersensitivity) to fungal antigens in the bronchi. |
| Resulting Pathology |
Bronchial wall inflammation, mucus impaction, eosinophilic infiltration, and eventual central bronchiectasis. |
| Structural Changes |
Dilated, mucus-filled bronchi (finger-in-glove), small airway plugging, central bronchiectasis, and centrilobular nodules. |
| Functional Changes |
Air trapping, obstructive ventilatory defect, and recurrent pulmonary symptoms in a sensitized host. |
| Clinical Diagnosis |
Asthma or CF with worsening respiratory symptoms, elevated IgE, eosinophilia, positive Aspergillus serology. |
| Imaging Diagnosis |
CT: finger-in-glove opacities, central bronchiectasis, centrilobular nodules, high-attenuation mucus. |
| Laboratory Workup |
Total IgE >1000 IU/mL, Aspergillus-specific IgE/IgG, eosinophilia, sputum culture sometimes positive for Aspergillus. |
| Treatment Strategies |
Systemic corticosteroids (mainstay); antifungals (e.g., itraconazole); bronchodilators and airway clearance therapy. |
Table 2 – Radiologic Subtypes and Complications
| Subtype / Pattern |
Relevance to ABPA |
| Central bronchiectasis |
Hallmark of chronic or recurrent ABPA; often affects upper lobes but may localize elsewhere |
| Finger-in-glove opacities |
Represent mucoid impaction within dilated bronchi |
| Centrilobular nodules |
Result from bronchiolar inflammation and small airway plugging |
| High-attenuation mucus |
Denser mucus is highly specific to ABPA on CT |
| Migratory opacities |
Radiographic findings may wax and wane between flares |
| Complications |
Permanent bronchiectasis, pulmonary fibrosis, secondary infection, chronic airflow limitation |
Key Points and Pearls Table
| Insight |
Explanation |
| Must distinguish from chronic infection |
Radiologic overlap with TB, NTM, and fungal infection—clinical and serologic context are critical |
| Worsening asthma with new opacities? Think ABPA |
Consider ABPA in asthma with mucus plugging or recurrent infiltrates |
| Serial imaging may change |
Findings may appear and resolve over weeks or months, complicating diagnosis |
| High-attenuation mucus is highly specific |
When present, strongly suggests ABPA over other mucus-impaction conditions |
4. Historical and Cultural
PAGE 5 – OTHER: Historical and Cultural Dimensions
Primary Focus: Allergic Bronchopulmonary Aspergillosis (ABPA)
Table 1 – Cultural Reflections on Radiologic Units and Diagnosis
| Radiologic Term |
Etymology / Historical Note |
| Finger-in-Glove Opacity |
Describes mucus-impacted bronchi resembling the shape of gloved fingers; the term originated in mid-20th century radiology. |
| Centrilobular Nodules |
Radiologic term denoting opacities centered around the terminal bronchioles; widely used in HRCT interpretation. |
| Bronchiectasis |
From Greek bronchion (airway) and ektasis (expansion); refers to pathologic, irreversible dilation of the bronchi. |
Table 2 – Medical History Related to Disease
| Topic |
Historical Significance |
| First Description of ABPA |
Described by Hinson et al. in 1952 as a form of pulmonary eosinophilia with fungal sensitization in asthmatics. |
| Aspergillus Discovery |
Aspergillus genus discovered by Italian priest/biologist Pier Antonio Micheli in 1729. |
| Role of Hypersensitivity |
Immunologic basis of ABPA clarified in the 1970s with identification of IgE and IgG elevation and eosinophilia. |
| CT Recognition of Mucus Plugs |
The finger-in-glove sign became a classic radiologic indicator of ABPA as CT evolved in the 1980s–1990s. |
Table 3 – Arts and Humanities (Alphabetical)
| Discipline |
Reflection of ABPA’s Themes (Concealment, Burden, Recurrence) |
| Dance |
Repetitive motion and constricted breathwork can symbolize the cyclical, relapsing burden of hypersensitive lungs. |
| Literature |
Themes of hidden threats or recurrent sabotage (e.g., Kafka’s The Trial) metaphorically mirror chronic inflammation. |
| Music |
Rhythmic disruptions and sudden pauses reflect the interruption of normal breathing during exacerbations. |
| Painting |
Works exploring “opacity” or “clogging” (e.g., abstract expressionism) resonate with the concept of airway obstruction. |
| Sculpture |
Mucus impaction may be artistically represented as swelling, blockage, or entanglement—visible but intangible. |
Table 4 – Notable Individuals with Asthma (Linked to ABPA Risk)
| Name |
Field |
Comment |
| Theodore Roosevelt |
Politics |
Had severe childhood asthma, placing him at theoretical risk for ABPA, though not documented. |
| David Beckham |
Sports |
Managed asthma throughout his career; no known ABPA, but fits susceptible demographic. |
| Diane Keaton |
Acting |
Publicly acknowledged her asthma—chronic inflammation increases theoretical risk of ABPA. |
6. Memory Image
Astmatic
Spores of Aspergillus
Allergic Bronchopulmonary Aspergillosis
Finger in Glove Sign
Bronchiectasis and Inspissated
Thick, tenacious mucus containing
eosinophils, Charcot-Leyden crystals, cellular debris, and colonizing Aspergillus hyphae.
Finger-in-Glove ABPA
Artistic rendering shows an asthmatic man with breathing difficulty. The lungs are overlaid with Aspergillus spores, and a CT scan reveals the classic finger-in-glove sign at the left base. The gloved hand reinforces the concept of mucus-impacted bronchi in ABPA.
Courtesy: Ashley Davidoff MD, TheCommonVein.com (140525.8lungs)
Challenge
2. Findings and Diagnosis
3. Clinical
4. Historical and Cultural
6. Memory Image
