•  40-year-old gentleman with Type 1 DM
  • presenting with several months of
    • worsening weakness, falls,
    • deconditioning brought in by EMS
    • in DKA

CXR – Vague Mid and Lower Lung Infiltrate

CXR – Vague Mid and Lower Lung Infiltrate
Ashley Davidoff

 

CXR 2 days later
The Frontal CXR shows a rapidly progressive interstitial infiltrate in the left upper lobe with a focal subsegmental infiltrate in the right lower lobe  Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net
  • Management
    • initially managed for DKA with
      • insulin drip,
      • fluid management, and
      • electrolyte management.
    • DKA resolved but
      • became acutely more ill and
      • developed chest pain.
    • Insulin was to transition back to an insulin drip

CXR 2 days later

CXR 2 days later
The Frontal CXR shows a rapidly progressive interstitial infiltrate in the left upper lobe with a focal subsegmental infiltrate in the right lower lobe  Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net
  • Chest CT
      • revealed bilateral consolidative opacities
      • reversed halo sign (Atoll)
      • concerning for fungal infection.
  • Bronchoscopy was performed
      • frank hyphae and
      • fungal balls in the bronchus.

CT Scan Large Infiltrate with Halo Sign and Reversed Halo 

CT Scan Large Infiltrate with Reversed Halo Sign and Halo Sign
The coronal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper lobe (halo sign) with a focal subsegmental infiltrate in the right lower lobe, showing features of a reversed halo sign (Atoll sign)  There is evidence of bronchial wall thickening.
Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net 219Lu-004

Features of the Left Sided Infiltrate

CT Scan Large Infiltrate with Halo Sign
The coronal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper lobe showing features of a halo sign  There is evidence of bronchial wall thickening.
Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net 219Lu-002

 

Note Significant Bronchial Wall Thickening

CT Scan Large Infiltrate with Halo Sign
The coronal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper lobe with a focal subsegmental infiltrate in the right lower lobe, both showing features of a reversed halo sign (Atoll sign)  There is evidence of bronchial wall thickening.
Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net 219Lu-003

 

CT Scan Large Infiltrate with Reversed Halo Sign
The coronal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper lobe showing features of a halo sign.  There is evidence of bronchial wall thickening.
Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net 219Lu-005
CT Scan Large Infiltrate with Halo Sign
The coronal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper lobe showing features of a halo sign  There is evidence of bronchial wall thickening.
Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net 219Lu-008

Consolidative Changes in the Lung Bases with Obstruction of the Lower Lobe Airways and Finger in Glove Appearance

Consolidative Changes in the Lung Bases with Obstruction of the Lower Lobe Airways and Finger in Glove Appearance
The sagittal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper and lower lobes showing features of a reversed halo sign (Atoll sign)  There is evidence of basilar consolidation   Extensive disease of the segmental and subsegmental airways are noted  Fungal Hyphae were identified at bronchoscopy
Diagnosis Aspergillus Infection 
Ashley Davidoff TheCommonVein.net 219Lu-006
Consolidative Changes in the left Lung Base with Obstruction of the Lower Lobe Airways
The sagittal CT scan  shows a rapidly progressive interstitial infiltrate in the left upper and lower lobes showing features of a halo sign.  In addition there is a left basilar consolidation   Extensive disease of the segmental and subsegmental airways is noted (red arrow)  Fungal Hyphae were identified at bronchoscopy
Diagnosis Aspergillus Infection 
Ashley Davidoff TheCommonVein.net 219Lu-007

Suggestion of Finger in Glove of the Posterior and Latera Segmental Airways 

Suggestion Obstruction of the Lower Lobe Airways  and Resulting in  Finger in Glove of the Posterior and Latera Segmental Airways.
The axial CT scan  shows  interstitial infiltrate in the left upper and lower lobes   There is evidence of basilar band like densities like due to impaction of dilated posterior and lateral segmental airways filled with hyphae of the fungus (bronchoscopic observation)  This appearance is reminiscent of the finger in glove sign. The red arrowhead shows a diffusely diseased anterior segmental airway 
Diagnosis Aspergillus Infection 
Ashley Davidoff TheCommonVein.net 219Lu-009

Ashley Davidoff TheCommonVein.net

Consolidative Changes in the left Lung Base with Obstruction of the Lower Lobe Airways and Finger in Glove Appearance
The axial CT scan  shows multi-segmental consolidation involving the posterior and lateral segments of the LLL Fungal hyphae were identified at bronchoscopy
Diagnosis Aspergillus Infection 
Ashley Davidoff TheCommonVein.net 219Lu-011

Atoll Sign in the Right Lower Lobe

Small Airway Disease Ground Glass Micronodules and Probable Tree in Bud Sign
Axial Ct scan focused on the right lung base shows ground glass micronodules revealing a combination of centrilobular nodules and tree in bud sign indicating small airway disease
Diagnosis Aspergillus Infection 
Ashley Davidoff TheCommonVein.net 219Lu-015
CT Scan shows a focal smaller focal region demonstrating features of a reversed halo sign (Atoll sign)  Fungal Hyphae were identified at bronchoscopy
Diagnosis Aspergillus Infection
Ashley Davidoff TheCommonVein.net219Lu-014

Small Airway Disease Ground Glass Micronodules and Probable Tree in Bud Sign

Small Airway Disease Ground Glass Micronodules and Probable Tree in Bud Sign
Axial Ct scan focused on the right lung base shows ground glass micronodules revealing a combination of centrilobular nodules and tree in bud sign indicating small airway disease
Diagnosis Aspergillus Infection 
Ashley Davidoff TheCommonVein.net 219Lu-015
    • became acutely altered,
    • unresponsive, with
    • sluggish pupils and
    • agonal breathing.
    • intubated for
      • airway protection and
      • hypoxemic respiratory failure. P
      • cardiac arrest
      • PEA arrest
      • repeat bronchoscopy
        • redemonstration of his fungal infection
      • cardiac arrest again
      • was pronounced dead