PHYSICIAN’S MEET

RADIOLOGICAL IMAGE
DR S LOKEISWAR
PROF DR GEETHA MAM UNIT
KMCH
CASE SCENARIO

• A 55 year old male patient a known diabetic for 15 years and

history of pulmonary tuberculosis 10 years back ATT completed
presents with
H/o low grade fever for 4 months with chills rigors , cough and
easy fatiguability for which he was taking OTC drugs and local
clinic visits
H/o hemoptysis for the last one week which increased in quantity
for last 2 days
ON EXAMINATION

Vitals
• BP 110/70 mm hg
• PR 118 per minute
• Spo2 92 percent with room air and 98 percent with oxygen
• RR 25 cycles per minute
• Auscultation shows bronchial breath sounds in left mammary
axillary infrascapular areas
CT IMAGING OF THE PATIENT
DESCRIPTION

Ct imaging of chest shows

• Air filled cavitory lesion in the left lower lobe
superior segment with homogenous mass within the
cavity separated from the wall
• Pleural thickening noted
DIAGNOSIS??
• From the clinical history examination findings and
imaging the diagnosis can be
FUNGAL BALL OR ASPERGILLOMA -
MONOD SIGN
ASPERGILLOSIS

• Caused by the saprophytic spore forming fungus

• Germinates to form hyaline septate mould with branching
hyphae and conidia formation
• Ubiquitous in environment and acquired by inhalation
• Healthy immune system eliminates it but in
immunocompromised individuals the disease manifests
SPECTRUM OF DISEASES

•INVASIVE – acute (< one month )

subacute and necrotising ( one to 3 months )

•CHRONIC (>3 months) – chronic pulmonary aspergillosis, chronic

fibrosing aspergillosis, aspergilloma, chronic maxillary sinusitis , fungal
sinus ball

•ALLERGIC – allergic bronchopulmonary aspergillosis(ABPA), severe

asthma with fungal sensitisation ,allergic aspergillus sinusitis
INVASIVE ASPERGILLOSIS
INVASIVE ASPERGILLOSIS CT IMAGE
AIR CRESCENT SIGN

• Should not be confused with Monod sign

• This is seen in recovering invasive aspergillosis and here
the mass is immobile
• Also seen in tuberculous cavity with blood clot or
Rasmussen aneurysm, hydration cyst, cavitary lung
cancer , lung abscess, and other fungal infections
ASPERGILLOMA - CRESCENT OF AIR SURROUNDING THE MOBILE
FUNGAL BALL – MONOD SIGN
ASPERGILLOMA CT IMAGE MONOD SIGN
DIAGNOSIS

• Invasive aspergillosis- antigen detection , PCR

testing , culture and histological examination
• Chronic aspergillosis- antibody detection and imaging
• Allergic aspergillosis- positive skin prick testing ,
estimation of total serum IgE and anti aspergillus IgE ,
fleeting infiltrates characteristic of ABPA
TREATMENT
• Invasive – intravenous therapy DOC is voriconazole
Others used are posaconazole isavuconazole ; duration for 3 months to
years
• Chronic- voriconazole itraconazole upto 6 months sometimes years
• Allergic aspergillosis- short course steroids with long course antifungals
• Surgery for single aspergilloma , invasive sinusitis, sinus ball
• Bronchial artery embolization for massive hemoptysis
PROPHYLAXIS

• Given for patients started on chemotherapy, long

duration steroids, transplant recipients
• Fluconazole for candidiasis
• Itraconazole or posaconazole for aspergillosis
DIFFERENTIAL DIAGNOSIS FOR CAVITY WITH
MASS LESION

• Primary lung malignancy

• Metastatic disease
• Hydatid disease
• Intracavitary hematoma
• Lung abscess
THANK YOU !!