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
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 Reversed Halo Sign
CT Scan Large Infiltrate with Reversed 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
Features of the Left Sided Infiltrate
CT Scan Large Infiltrate with Reversed 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
Note Significant Bronchial Wall Thickening
CT Scan Large Infiltrate with Reversed 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
CT Scan Large Infiltrate with Reversed Halo Sign The coronal 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 focal regions of consolidation in the left lower lobe Diagnosis Aspergillus Infection Ashley Davidoff TheCommonVein.net
CT Scan Large Infiltrate with Reversed Halo Sign The coronal 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 bronchial wall irregularity (arrowhead) Fungal Hyphae were identified at bronchoscopy Diagnosis Aspergillus Infection Ashley Davidoff TheCommonVein.net
CT Scan Large Infiltrate with Reversed Halo Sign The coronal 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 bronchial wall irregularity (arrowhead) Fungal Hyphae were identified at bronchoscopy Diagnosis Aspergillus Infection Ashley Davidoff TheCommonVein.net
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
Consolidative Changes in the Lung Bases 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 reversed halo sign (Atoll sign) There is evidence of 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
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
Consolidative Changes in the Lung Bases with Obstruction of the Lower Lobe Airways and Finger in Glove Appearance The axial CT scan shows multisegmental consolidation involving the posterior and lateral segments of the LLL Fungal hyphae were identified at bronchoscopy Diagnosis Aspergillus Infection Ashley Davidoff TheCommonVein.net
Atoll Sign in the Right Lower Lobe
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.net
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
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