Imaging of fungal pneumonia in the ICU
Transcript of Imaging of fungal pneumonia in the ICU
Avraham Cooper, HMS IIIGillian Lieberman, MD
Imaging of fungal pneumonia in the ICU
Avraham Cooper, HMS IIIGillian Lieberman, MD
1/23/12
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Outline• ICU patients and their susceptibility to fungal
pneumonia• Common fungal etiologies in ICUs• Index Case• Radiologic hallmarks of fungal pneumonias• Summary
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Outline• ICU patients and their susceptibility to fungal
pneumonia• Common fungal etiologies in ICUs• Index Case• Radiologic hallmarks of fungal pneumonias• Summary
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Immuno-susceptibility and the ICU• Changes in innate and adaptive immune function (1) • Use of immunosuppressant drugs such as
corticosteroids• Many patients have secondary pre-disposing diseases
such as neutropenia, malignancy (2), or late sepsis (3) • Frequent ventilation introduces pathogens directly into
lungs
Monneret G et al, 2010.Nseir S et al, 2011.Boomer JS et al, 2011.
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Outline•ICU patients and their susceptibility to fungal pneumonia•Common fungal etiologies in ICUs•Index Case•Radiologic hallmarks of fungal pneumonias•Summary
Avraham Cooper, HMS IIIGillian Lieberman, MD
Common fungal etiologies in ICUs•Aspergillus•Candida•Fusarium•Zygomycetes
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Aspergillus•Aerobic mold•Fumigatus is most common species•Causes invasive pulmonary aspergillosis (IPA)•Also causes semi-invasive pulmonary aspergillosis, allergic bronchopulmonary aspergillosis (ABPA), as well as aspergillomas (asymptomatic fungus balls) in pre-exisiting lung cavitations
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IPA• Presents with symptoms of pneumonia including
fever, dyspnea, and productive cough (4)• Pleuritic chest pain is a common complaint
(angio-invasive infection leads to infarction) (4)• The most common fungal pnuemonia in the ICU• Sputum cultures only positive in 10% of affected
patients (7) making imaging key to diagnosis
Miller, 1996.Abramson S, 2001.
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Outline•ICU patients and their susceptibility to fungal pneumonia•Common fungal etiologies in ICUs•Index Case•Radiologic hallmarks of fungal pneumonias•Summary
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Index Patient: HPI •Our index patient is a 75 year old man with a history of MDS/AML, Wegener’s (in remission), and CKD on HD•At time of admission he had recently taken a course of Revlimid (thalidomide analogue) with resultant pancytopenia•He presented with one week of anorexia, headache, fatigue, fevers, cough with brown sputum, and left-sided “rib” pain with coughing
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Index Patient: Physical Exam
•Vitals: T 102.5, HR 80, BP 140/80, Sp02 92%•Poor dentition noted in oropharynx•On chest auscultation, musical rhonchi heard in inspiration. Tenderness over 5th ribs present in mid-axillary line•Spleen tip was palpable
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Index Patient: Pertinent labs•WBC 3.1 (76% neutrophils)•Creat 4.6•ANCA negative
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Index Patient: Chest radiograph at presentation
Left upper lobeconsolidation
PACS, BIDMC
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Index Patient: CT chest at presentation
Ground-glass opacityindicating likely siteof hemorrhage with
multiple consolidationsin both lung fields
14Axial chest CT, C-PACS, BIDMC
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Index Patient: Differential diagnosis• Recurrence of Wegener’s vasculitis• Opportunistic infections such as fungal, viral,
nocardia, PCP and mycobacteriurm• Pyogenic infection• Hemorrhage
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Index Patient: Decompensation
•After admission, he de-saturated to mid 80’s on low-flow nasal cannula•Out of concern for tenuous respiratory status he was transferred to the ICU.
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Index Patient: Chest radiograph in the ICU
Almost complete opacification of the
left lung field withright-sided shift
of the mediastinum
PACS, BIDMC
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Index Patient: Chest CT in the ICU
Expansile consolidative opacityin the left upper lobe. Density is 40 HU, indicating intermediate density, with central hypodensity which may be necrotic.There is evident mediastinal shift.
Axial CT chest, C-PACS, BIDMC
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Index Patient: ICU course•His respiratory status continued to decline and he was intubated and treated with broad spectrum antibiotics and anti-fungals•Per the patient’s previous wishes care was withdrawn and he passed away•Post-mortem bronchoscopy revealed aspergillus
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Outline• ICU patients and their susceptibility to fungal
pneumonia• Common fungal etiologies in ICUs• Index Case• Radiologic hallmarks of fungal pneumonias• Summary
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Companion Patient 1: The Halo Sign in IPA
The Halo Sign
Solid nodular coresurrounded by
ground glass opacity
Greene R E et al, 2007.
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The Halo sign• Results from a necrotic nodule surrounded by a
hemorrhagic/necrotic rim (6)• Specific for invasive aspergillosis, allowing for
early diagnosis and institution of therapy(7)
Hruban RH et al, 1987Abramson S, 2001.
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The Halo Sign: Clinical Implications
The halo sign isassociated with
decreased mortalityin patients with IPA
Greene R E et al, 2007
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Index patient: Halo Sign on initial presentation?
Nodule surrounded by ground glass opacities
24Axial CT chest, C-PACS, BIDMC
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Companion Patient 2: Initial Radiograph
Invasive aspergillosis in a6-year-old girl with neutropenia
and acute lymphocytic leukemia,revealing a lingular infiltrate
25Abramson S, 2001.
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Companion Patient 2: The Air Crescent Sign
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One week later there aremultiple crescentic
lucencies surrounded by soft-tissue
density opacities
Abramson S, 2001.
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The Air-Crescent Sign•Specific for IPA (7)•Crescentic lucency surrounded by soft-tissue density opacities (7)•Results from air in between necrotic/hemorrhagic lung (7)
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Abramson S, 2001.
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Companion Patient 2: Air Crescent sign on CT
Crescentic lucency surrounded
by enhancing opacities (box)
28Axial CT chest, C+Abramson S, 2001.
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Candida Pneumonia•Yeast•Albicans is the most common species•Candida was isolated from respiratory secretions in 26% of ICU patients in one series (8)•This usually represents colonization rather than infection, except rarely in severely immunosuppressed patients (8)
C H E SAzoulay E et al, 2006.
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Candida Pneumonia• Radiographic appearance depends on route of spread
(4)• Hematogenous spread (99%[9]) from disseminated
infection produces diffuse miliary, nodular (4) microabscesses (10)
• Primary pneumonia (1% [9] ) usually reveals non- specific alveolar consolidations from pharyngeal aspiration of overgrown candida in the oropharynx of immunosuppressed patients (4)
Haron E et al, 1993. Kauffman C, UptoDate.Miller, 1996.
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Companion Patient 4: Candida - Hematogenous Spread
Miller, 1996.
Diffuse bilateral nodularopacities representinglikely micro-abscesses
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Companion Patient 5: Candida - Aspiration
Fluffy right-sided infiltrate (box) in a patient who
aspirated and laterdeveloped candidemia
32Kobayashi T et al, 2005.
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Fusarium sp.•Filamentous mold •Solani is the most common species•Second most common mold infection in immunosuppressed patients after Aspergillus (12)• Imaging reveals non-specific infiltrates and nodular or cavitary lesions (12)
33Gorman SR et al, 2006.
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Axial CT chest, C-
Gorman SR et al, 2006.
Multiple small right apical nodules in an
immunocompetentpatient who cleanedbird droppings (box)
Companion Patient 6: Primary Fusarium Pneumonia
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Zygomycetes•Spore-forming, commonly found on decaying vegetation and soil (13)•Rhizopus and Mucor are most common species•Inhalation of spores by immuncompromised patients leads to rapidly progressive pneumonia with infarction and necrosis, and can spread to nearby structures such as the mediastinum and heart (13)•Characteristic finding is the reverse-halo sign: a focal ground glass opacity surrounded by a ring of consolidation – non-specific, as also seen in COP
35Cox GM, UptoDate.Busca A et al, 2011.
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Companion Patient 7: Zygomycosis
Axial CT chest, C-
Busca A et al, 2011
The Reverse Halo SignGround glass opacitysurrounded by a ring
of consolidationin a stem cell
transplant recipient
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Compare Reverse halo sign vs. Halo sign
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Axial CT chest, C-Busca A et al, 2011.
Greene R E et al, 2007.
Ground glass opacity surrounded by consolidation Consolidation surrounded
by ground glass opacity
Avraham Cooper, HMS IIIGillian Lieberman, MD
Outline•ICU patients and their susceptibility to fungal pneumonia•Common fungal etiologies in ICUs•Index Case•Radiologic hallmarks of fungal pneumonias•Summary
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Summary•Fungal pneumonia is a relatively common concern in ICUs, especially in immunosuppressed patients•Distinguishing invasive disease vs. colonization can be difficult, especially regarding candida sp.•Radiographic hallmarks can aid in early diagnosis, such as the halo and air-crescent signs in Aspergillus and reverse-halo sign in Zygomycosis
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Avraham Cooper, HMS IIIGillian Lieberman, MD
1. Monneret G, Venet F, Kullberg BJ, Netea MG: Med Mycol. 2011 Apr;49 Suppl 1:S17-23. Epub 2010 Aug 18.2. Nseir S, Di Pompeo C, Diarra M, et al. Relationship between immunosuppression and intensive care unit-
acquired multidrug-resistant bacteria: a case-control study. Crit Care Med 2007;35:1318-233. Boomer JS et al. JAMA. 2011;306(23):2594-26054. Seminars in Roentgenology, Wallace T. Miller, vol XXXXI, No. 1, January 1996 5. Greene R E et al. Clin Infect Dis. 2007;44:373-3796. Hruban RH, Meziane MA, Zerhouni EA, et al. Radiologic-pathologic correlation of the CT-halo sign in invasive
pulmonary aspergillosis. J Comp. Assist. Tomogr.-1987; 11; 534-536. 7. Abramson S Radiology 2001;218:230-2328. Azoulay E et al. CHEST January 2006 vol. 129 no. 1:110-1179. Haron E et al. Medicine (Baltimore). 1993 May;72(3):137-42.10. Kauffman C. Candida Infections in the Abdomen and Thorax. UptoDate.
http://www.uptodate.com/contents/candida-infections-of-the-abdomen-and- thorax?source=search_result&search=candida+pneumonia&selectedTitle=1%7E4#H4. 1/18/12.
11. Kobayashi T et al. Intern Med. 2005 Nov;44(11):1191-4.12. Gorman SR et al. South Med J. 2006 Jun;99(6):613-6.13. Cox GM. Mucormycosis (zygomycosis). UptoDate. http://www.uptodate.com/contents mucormycosis-
zygomycosissource=search_result&search=zygomycetes&selectedTitle=1%7E55. 1/22/12.
14. Busca A et al. Infection. 2011 Jul 7. [Epub ahead of print].
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References
Avraham Cooper, HMS IIIGillian Lieberman, MD
Acknowledgements •Dr. Paul Spirn, MD•Dr. Woodrow Weiss, MD•Dr. Praveen Akuthota, MD•Dr. Gillian Lieberman, MD•Dr. Mai-Lan Ho, MD•Dr. Patrick Redmond, MD•Claire Odom•Narie Storer•Susan Mcgirr•Mekeme Utuk
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