November 2021 Imaging Case of the Month: Let’s Not Dance the Twist

Prasad M. Panse MD and Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

Editor’s Note: Parts of this presentation were used in the June 2020 Pulmonary Case of the Month.

History of Present Illness: An 82-year-old man presented to his physician for general health maintenance as well as a complaint of persistently poor quality sleep and poor appetite with weight loss. The patient had undergone robotic-assisted radical left nephroureterectomy and cystectomy with pelvic lymph node dissection and urinary diversion for left clear cell renal cell carcinoma (staged T2a, grade 2) and transitional cell carcinoma of the bladder (carcinoma in situ at surgery), approximately 9 months earlier. The patient’s bladder malignancy was initially treated with transurethral resection, with histopathology at that procedure showing high-grade papillary urothelial malignancy with lamina propria invasion, but no muscular invasion; this procedure was followed by formal complete resection approximately 3 months later. The patient’s post-operative course was complicated by significant bleeding which required transfusion of 3 units of blood. He had undergone inferior vena caval filter placement prior to surgery when preoperative testing revealed lower extremity deep venous thrombus and pulmonary embolism.

Past Medical History: The patient’s past medical history was remarkable for atrial fibrillation treated with anticoagulation and hypertension. He also had a history of coronary artery disease and myocardial infarction with moderate systolic dysfunction His medical list included warfarin (for his atrial fibrillation), acetaminophen, vitamin supplementation, hydrochlorothiazide, atorvastatin, ramipril, metoprolol, and zolpidem. He denied allergies. The patient was a former smoker, previously smoking 2 packs-per day for 35 years, quitting over 30 years prior to presentation.

His past surgical history was remarkable for laminectomy in addition to the recent urinary surgery. He also had a history of rectal laceration complicating previous prostatectomy for prostate carcinoma (Gleason 3 + 4, T2).

Physical Examination: showed the patient to be afebrile with normal heart and respiratory rates and blood pressure. Her room air oxygen saturation was 99%. The physical examination did not disclose any salient abnormalities.

Initial Laboratory: The patient’s complete blood count and serum chemistries showed largely normal values, with the white blood cell count was normal at 6.7 x 10⁹ /L (normal, 4-10 x 10⁹ /L). His liver function testing and renal function testing parameters were also within normal limits. Echocardiography showed mildly decreased left ventricular systolic function, but this finding was stable. The patient underwent frontal chest radiography (Figure 1A).

Figure 1. A: Frontal chest radiography. B: Frontal chest radiography performed just over 1 year prior to A shows no specific abnormalities.

Which of the following represents an appropriate interpretation of his frontal chest radiograph? (Click on the correct answer to be directed to the second of fourteen pages).

1. Frontal chest radiography shows no specific abnormalities
2. Frontal chest radiograph shows a nodule
3. Frontal chest radiography shows bilateral interstitial thickening
4. Frontal chest radiography shows bilateral pleural effusions
5. Frontal chest radiography shows mediastinal and peribronchial lymph node enlargement

Cite as: Panse PM, Gotway MB. November 2021 Imaging Case of the Month: Let’s Not Dance the Twist. Southwest J Pulm Crit Care. 2021;23(5):115-25. doi: https://doi.org/10.13175/swjpcc053-21 PDF

Medical Image of the Month: COVID-19-Associated Pulmonary Aspergillosis in a Post-Liver Transplant Patient

Figure 1. Axial (A) and coronal (B) CT views before transplantation. The lung parenchyma appears normal.

Figure 2. Postoperative axial (A) and coronal (B) CT views 14 days later. Multiple consolidatory nodules with central break down seen involving both lungs, the largest 43mm x 47 mm in the lower lobe of right lung.

A previously healthy, 48-year-old woman, admitted with a working diagnosis of acute-on-chronic liver failure (Grade III) secondary to an autoimmune etiology, was found to be SARS COV-2 RTPCR positive on routine admission screening. She was initially managed with standard medical care for COVID, including steroids. She required invasive ventilation for worsening encephalopathy and when her antigen test was negative 10 days later, she underwent an urgent liver transplantation.

Her preoperative infection screen (culture of blood, bronchoalveolar lavage, urine) was negative and computerised tomography (CT) of the chest was normal (Figure 1). She was extubated on day 3 after liver transplantation. Her recovery was uneventful until the 10th postoperative day when she developed cough and oxygen desaturation. A repeat CT chest showed multiple multilobular consolidatory nodules with central breakdown involving both lung (Figure 2).  Her bronchoalveolar lavage culture grew Aspergillus fumigatus (azole sensitive) which fulfilled criteria for proven COVID-19 Associated pulmonary aspergillosis (pulmonary form) which the host criteria already met (1). Although she was aggressively managed with intravenous voriconazole and liposomal amphotericin, she subsequently succumbed to her illness.

COVID-19 infection shows a propensity to dysregulate the immune system and decreases T-cell lymphocytes. The dysfunctional immune system with a direct damage of respiratory epithelium by the viral infection facilitates superadded bacterial and fungal infections (2).  The use of corticosteroids and antiinterleukins in the therapy elevates the risk. Immunosuppression in an organ transplanted patient can complicate this further. Though patients with invasive fungal disease (IFD) are diagnosed and classified based on host factors, clinical factors and mycological evidences, CAPA essentially need not present with all the typical host and clinical elements (3). A high index of suspicion is essential for an early diagnosis of this condition.

Anandajith Kartha P¹, Zubair Umer Mohamed¹, Dinesh Balakrishnan², S Sudhindran²

Department of ¹Anaesthesiology and Critical Care, ²Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

References

1. Koehler P, Bassetti M, Chakrabarti A, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis. 2021 Jun;21(6):e149-e162. [CrossRef] [PubMed]
2. Herold S, Becker C, Ridge KM, Budinger GR. Influenza virus-induced lung injury: pathogenesis and implications for treatment. Eur Respir J. 2015 May;45(5):1463-78. [CrossRef] [PubMed]
3. Donnelly JP, Chen SC, Kauffman CA, et al. Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin Infect Dis. 2020 Sep 12;71(6):1367-1376. [CrossRef] [PubMed]

Cite as: P AK, Mohamed ZU, Balakrishnan D, Sudhindran S. Medical Image of the Month: COVID-19-Associated Pulmonary Aspergillosis in a Post-Liver Transplant Patient. Southwest J Pulm Crit Care. 2021;23(4):98-99. doi: https://doi.org/10.13175/swjpcc029-21 PDF