title: Initial CT manifestations of invasive pulmonary aspergillosis in 45 non-HIV immunocompromised patients: association with patient outcome?
abstract: OBJECTIVE
  To assess early high-resolution computer tomographic (CT) signs of invasive pulmonary aspergillosis (IPA) in non-HIV immunosuppressed patients and their potential association with patient's outcome, including frequency and severity of pulmonary hemorrhage, taking also in consideration the impact of other known risk factors contributory to IPA.
  
  
  METHODS
  A retrospective review of serial CT scans was performed in 45 immunocompromised patients with a total of 46 episodes of invasive pulmonary aspergillosis. All patients underwent CT beginning with the day they showed clinical or laboratory signs of infection. Serial follow-up CT included more than two, up to 12 CT examinations. Patient's outcome was judged by clinical and radiological follow-up and classified as survival, death by IPA, or death unrelated to IPA. The influence of patient's age, underlying disease, hematopoietic stem cell transplantation, neutropenia, graft versus host disease, and antifungal therapy onset was also statistically considered.
  
  
  RESULTS
  Three main CT findings were identified: small nodules (<1cm) 43% (20/46), large nodules 21% (10/46) and consolidations, either in patchy+/-segmental 26% (12/46), or peribronchial distribution+/-tree in bud 9% (4/46). In 11 patients (24%) we found a combination of two or more of these signs: 9 (19%) patients presented concurrent small nodules accompanied by reticulation, tree in bud or peribronchial infiltrates, while 2 (4%) patients showed large pulmonary nodules accompanied by large consolidations. An accompanying "halo" sign was observed in 38 patients (82%). Crescent sign followed by cavitation was encountered in 29 patients (63%). Two patients succumbed to massive pulmonary bleeding caused by IPA. Twenty-one patients (15/46) deceased in this series, 12 of them succumbed to IPA, 1 died from cerebral invasive aspergillosis, while in 9 patients the cause of death was not primarily IPA. Manifest pulmonary hemorrhage occurred in 19% (9/46) of IPA episodes.
  
  
  CONCLUSIONS
  Initial CT findings of invasive pulmonary aspergillosis consist mainly of small nodules or patchy consolidations, showing in 82% of cases an early halo sign. Serious pulmonary hemorrhage was an infrequent clinical complication in our series, with an attributable mortality of 4.3%. IPA-related lethality was 26%, in our cohort. None of the early HRCT signs seemed to predict outcome.
authors.affiliation: Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany. mshorger@med.uni-tuebingen.de
authors.forename: Marius
authors.initials: M
authors.lastname: Horger
authors.forename: Holger
authors.initials: H
authors.lastname: Hebart
authors.forename: Hermann
authors.initials: H
authors.lastname: Einsele
authors.forename: Claudia
authors.initials: C
authors.lastname: Lengerke
authors.forename: C D
authors.initials: CD
authors.lastname: Claussen
authors.forename: Reinhard
authors.initials: R
authors.lastname: Vonthein
authors.forename: Christina
authors.initials: C
authors.lastname: Pfannenberg
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001228:Aspergillosis / Q000000981:diagnostic imaging*; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D008172:Lung Diseases, Fungal / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods*