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Long-Term CT Follow-Up in 40 Non-HIV Immunocompromised Patients with Invasive Pulmonary Aspergillosis: Kinetics of CT Morphology and Correlation with Clinical Findings and Outcome

Harald Brodoefel1, Monika Vogel1, Holger Hebart2, Hermann Einsele2, Reinhard Vonthein3, Claus Claussen1 and Marius Horger1

1 Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany.
2 Department of Internal Medicine-Onocology, Eberhard-Karls-University, Tuebingen, Germany.
3 Department of Medical Biometry, Eberhard-Karls-University, Tuebingen, Germany.


Figure 1
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  		Fig. 1A —Graphs illustrate CT kinetics. Kinetics of lesion size (A) and numbers (B). Median values and interquartile ranges are provided for lesion size, lesion number, and time (days). Time points (X) indicated are first diagnosis, first sight of maximal area, last sight of maximal area, time at halved maximal area, and time at complete radiologic remission. Mean values for these time points were 0, 9, 16, and 85.5 days, respectively. Ninety percent of 40 patients showed increase of lesion size after day of diagnosis; 62.5% had reduction down to 50% of maximum size, and 42.5% had complete radiologic remission.

 

Figure 2
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  		Fig. 1B —Graphs illustrate CT kinetics. Kinetics of lesion size (A) and numbers (B). Median values and interquartile ranges are provided for lesion size, lesion number, and time (days). Time points (X) indicated are first diagnosis, first sight of maximal area, last sight of maximal area, time at halved maximal area, and time at complete radiologic remission. Mean values for these time points were 0, 9, 16, and 85.5 days, respectively. Ninety percent of 40 patients showed increase of lesion size after day of diagnosis; 62.5% had reduction down to 50% of maximum size, and 42.5% had complete radiologic remission.

 

Figure 3
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  		Fig. 2A —Remission with fibrotic residual lesion in 63-year-old man with acute lymphatic leukemia and neutropenia after intensive chemotherapy. On day invasive pulmonary aspergillosis (IPA) was diagnosed, axial CT scan showed multiple masses and nodules with halo sign.

 

Figure 4
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  		Fig. 2B —Remission with fibrotic residual lesion in 63-year-old man with acute lymphatic leukemia and neutropenia after intensive chemotherapy. Eight days later, CT scan revealed confluence and increasing size of lesions. Combination of halo sign and extensive ground-glass opacity points to massive hemorrhage.

 

Figure 5
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  		Fig. 2C —Remission with fibrotic residual lesion in 63-year-old man with acute lymphatic leukemia and neutropenia after intensive chemotherapy. Twenty days later, signs of active hemorrhage had disappeared and lesions had regressed to residual segmental or nonsegmental parenchymal consolidation. Right middle lobe showed signs of shrinkage.

 

Figure 6
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  		Fig. 2D —Remission with fibrotic residual lesion in 63-year-old man with acute lymphatic leukemia and neutropenia after intensive chemotherapy. Finally, 90 days after initial diagnosis, two lesions had completely resolved, whereas largest mass has regressed to thin circular wall of fibrotic tissue without any further dynamics on follow-up CT scans. Patient survived IPA.

 

Figure 7
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  		Fig. 3A —Complete remission in 34-year-old man with acute lymphatic leukemia and aplasia after high-dose chemotherapy. On day of invasive pulmonary aspergillosis diagnosis, axial CT scan showed multiple nodules, one of three on given slice surrounded by halo of discrete hemorrhage.

 

Figure 8
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  		Fig. 3B —Complete remission in 34-year-old man with acute lymphatic leukemia and aplasia after high-dose chemotherapy. Eight days following initial diagnosis, lesions had increased in size and number and were still accompanied by halo sign.

 

Figure 9
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  		Fig. 3C —Complete remission in 34-year-old man with acute lymphatic leukemia and aplasia after high-dose chemotherapy. Fifteen days following initial diagnosis, halo sign had disappeared and all lesions were in decline.

 

Figure 10
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  		Fig. 3D —Complete remission in 34-year-old man with acute lymphatic leukemia and aplasia after high-dose chemotherapy. Forty-five days following initial diagnosis, chest CT showed complete radiologic remission.

 

Figure 11
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  		Fig. 4A —Postsurgical relapse in 54-year-old man with acute myelogenous leukemia and neutropenia after hematopoietic stem cell transplantation (HSCT). On day of invasive pulmonary aspergillosis diagnosis, axial CT scan showed solitary mass with discrete halo sign. Cavitation occurred at day 20 postdiagnosis and proved resistant to standard antifungal therapy.

 

Figure 12
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  		Fig. 4B —Postsurgical relapse in 54-year-old man with acute myelogenous leukemia and neutropenia after hematopoietic stem cell transplantation (HSCT). Two months postdiagnosis, walls of cavitation showed marked increase of thickness, and patient developed hemoptysis. For this reason, patient underwent lung resection 3 months postdiagnosis.

 

Figure 13
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  		Fig. 4C —Postsurgical relapse in 54-year-old man with acute myelogenous leukemia and neutropenia after hematopoietic stem cell transplantation (HSCT). Postoperative CT revealed bandlike fibrotic tissue and volume shrinkage but no signs of residual fungal infection.

 

Figure 14
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  		Fig. 4D —Postsurgical relapse in 54-year-old man with acute myelogenous leukemia and neutropenia after hematopoietic stem cell transplantation (HSCT). Three weeks postsurgery, chest CT showed relapse of fungal disease at site of resection with discrete crescent sign. Patient showed complete resolution months later related to prolonged antifungal therapy.

 

Figure 15
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  		Fig. 5 —Kaplan-Meier graph highlighting prolonged remission time of all observed cavitations in comparison with noncavitary lesions (risk ratio, 0.5; confidence interval, 0.31-0.76). Size of cavitations did not have significant effect on time to complete regression.

 

Figure 16
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  		Fig. 6 —Box plot illustrating effect of cavitary lesions on radiologic duration of disease. Time until complete radiologic remission was 2.5 times longer in patients with cavitary lesions (confidence interval, 1.007-6.3).

 

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