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High-Attenuation Mucus in Allergic Bronchopulmonary Aspergillosis: Another Cause of Diffuse High-Attenuation Pulmonary Abnormality

Postgraduate Institute of Medical Education and Research Chandigarh, India 160012

We read with interest the January 2005 AJR article "Diffuse High-Attenuation Pulmonary Abnormalities: A Pattern-Oriented Diagnostic Approach on High-Resolution CT" [1]. The authors describe a classification scheme of the various entities that can result in diffuse high-attenuation pulmonary abnormalities based on the pattern and distribution of findings on high-resolution CT. We would like to describe another entity characterized by high-attenuation pulmonary abnormality.

A 40-year-old man, a known asthmatic since childhood, presented with a history of worsening cough and exertional breathlessness of 6 months' duration. There was no history of fever, chest pain, or hemoptysis. Examination of the respiratory system revealed diffuse expiratory polyphonic wheeze. The rest of the physical examination was unremarkable. High-resolution CT (Fig. 1A) showed bilateral high-attenuation pulmonary lesions. Lung window setting (Fig. 1B) showed central bronchiectasis, numerous mucus-filled bronchi, and centrilobular nodules with tree-in-bud pattern confirming the high-attenuation lesions to be inspissated mucus. A skin test for Aspergillus fumigatus was positive, total IgE count was 7,800 IU/mL, IgE specific to A. fumigatus was 12 kU/L, and absolute eosinophil count was 4,000/mL. The final diagnosis was allergic bronchopulmonary aspergillosis (ABPA).

View larger version (51K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —40-year-old man with known asthma and worsening cough. High-resolution CT image (soft-tissue window setting) shows bilateral high-attenuation lesions (arrows).

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —40-year-old man with known asthma and worsening cough. High-resolution CT image (lung window setting) shows central bronchiectasis, numerous mucus-filled bronchi (large arrow), and centrilobular nodules with tree-in-bud pattern (small arrow).

ABPA is a pulmonary disorder characterized by hypersensitivity to fungi, most commonly A. fumigatus. The chest radiograph findings include the gloved-finger sign, toothpaste shadows, air-fluid levels from dilated bronchi, and tramline shadows from edematous bronchial walls. High-resolution CT is more sensitive than chest radiography and characteristically shows central bronchiectasis, mucus-filled bronchi (also called bronchoceles), consolidation, and centrilobular nodules. Herein we describe an uncommon presentation of ABPA—hyperdense mucus impaction.

The differential diagnosis of mucoid impaction includes endobronchial lesions, inhalation of foreign bodies, bronchial atresia, and bronchiectasis of any cause. The presence of high-density mucoid impaction, on the other hand, is peculiar to ABPA and if present should be considered characteristic [2-4]. First described in association with chronic fungal sinusitis, high-density mucus presumably represents the presence of calcium ions, metallic ions, or both within the inspissated mucus [5] and was reported to be as high as 28% in one series [5].

References

Top References

 

1. Marchiori E, Souza AS Jr, Franquet T, Müller NL. Diffuse high-attenuation pulmonary abnormalities: a pattern-oriented diagnostic approach on high-resolution CT. AJR 2005;184 : 273-282[Free Full Text]
2. Goyal R, White CS, Templeton PA, Britt EJ, Rubin LJ. High attenuation mucus plugs in allergic bronchopulmonary aspergillosis: CT appearance. J Comput Assist Tomogr 1992;16 : 649-650[Medline]
3. Logan PM, Muller NL. High-attenuation mucus plugging in allergic bronchopulmonary aspergillosis. Can Assoc Radiol J1996; 47:374 -377[Medline]
4. Molinari M, Ruiu A, Biondi M, Zompatori M. Hyperdense mucoid impaction in allergic bronchopulmonary aspergillosis: CT appearance. Monaldi Arch Chest Dis 2004;61 : 62-64[Medline]
5. Zinreich SJ, Kennedy DW, Malat J, et al. Fungal sinusitis: diagnosis with CT and MR imaging. Radiology1988; 169:439 -444[Abstract/Free Full Text]

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				R. Agarwal, D. Gupta, A. N. Aggarwal, A. K. Saxena, A. Chakrabarti, and S. K. Jindal Clinical Significance of Hyperattenuating Mucoid Impaction in Allergic Bronchopulmonary Aspergillosis: An Analysis of 155 Patients Chest, October 1, 2007; 132(4): 1183 - 1190. [Abstract] [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Agarwal, R. Articles by Gupta, D. Search for Related Content PubMed PubMed Citation Articles by Agarwal, R. Articles by Gupta, D. Social Bookmarking                      What's this?