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Pulmonary Histoplasmosis Presenting With the Reversed Halo Sign on High-Resolution CT Scan
CHEST Pulmonary Histoplasmosis Presenting With the Reversed Halo Sign on High-Resolution CT Scan Edson Marchiori, MD, PhD; Saulo Maia Davila Melo, MD; Flávia Gavinho Vianna, MD; Bárbara Santana D. Melo, MD; Saulo Santana D. Melo, MD; and Gláucia Zanetti, MD, PhD
We describe the case of a 23-year-old man with pulmonary histoplasmosis whose high-resolution CT scan demonstrated the reversed halo sign. We also extensively review the literature about this CT scan sign. The reversed halo sign has been described in a number of diseases, both infectious and noninfectious. However, to our knowledge, this is the first reported case of pulmonary histoplasmosis presenting with this radiologic finding. CHEST 2011; 140(3):789–791
Selected Reports
Case Report A 23-year-old man presented with a 3-month history of persistent dry cough, episodes of fever, anorexia, and a 2-kg weight loss. He was a nonsmoker and denied the use of illicit drugs, relevant travel history, or exposure to birds, caves, or a rural environment. He lived in an urban area in Brazil and had worked in a weaving factory for 2 years as a mechanic. Physical examination was normal except for mild crackles in both lungs. A blood chemistry screen was normal, and an HIV test was negative. Chest radiographs showed bilateral diffuse reticulonodular opacities and a discrete focus of consolidation in the upper lung zones. High-resolution CT (HRCT) scan showed bilateral ground-glass irregular opacities surrounded by rings of consolidation (the RHS), distributed mainly in the upper zones of the lungs (Fig 1). The patient was hospitalized for investigation. During hospital admission, he reported exposure to bats in his workplace. A bronchoscopy showed diffuse hyperemia of the bronchial tree. Microscopic examination and BAL
Abbreviations: COP 5 cryptogenic organizing pneumonia; HRCT 5 high-resolution CT; OP 5 organizing pneumonia; RHS 5 reversed halo sign
T
he reversed halo sign (RHS) is defined as a focal, rounded area of ground-glass opacity surrounded by a nearly complete ring of consolidation observed by CT scanning.1 Although Kim et al2 were the first to coin the term “reversed halo sign,” the association between cryptogenic organizing pneumonia (COP) and this radiologic finding was first described by Voloudaki et al,3 who reported the CT scan findings of two patients with COP. However, other studies have demonstrated the presence of this sign in several other infectious and noninfectious conditions.4 We report a case of a 23-year-old man with pulmonary histoplasmosis who presented with the RHS and extensively review the literature about this tomographic sign. Manuscript received January 8, 2011; revision accepted February 19, 2011. Affiliations: From the Federal University of Rio de Janeiro (Drs Marchiori, Vianna, and Zanetti), Rio de Janeiro; the Federal University of Sergipe (Dr S. M. D. Melo), Aracaju, Sergipe; and the University Center Serra dos Órgãos (Drs B. S. D. Melo and S. S. D. Melo), Teresópolis, Rio de Janeiro, Brazil. Correspondence to: Edson Marchiori, MD, PhD, Rua Thomaz Cameron, 438 Valparaiso CEP 25685.120, Petrópolis, Rio de Janeiro, Brazil; e-mail: [email protected] © 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-0055 www.chestpubs.org
Figure 1. A and B, High-resolution CT scans of the upper lobes demonstrate irregular and bizarre-shaped localized areas containing central ground-glass opacities surrounded by denser ring of consolidation, indicative of the reversed halo sign. B, Highresolution CT scan obtained at a level below the scan shown in A. CHEST / 140 / 3 / SEPTEMBER, 2011
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cultures were negative for mycobacteria and positive for Histoplasma capsulatum. An immunodiffusion test was also positive for histoplasmosis. The patient was treated with 400 mg of ketoconazole for 6 months and showed remarkable improvement. One year after treatment completion, he remains well, with a normal chest radiograph.
Data Assessment We performed a search on the database of the US National Library of Medicine (PubMed) using the term “reversed halo sign” and found 21 reports2-22 describing 52 cases in which the RHS was seen in several infectious diseases and noninfectious conditions. The reports were published between 1996 and 2010 in the English literature as full-length articles or letters. We also searched using the keywords “atoll sign”13,14 and “fairy ring,”21 which were initially used to describe the RHS. We determined from each study the patient’s age, sex, and diagnosis, and the number of RHSs and their lung distribution.
Results The 52 patients reported in the literature and the case of histoplasmosis presented here comprised 25 men, 16 women, and 11 subjects of unknown sex. Ages ranged from 15 to 87 years (median, 51 years). The RHS was seen in 29 patients with infectious conditions and in 23 patients with noninfectious conditions (Table 1). Of note, according to the authors, secondary organizing pneumonia (OP) could not be excluded in the patients with pneumococcal pneumonia, lipoid pneumonia, or dermatomyositis. A single RHS was seen in 13 cases, and multiple RHSs were observed for 27 subjects. The RHS was identified in the upper lung zones in 16 patients, in the middle lung zones in six, and in the lower lung zones in 14.
Discussion In 1996, Voloudaki et al3 reported two cases of COP that manifested on HRCT scan as central ground-glass opacity Table 1—Classification of 53 Patients With the Reversed Halo Sign Cause
No. of Patients
Organizing pneumonia (cryptogenic or secondary)2,3,11-14 Paracoccidioidomycosis5 Zygomatosis6 Sarcoidosis19-21 TB4,7 Wegener granulomatosis16,17 Angioinvasive pulmonary aspergillosis6 Mucormycosis9 Pneumocystis jirovecii pneumonia10 Histoplasmosis Lymphomatoid granulomatosis15 Pneumonococcal pneumonia8 Lipoid pneumonia18 Dermatomyositis22
15 15 7 4 2 2 1 1 1 1 1 1 1 1
surrounded by a denser airspace consolidation of crescent and ring shapes. In 2003, Kim et al2 reviewed the HRCT scan findings of 31 patients with COP. In six, they identified a central ground-glass opacity surrounded by denser consolidation of crescent or ring shape, similar to the finding described by Voloudaki et al.3 Kim et al2 named this finding the “reversed halo sign” and reported it as a finding relatively specific for a diagnosis of COP. Gasparetto et al5 found the sign in approximately 10% of patients with pulmonary paracoccidioidomycosis and questioned the specificity of the sign. They concluded that the sign can be seen in patients with active infection and without OP; hence, it was not specific for COP. Various authors later demonstrated the presence of this sign in a wide spectrum of diseases, including infectious and noninfectious conditions such as TB,4 zygomycosis,6 aspergillosis,6 Pneumocystis jirovecii pneumonia,10 Wegener granulomatosis,16,17 lymphomatoid granulomatosis,15 sarcoidosis,19-21 and others.5 OP can be primary or cryptogenic or secondary to other known causes. COP is classified as an idiopathic interstitial pneumonia, whereas secondary OP is associated with a variety of diseases known to induce OP. These entities include connective tissue diseases, infections, malignancies, drugs, radiation injury, organ transplantation, and aspiration, among others.23 Thus, in some cases, especially when the RHS appears in the course of the pulmonary disease, secondary OP should be considered. Although the differential diagnosis is quite broad, a nodular appearance of the ring in the RHS is a useful finding, since it indicates the presence of active granulomatous disease (infection or sarcoidosis), rather than OP.24 To our knowledge, the case presented here is the first report of histoplasmosis showing the RHS. Histoplasmosis is a systemic mycosis caused by a small fungus, H capsulatum. It has characteristics of granulomatous disease and primarily affects the lungs and the immune system.25 Although the organism has a worldwide distribution, most reports of disease originated from North America, particularly the central and eastern portions, and notably in the Ohio, Mississippi, and St. Lawrence river valleys, where the organism is considered endemic.26 It is acquired through the inhalation of soil dust particles contaminated by bird or bat excrement containing the microconidia infectious form that enters the airways and, upon reaching the alveoli, causes focal pneumonitis or pneumonitis after inoculation.25,27 Histoplasmosis has a wide spectrum of clinical manifestations ranging from asymptomatic infection to severe disseminated disease, depending on the inoculum size, the immune status of the host, and the virulence of the fungal strain.28 Clinical suspicion of histoplasmosis is based on clinical, radiologic, and epidemiologic aspects.23 A careful history of possible exposure to H capsulatum in daily activities or during the course of travel is crucial to arriving at the correct diagnosis.29 The gold standard for histoplasmosis diagnosis is the identification or culture growth of the fungus from sputum or fiberoptic bronchoscopy specimens.23,28 The most common radiologic findings for acute pulmonary histoplasmosis are diffuse reticulonodular opacities in both lungs and hilar and mediastinal lymph node enlargement. The radiologic findings for chronic pulmonary histoplasmosis
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Selected Reports
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians
are similar to those in adult or reinfection TB, specifically progressive infiltrate in the upper lobe, cavitation, and signs of fibrosis.23 In the case presented here, the history of exposure to bats suggested a fungal pulmonary disease, which was confirmed by the isolation of H capsulatum from a BAL sample culture. In conclusion, pulmonary histoplasmosis should be included in the spectrum of the diseases that may present with the RHS on HRCT scan.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
References 1. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722. 2. Kim SJ, Lee KS, Ryu YH, et al. Reversed halo sign on highresolution CT of cryptogenic organizing pneumonia: diagnostic implications. AJR Am J Roentgenol. 2003;180(5):1251-1254. 3. Voloudaki AE, Bouros DE, Froudarakis ME, Datseris GE, Apostolaki EG, Gourtsoyiannis NC. Crescentic and ringshaped opacities. CT features in two cases of bronchiolitis obliterans organizing pneumonia (BOOP). Acta Radiol. 1996; 37(6):889-892. 4. Marchiori E, Grando RD, Simões Dos Santos CE, et al. Pulmonary tuberculosis associated with the reversed halo sign on high-resolution CT. Br J Radiol. 2010;83(987):e58-e60. 5. Gasparetto EL, Escuissato DL, Davaus T, et al. Reversed halo sign in pulmonary paracoccidioidomycosis. AJR Am J Roentgenol. 2005;184(6):1932-1934. 6. Wahba H, Truong MT, Lei X, Kontoyiannis DP, Marom EM. Reversed halo sign in invasive pulmonary fungal infections. Clin Infect Dis. 2008;46(11):1733-1737. 7. Ahuja A, Gothi D, Joshi JM. A 15-year-old boy with “reversed halo.” Indian J Chest Dis Allied Sci. 2007;49(2):99-101. 8. Tzilas V, Bastas A, Provata A, Koti A, Tzouda V, Tsoukalas G. The “reversed halo” sign in pneumonococcal pneumonia: a review with a case report. Eur Rev Med Pharmacol Sci. 2010; 14(5):481-486. 9. Chung JH, Godwin JD, Chien JW, Pipavath SJ. Case 160: pulmonary mucormycosis. Radiology. 2010;256(2):667-670. 10. Otera H, Tada K, Sakurai T, Hashimoto K, Ikeda A. Reversed halo sign in pneumocystis pneumonia: a case report. BMC Med Imaging. 2010;10:26. 11. Maimon N. A 47-year-old female with shortness of breath and “reversed halo sign”. Eur Respir Rev. 2010;19(115):83-85. 12. Bravo Soberón A, Torres Sánchez MI, García Río F, Sánchez Almaraz C, Parrón Pajares M, Pardo Rodríguez M. High-resolution computed tomography patterns of organizing pneumonia [in Spanish]. Arch Bronconeumol. 2006;42(8): 413-416. 13. Walsh SL, Roberton BJ. Images in thorax. The atoll sign. Thorax. 2010;65(11):1029-1030. 14. Zompatori M, Poletti V, Battista G, et al. Bronchiolitis obliterans with organizing pneumonia (BOOP), presenting as a ring-shaped opacity at HRCT (the atoll sign). A case report. Radiol Med. 1999;97(4):308-310. 15. Benamore RE, Weisbrod GL, Hwang DM, et al. Reversed halo sign in lymphomatoid granulomatosis. Br J Radiol. 2007; 80(956):e162-e166. www.chestpubs.org
16. Agarwal R, Aggarwal AN, Gupta D. Another cause of reverse halo sign: Wegener’s granulomatosis. Br J Radiol. 2007; 80(958):849-850. 17. Choi YH, Im JG, Park CK. Notes from the 2001 Annual Meeting of the Korean Society of Thoracic Radiology. J Thorac Imaging. 2002;17(2):170-175. 18. Kanaji N, Bandoh S, Nagamura N, et al. Lipoid pneumonia showing multiple pulmonary nodules and reversed halo sign. Respir Med Extra. 2007;3(3):98-101. 19. Kumazoe H, Matsunaga K, Nagata N, et al. “Reversed halo sign” of high-resolution computed tomography in pulmonary sarcoidosis. J Thorac Imaging. 2009;24(1):66-68. 20. Marchiori E, Zanetti G, Mano CM, Hochhegger B, Irion KL. The reversed halo sign: another atypical manifestation of sarcoidosis. Korean J Radiol. 2010;11(2):251-252. 21. Marlow TJ, Krapiva PI, Schabel SI, Judson MA. The “fairy ring”: a new radiographic finding in sarcoidosis. Chest. 1999; 115(1):275-276. 22. Tokuyasu H, Isowa N, Shimizu E, Yamadori I. Reversed halo sign associated with dermatomyositis. Intern Med. 2010; 49(15):1677-1678. 23. Drakopanagiotakis F, Paschalaki K, Abu-Hijleh M, et al. Cryptogenic and secondary organizing pneumonia: clinical presentation, radiographic findings, treatment response, and prognosis. Chest. 2011;139(4):893-900. 24. Marchiori E, Zanetti G, Hochhegger B, Irion KL. Re: reversed halo sign: nodular wall as criterion for differentiation between cryptogenic organizing pneumonia and active granulomatous diseases. Clin Radiol. 2010;65(9):770-771. 25. Aidé MA. Chapter 4—histoplasmosis. J Bras Pneumol. 2009; 35(11):1145-1151. 26. Fraser RS, Müller NL, Colman N, et al. Diagnosis of Diseases of the Chest. 4th ed. Philadelphia, PA: WB Saunders; 1999. 27. Zöllner MS, Rezende KM, Birman S, Elias CP, Arisawa EÂ, Santos MA. Clinical and evolutionary characteristics of four patients with pulmonary histoplasmosis reported in the Paraíba Paulista Valley region. Rev Soc Bras Med Trop. 2010;43(5): 599-601. 28. Leimann BC, Pizzini CV, Muniz MM, et al. Histoplasmosis in a Brazilian center: clinical forms and laboratory tests. Rev Iberoam Micol. 2005;22(3):141-146. 29. Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115-132.
The Many Faces of Merlin IgG4-Associated Pulmonary-Renal Disease Ben Sprangers, MD, PhD; Pieter Lioen, MD; Björn Meijers, MD, PhD; Evelyne Lerut, MD, PhD; Joke Meersschaert, MD; Daniel Blockmans, MD, PhD; and Kathleen Claes, MD
Pulmonary-renal syndrome is a common and serious disorder with a broad differential diagnosis. We describe a case of a middle-aged man presenting with interstitial pulmonary disease and severe renal impairment caused by a hypocomplementemic immunecomplex-mediated interstitial nephritis. Serum levels of IgG4 were elevated, and renal biopsy specimens revealed the presence of interstitial IgG41 plasma cells. There was a rapid improvement of both CHEST / 140 / 3 / SEPTEMBER, 2011
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We describe the case of a 23-year-old man with pulmonary histoplasmosis whose high-resolution CT scan demonstrated the reversed halo sign. We also extensively review the literature about this CT scan sign. The reversed halo sign has been described in a number of diseases, both infectious and noninfectious. However, to our knowledge, this is the first reported case of pulmonary histoplasmosis presenting with this radiologic finding. CHEST 2011; 140(3):789–791
Selected Reports
Case Report A 23-year-old man presented with a 3-month history of persistent dry cough, episodes of fever, anorexia, and a 2-kg weight loss. He was a nonsmoker and denied the use of illicit drugs, relevant travel history, or exposure to birds, caves, or a rural environment. He lived in an urban area in Brazil and had worked in a weaving factory for 2 years as a mechanic. Physical examination was normal except for mild crackles in both lungs. A blood chemistry screen was normal, and an HIV test was negative. Chest radiographs showed bilateral diffuse reticulonodular opacities and a discrete focus of consolidation in the upper lung zones. High-resolution CT (HRCT) scan showed bilateral ground-glass irregular opacities surrounded by rings of consolidation (the RHS), distributed mainly in the upper zones of the lungs (Fig 1). The patient was hospitalized for investigation. During hospital admission, he reported exposure to bats in his workplace. A bronchoscopy showed diffuse hyperemia of the bronchial tree. Microscopic examination and BAL
Abbreviations: COP 5 cryptogenic organizing pneumonia; HRCT 5 high-resolution CT; OP 5 organizing pneumonia; RHS 5 reversed halo sign
T
he reversed halo sign (RHS) is defined as a focal, rounded area of ground-glass opacity surrounded by a nearly complete ring of consolidation observed by CT scanning.1 Although Kim et al2 were the first to coin the term “reversed halo sign,” the association between cryptogenic organizing pneumonia (COP) and this radiologic finding was first described by Voloudaki et al,3 who reported the CT scan findings of two patients with COP. However, other studies have demonstrated the presence of this sign in several other infectious and noninfectious conditions.4 We report a case of a 23-year-old man with pulmonary histoplasmosis who presented with the RHS and extensively review the literature about this tomographic sign. Manuscript received January 8, 2011; revision accepted February 19, 2011. Affiliations: From the Federal University of Rio de Janeiro (Drs Marchiori, Vianna, and Zanetti), Rio de Janeiro; the Federal University of Sergipe (Dr S. M. D. Melo), Aracaju, Sergipe; and the University Center Serra dos Órgãos (Drs B. S. D. Melo and S. S. D. Melo), Teresópolis, Rio de Janeiro, Brazil. Correspondence to: Edson Marchiori, MD, PhD, Rua Thomaz Cameron, 438 Valparaiso CEP 25685.120, Petrópolis, Rio de Janeiro, Brazil; e-mail: [email protected] © 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.11-0055 www.chestpubs.org
Figure 1. A and B, High-resolution CT scans of the upper lobes demonstrate irregular and bizarre-shaped localized areas containing central ground-glass opacities surrounded by denser ring of consolidation, indicative of the reversed halo sign. B, Highresolution CT scan obtained at a level below the scan shown in A. CHEST / 140 / 3 / SEPTEMBER, 2011
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians
789
cultures were negative for mycobacteria and positive for Histoplasma capsulatum. An immunodiffusion test was also positive for histoplasmosis. The patient was treated with 400 mg of ketoconazole for 6 months and showed remarkable improvement. One year after treatment completion, he remains well, with a normal chest radiograph.
Data Assessment We performed a search on the database of the US National Library of Medicine (PubMed) using the term “reversed halo sign” and found 21 reports2-22 describing 52 cases in which the RHS was seen in several infectious diseases and noninfectious conditions. The reports were published between 1996 and 2010 in the English literature as full-length articles or letters. We also searched using the keywords “atoll sign”13,14 and “fairy ring,”21 which were initially used to describe the RHS. We determined from each study the patient’s age, sex, and diagnosis, and the number of RHSs and their lung distribution.
Results The 52 patients reported in the literature and the case of histoplasmosis presented here comprised 25 men, 16 women, and 11 subjects of unknown sex. Ages ranged from 15 to 87 years (median, 51 years). The RHS was seen in 29 patients with infectious conditions and in 23 patients with noninfectious conditions (Table 1). Of note, according to the authors, secondary organizing pneumonia (OP) could not be excluded in the patients with pneumococcal pneumonia, lipoid pneumonia, or dermatomyositis. A single RHS was seen in 13 cases, and multiple RHSs were observed for 27 subjects. The RHS was identified in the upper lung zones in 16 patients, in the middle lung zones in six, and in the lower lung zones in 14.
Discussion In 1996, Voloudaki et al3 reported two cases of COP that manifested on HRCT scan as central ground-glass opacity Table 1—Classification of 53 Patients With the Reversed Halo Sign Cause
No. of Patients
Organizing pneumonia (cryptogenic or secondary)2,3,11-14 Paracoccidioidomycosis5 Zygomatosis6 Sarcoidosis19-21 TB4,7 Wegener granulomatosis16,17 Angioinvasive pulmonary aspergillosis6 Mucormycosis9 Pneumocystis jirovecii pneumonia10 Histoplasmosis Lymphomatoid granulomatosis15 Pneumonococcal pneumonia8 Lipoid pneumonia18 Dermatomyositis22
15 15 7 4 2 2 1 1 1 1 1 1 1 1
surrounded by a denser airspace consolidation of crescent and ring shapes. In 2003, Kim et al2 reviewed the HRCT scan findings of 31 patients with COP. In six, they identified a central ground-glass opacity surrounded by denser consolidation of crescent or ring shape, similar to the finding described by Voloudaki et al.3 Kim et al2 named this finding the “reversed halo sign” and reported it as a finding relatively specific for a diagnosis of COP. Gasparetto et al5 found the sign in approximately 10% of patients with pulmonary paracoccidioidomycosis and questioned the specificity of the sign. They concluded that the sign can be seen in patients with active infection and without OP; hence, it was not specific for COP. Various authors later demonstrated the presence of this sign in a wide spectrum of diseases, including infectious and noninfectious conditions such as TB,4 zygomycosis,6 aspergillosis,6 Pneumocystis jirovecii pneumonia,10 Wegener granulomatosis,16,17 lymphomatoid granulomatosis,15 sarcoidosis,19-21 and others.5 OP can be primary or cryptogenic or secondary to other known causes. COP is classified as an idiopathic interstitial pneumonia, whereas secondary OP is associated with a variety of diseases known to induce OP. These entities include connective tissue diseases, infections, malignancies, drugs, radiation injury, organ transplantation, and aspiration, among others.23 Thus, in some cases, especially when the RHS appears in the course of the pulmonary disease, secondary OP should be considered. Although the differential diagnosis is quite broad, a nodular appearance of the ring in the RHS is a useful finding, since it indicates the presence of active granulomatous disease (infection or sarcoidosis), rather than OP.24 To our knowledge, the case presented here is the first report of histoplasmosis showing the RHS. Histoplasmosis is a systemic mycosis caused by a small fungus, H capsulatum. It has characteristics of granulomatous disease and primarily affects the lungs and the immune system.25 Although the organism has a worldwide distribution, most reports of disease originated from North America, particularly the central and eastern portions, and notably in the Ohio, Mississippi, and St. Lawrence river valleys, where the organism is considered endemic.26 It is acquired through the inhalation of soil dust particles contaminated by bird or bat excrement containing the microconidia infectious form that enters the airways and, upon reaching the alveoli, causes focal pneumonitis or pneumonitis after inoculation.25,27 Histoplasmosis has a wide spectrum of clinical manifestations ranging from asymptomatic infection to severe disseminated disease, depending on the inoculum size, the immune status of the host, and the virulence of the fungal strain.28 Clinical suspicion of histoplasmosis is based on clinical, radiologic, and epidemiologic aspects.23 A careful history of possible exposure to H capsulatum in daily activities or during the course of travel is crucial to arriving at the correct diagnosis.29 The gold standard for histoplasmosis diagnosis is the identification or culture growth of the fungus from sputum or fiberoptic bronchoscopy specimens.23,28 The most common radiologic findings for acute pulmonary histoplasmosis are diffuse reticulonodular opacities in both lungs and hilar and mediastinal lymph node enlargement. The radiologic findings for chronic pulmonary histoplasmosis
790
Selected Reports
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 7, 2011 © 2011 American College of Chest Physicians
are similar to those in adult or reinfection TB, specifically progressive infiltrate in the upper lobe, cavitation, and signs of fibrosis.23 In the case presented here, the history of exposure to bats suggested a fungal pulmonary disease, which was confirmed by the isolation of H capsulatum from a BAL sample culture. In conclusion, pulmonary histoplasmosis should be included in the spectrum of the diseases that may present with the RHS on HRCT scan.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
References 1. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722. 2. Kim SJ, Lee KS, Ryu YH, et al. Reversed halo sign on highresolution CT of cryptogenic organizing pneumonia: diagnostic implications. AJR Am J Roentgenol. 2003;180(5):1251-1254. 3. Voloudaki AE, Bouros DE, Froudarakis ME, Datseris GE, Apostolaki EG, Gourtsoyiannis NC. Crescentic and ringshaped opacities. CT features in two cases of bronchiolitis obliterans organizing pneumonia (BOOP). Acta Radiol. 1996; 37(6):889-892. 4. Marchiori E, Grando RD, Simões Dos Santos CE, et al. Pulmonary tuberculosis associated with the reversed halo sign on high-resolution CT. Br J Radiol. 2010;83(987):e58-e60. 5. Gasparetto EL, Escuissato DL, Davaus T, et al. Reversed halo sign in pulmonary paracoccidioidomycosis. AJR Am J Roentgenol. 2005;184(6):1932-1934. 6. Wahba H, Truong MT, Lei X, Kontoyiannis DP, Marom EM. Reversed halo sign in invasive pulmonary fungal infections. Clin Infect Dis. 2008;46(11):1733-1737. 7. Ahuja A, Gothi D, Joshi JM. A 15-year-old boy with “reversed halo.” Indian J Chest Dis Allied Sci. 2007;49(2):99-101. 8. Tzilas V, Bastas A, Provata A, Koti A, Tzouda V, Tsoukalas G. The “reversed halo” sign in pneumonococcal pneumonia: a review with a case report. Eur Rev Med Pharmacol Sci. 2010; 14(5):481-486. 9. Chung JH, Godwin JD, Chien JW, Pipavath SJ. Case 160: pulmonary mucormycosis. Radiology. 2010;256(2):667-670. 10. Otera H, Tada K, Sakurai T, Hashimoto K, Ikeda A. Reversed halo sign in pneumocystis pneumonia: a case report. BMC Med Imaging. 2010;10:26. 11. Maimon N. A 47-year-old female with shortness of breath and “reversed halo sign”. Eur Respir Rev. 2010;19(115):83-85. 12. Bravo Soberón A, Torres Sánchez MI, García Río F, Sánchez Almaraz C, Parrón Pajares M, Pardo Rodríguez M. High-resolution computed tomography patterns of organizing pneumonia [in Spanish]. Arch Bronconeumol. 2006;42(8): 413-416. 13. Walsh SL, Roberton BJ. Images in thorax. The atoll sign. Thorax. 2010;65(11):1029-1030. 14. Zompatori M, Poletti V, Battista G, et al. Bronchiolitis obliterans with organizing pneumonia (BOOP), presenting as a ring-shaped opacity at HRCT (the atoll sign). A case report. Radiol Med. 1999;97(4):308-310. 15. Benamore RE, Weisbrod GL, Hwang DM, et al. Reversed halo sign in lymphomatoid granulomatosis. Br J Radiol. 2007; 80(956):e162-e166. www.chestpubs.org
16. Agarwal R, Aggarwal AN, Gupta D. Another cause of reverse halo sign: Wegener’s granulomatosis. Br J Radiol. 2007; 80(958):849-850. 17. Choi YH, Im JG, Park CK. Notes from the 2001 Annual Meeting of the Korean Society of Thoracic Radiology. J Thorac Imaging. 2002;17(2):170-175. 18. Kanaji N, Bandoh S, Nagamura N, et al. Lipoid pneumonia showing multiple pulmonary nodules and reversed halo sign. Respir Med Extra. 2007;3(3):98-101. 19. Kumazoe H, Matsunaga K, Nagata N, et al. “Reversed halo sign” of high-resolution computed tomography in pulmonary sarcoidosis. J Thorac Imaging. 2009;24(1):66-68. 20. Marchiori E, Zanetti G, Mano CM, Hochhegger B, Irion KL. The reversed halo sign: another atypical manifestation of sarcoidosis. Korean J Radiol. 2010;11(2):251-252. 21. Marlow TJ, Krapiva PI, Schabel SI, Judson MA. The “fairy ring”: a new radiographic finding in sarcoidosis. Chest. 1999; 115(1):275-276. 22. Tokuyasu H, Isowa N, Shimizu E, Yamadori I. Reversed halo sign associated with dermatomyositis. Intern Med. 2010; 49(15):1677-1678. 23. Drakopanagiotakis F, Paschalaki K, Abu-Hijleh M, et al. Cryptogenic and secondary organizing pneumonia: clinical presentation, radiographic findings, treatment response, and prognosis. Chest. 2011;139(4):893-900. 24. Marchiori E, Zanetti G, Hochhegger B, Irion KL. Re: reversed halo sign: nodular wall as criterion for differentiation between cryptogenic organizing pneumonia and active granulomatous diseases. Clin Radiol. 2010;65(9):770-771. 25. Aidé MA. Chapter 4—histoplasmosis. J Bras Pneumol. 2009; 35(11):1145-1151. 26. Fraser RS, Müller NL, Colman N, et al. Diagnosis of Diseases of the Chest. 4th ed. Philadelphia, PA: WB Saunders; 1999. 27. Zöllner MS, Rezende KM, Birman S, Elias CP, Arisawa EÂ, Santos MA. Clinical and evolutionary characteristics of four patients with pulmonary histoplasmosis reported in the Paraíba Paulista Valley region. Rev Soc Bras Med Trop. 2010;43(5): 599-601. 28. Leimann BC, Pizzini CV, Muniz MM, et al. Histoplasmosis in a Brazilian center: clinical forms and laboratory tests. Rev Iberoam Micol. 2005;22(3):141-146. 29. Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115-132.
The Many Faces of Merlin IgG4-Associated Pulmonary-Renal Disease Ben Sprangers, MD, PhD; Pieter Lioen, MD; Björn Meijers, MD, PhD; Evelyne Lerut, MD, PhD; Joke Meersschaert, MD; Daniel Blockmans, MD, PhD; and Kathleen Claes, MD
Pulmonary-renal syndrome is a common and serious disorder with a broad differential diagnosis. We describe a case of a middle-aged man presenting with interstitial pulmonary disease and severe renal impairment caused by a hypocomplementemic immunecomplex-mediated interstitial nephritis. Serum levels of IgG4 were elevated, and renal biopsy specimens revealed the presence of interstitial IgG41 plasma cells. There was a rapid improvement of both CHEST / 140 / 3 / SEPTEMBER, 2011
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791