Reversed Halo Sign in Invasive Fungal Infections

Marchiori, Edson; Marom, Edith M.; Zanetti, Gláucia; Hochhegger, Bruno; Irion, Klaus; Godoy, Myrna C.B.

doi:10.1378/chest.12-0114

Cited by 49 publications

(22 citation statements)

References 21 publications

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“…, 12 In cases of multiple pulmonary nodules, halo thickness tended to be greater in immunocompromised patients than in immunocompetent patients. This finding is consistent with those of a study investigating characteristics of the reversed halo sign, in which greater rim thickness was associated with invasive fungal infection 13 . The same cannot be concluded for solitary nodules, and this is possibly due to a statistically insufficient number of single lesions among the immunosuppressed patients (i.e., only three).…”

Section: Discussionsupporting

confidence: 88%

The halo sign: HRCT findings in 85 patients

et al. 2016

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Objective: The halo sign consists of an area of ground-glass opacity surrounding pulmonary lesions on chest CT scans. We compared immunocompetent and immunosuppressed patients in terms of halo sign features and sought to identify those of greatest diagnostic value. Methods: This was a retrospective study of CT scans performed at any of seven centers between January of 2011 and May of 2015. Patients were classified according to their immune status. Two thoracic radiologists reviewed the scans in order to determine the number of lesions, as well as their distribution, size, and contour, together with halo thickness and any other associated findings. Results: Of the 85 patients evaluated, 53 were immunocompetent and 32 were immunosuppressed. Of the 53 immunocompetent patients, 34 (64%) were diagnosed with primary neoplasm. Of the 32 immunosuppressed patients, 25 (78%) were diagnosed with aspergillosis. Multiple and randomly distributed lesions were more common in the immunosuppressed patients than in the immunocompetent patients (p < 0.001 for both). Halo thickness was found to be greater in the immunosuppressed patients (p < 0.05). Conclusions: Etiologies of the halo sign differ markedly between immunocompetent and immunosuppressed patients. Although thicker halos are more likely to occur in patients with infectious diseases, the number and distribution of lesions should also be taken into account when evaluating patients presenting with the halo sign.

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Section: Discussionsupporting

confidence: 88%

The halo sign: HRCT findings in 85 patients

et al. 2016

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“…This finding, associated with pleural effusion, strongly suggests the diagnosis of pulmonary infarction, and may be associated with PE or with invasive fungal infection in a severely immunocompromised host. 17,19 Most RHS lesions in our series were bilateral, with no central or peripheral zones predominance. Almost half of the lesions showed diffuse distribution along the upper, middle and lower lobes.…”

Section: Discussionmentioning

confidence: 70%

“…This smooth appearance has been described in a variety of diseases, 9,12,14,19 especially in OP, which is the most common cause of this sign. 18 Hence, this feature alone cannot be used to distinguish PCM from OP.…”

Section: Discussionmentioning

confidence: 71%

“…Several authors have attempted to document the presence of multiple RHSs in a wide spectrum of diseases, such as cryptogenic OP (COP), tuberculosis, sarcoidosis, invasive fungal infections and granulomatosis with polyangiitis. 10,12,[17][18][19][20] Nevertheless, in a study comparing RHS characteristics in tuberculosis and COP, 18 solitary and multiple lesions were observed in both diseases. Indeed, although multiple RHSs were found in all patients with PCM in our study, this finding is not specific.…”

Section: Discussionmentioning

confidence: 93%

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CT morphological features of the reversed halo sign in pulmonary paracoccidioidomycosis

Barreto

Marchiori

Brito³

et al. 2015

BJR

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Objective: The purpose of this study was to identify morphological characteristics of the reversed halo sign (RHS) on chest CT in patients with pulmonary paracoccidioidomycosis (PCM) that may aid the diagnosis of this fungal disease. Methods: We retrospectively reviewed chest CT images from 23 patients with proven pulmonary PCM who demonstrated the RHS. Two chest radiologists analysed the morphological characteristics of the lesions and reached decisions by consensus. Results: We identified 64 RHSs on CT images from the 23 patients. Multiple lesions were observed in all cases, with middle and lower lung zone predominance occurring in 17 patients (73.9% of cases). 34 (53.1%) RHSs were round and 30 (46.9%) were oval. Outer borders of the RHSs were smooth in 32 (50%) lesions, nodular in 16 (25%) lesions and irregular/spiculated in 16 (25%) lesions. Groundglass opacity was observed inside 63 (98.4%) lesions. Conclusion: Our data suggest that morphological characteristics of the RHS on chest CT, such as the presence of multiple lesions, middle and lower lung zone predominance and a spiculated RHS ring, as well as the association with other parenchymal patterns, should lead radiologists to include PCM in the differential diagnosis of PCM in endemic areas. Advances in knowledge: This is the largest series of patients with RHS due to PCM and is also the first study to report RHS lesions with spiculated or irregular walls. The study adds information regarding morphological characteristics of the RHS that may raise suspicion of PCM on chest CT, particularly in endemic areas of the disease.

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“…The frontal chest radiograph shows large lung volumes with a cystic appearance 4. The frontal chest radiograph shows new peribronchial lymph node enlargement 5. The frontal chest radiograph shows new poorly defined nodular opacities bilaterally…”

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confidence: 97%

March 2016 imaging case of the month

Gotway¹

2016

Southwest J Pulm Crit Care

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Clinical History: A 66 year-old man with orthotopic heart transplantation 1 year previously presented with complaints of recent-onset small volume (<1 teaspoon) hemoptysis, post-nasal drip, and night sweats. The patient indicated he had recent contact with several young grandchildren who had upper respiratory tract symptoms. The patient's past medical history was remarkable for recurrent constrictive pericarditis (surgically treated), hypertension, type II diabetes mellitus (treated with insulin), psoriasis, sleep-disordered breathing, and grade 2 cardiac transplant rejection diagnosed 6 months earlier. The patient's medication list included insulin, Cellcept (mycophenolate mofetil), Prograf (tacrolimus), prednisone, among others. On physical examination, the patient was mildly tachycardic (heart rate = 104 beats/minute) with an oxygen saturation on room air of 92%. The white blood cell count was within the normal range, but C-reactive protein and B-type natriuretic peptide levels were reportedly elevated. Frontal chest radiography (Figure 1) was performed, with a radiograph from one month other also shown for comparison.

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Reversed Halo Sign in Invasive Fungal Infections

Cited by 49 publications

References 21 publications

The halo sign: HRCT findings in 85 patients

The halo sign: HRCT findings in 85 patients

CT morphological features of the reversed halo sign in pulmonary paracoccidioidomycosis

March 2016 imaging case of the month

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