Lobar Collapse and Obliteration of Air Bronchogram Allowing Early Diagnosis of Endobronchial Aspergillus Infection following Hematopoietic Stem Cell Transplantation

Abstract

Endobronchial fungal infection (EBFI) is notoriously difficult to diagnose early since it may present few systemic features and does not cause characteristic parenchymal lesions on lung CT scanning. We report a 9-year-old girl who suffered extended neutropenia following graft failure after haematopoietic stem cell transplantation (HSCT) for severe aplastic anaemia. CT scan prior to retransplantation was normal despite persistent cough but lobar collapse was shown on repeat scan 16 days later. The probable diagnosis of EBFI (later proven on bronchoscopy) was only suspected when subsequent chest X-ray (CXR) demonstrated lack of an air bronchogram in the partially collapsed lung. Early radiological suspicion resulted in multiagent antifungal therapy followed by delayed lobectomy, and led to this being the first reported case of Aspergillus EBFI not to result in respiratory failure.

Figure 1

CT scan of the chest prior to start of HSCT. This showed no lung abnormality.

Figure 2

Graphs depicting temperature, CRP, and neutrophil count for 20 days following HSCT. Arrows indicate dates of CT and CXRs. The dotted line on the bottom panel indicates the threshold of neutropenia.

Figure 3

Chest X-rays performed on days 7 and 11 following transplant. No lung abnormality is seen at day 7 but left upper lobe collapse has developed by day 11 after HSCT.

Figure 4

CT scan images of the chest performed on day 9 after transplant. (a) demonstrates complete collapse of the left upper lobe with abrupt cut-off of the left upper lobe bronchus and (b) absence of air bronchograms within the collapsed lung.