Boy with ALL and stem cell transplant is neutropenic and febrile.

Our appreciation is extended to Dr.  Mark Allen, Indiana University Department of Radiology, for contributing this case.

Boy with ALL and stem cell transplant is neutropenic and febrile.

Boy with ALL and stem cell transplant is neutropenic and febrile.

Findings:

CT chest:  Multiple varying sized nodular opacities throughout the right lung with a surrounding ground-glass halo.

CT Abdomen and pelvis:  There is cecal and ascending colonic wall thickening and enhancement.  The small bowel also appears to mildly enhance.

Differential Diagnosis: 

Chest:

• Opportunistic fungal infection such as aspergillis
• Septic Emboli
• Lymphoma / metastases
• (In appropriate clinical setting) Necrotizing angiitis such as Wegeners.

Abdomen:

• Graft vs host disease
• Typhlitis
• CMV colitis or inflammatory colitis

Diagnoses:

Chest:  Presumed angioinvasive aspergillosis.

Abdomen: Presumed graft vs host disease.  See the additional images below.

Boy with ALL and stem cell transplant is neutropenic and febrile.

• Chest:
  • A type of Aspergillus infection occurs in immunocompetent patients, typically patients with pre-existing bullous emphysema. These patients can form an Aspergillus mycetoma within a bulla.
  • Another type of Aspergillus infection is ABPA (Allergic bronchopulmonary aspergillosis). This typically occurs in asthmatic patients. 3 or more lobes with bronchiectasis is highly suggestive of ABPA, although recurrent ABPA may result in widespread bronchiectasis. The treatment is typically high dose steroids.
  • Angioinvasive aspergillosis is what we see in this patient who is immunocompromised. The CT findings are nodules in the lungs with a surrounding groundglass opacity representing hemorrhage. Other considerations for this finding would be other fungal infections, Wegeners granulomatosis and hemorrhagic pulmonary metastasis.
• Abdomen:
  • Donor bone marrow T-lymphocytes may cause damage to the epithelial lining of organs such as bowel in GVHD. With this you can see central mucosal enhancement of intra-abdominal organs as shown in this case.. Also seen can be fluid filled bowel and infiltration of mesenteric fat.
  • Also in the differential would be Typhlitis which typically is confined to the cecum with wall thickening and possibly necrosis. On CT, CMV colitis shows nonspecific bowel wall thickening and inflammatory changes.

1. statdx.com 11/22/2011

Boy with ALL and stem cell transplant is neutropenic and febrile.