Multiple chest nodules on computed tomography scan.

Digital Object Identifier: 10.1188/03.CJON.697-698 Mr. M is a 75-year-old man recently diagnosed with chronic lymphocytic leukemia. The first two courses of chemotherapy were administered without problems, and Mr. M said he was feeling well enough to continue the remodeling of his home. While undergoing his third course of chemotherapy, he returned to the outpatient clinic with neutropenia, fever, chest pain, and shortness of breath. A chest x-ray revealed a left peripheral infiltrate, initially thought to be a slow-healing left lower lobe pneumonia. Mr. M was started on antibiotics and returned home. During a follow-up visit one week later, his chest xray findings had improved but were not resolved. Mr. M was admitted to the hospital for IV antibiotics. He continued to be neutropenic and progressively developed a lowgrade fever that reached 101°F with chills, headache, posterior nasal drainage, intermittent nosebleeds, and hemoptysis. During the course of several weeks, a macular pruritic rash also developed on his chest. Differential diagnoses included bacterial or fungal infection and allergic pulmonary diseases of the lung. Patients with hematologic malignancies and those undergoing hematopoietic stem cell transplantation are at high risk for invasive fungal infections. In this population, these infections cause morbidity and mortality with an overall fatality rate exceeding 50% (Groll & Walsh, 2002). Aspergillus and Candida species account for a majority of documented infections, although recent trends indicate a shift toward infections of the Aspergillus species and nonalbicans Candida species. Based on the persistence of Mr. M’s symptoms, he was sent to a pulmonologist for bronchial alveolar lavage and biopsy. Cultures were negative for bacterial and fungal infections. No indication of allergic pathology was noted. A computed tomography (CT) scan of the chest was performed, and it showed a 2.8 cm rounded mass with somewhat indistinct margins involving the left lower lobe immediately posterior to the left hilum. This mass was surrounded by a “halo” or “crescent sign” of low attenuation (see Figure 1). Given the history and rapid onset of the condition, the radiologist concluded that the mass most likely represented an aspergilloma in an inflammatory cavity. The classic “halo sign,” characterized by a ground-glass opacity surrounding a nodule, results from hemorrhage and edema around the focus of a fungal infection. This is a valuable early sign of invasive aspergillosis in high-risk patients with neutropenia, although the sign is not as specific in patients at lower risk and may be found in other types of fungal infections (Soubani & Chandrasekar, 2002).