PMC5259602_01
(a) Chest X-ray: Pneumothorax in left hemithorax, (b) and (c) thorax BT (sagittal and coronal sections): Bilateral chronic fibrotic changes with bronchiectasis and severe emphysema with air trapping in addition to left pneumothorax.
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CT (Figure 1). Ciprofloxacin, teicoplanin, and fluconazole were started empirically.
(a) and (b) Initial abdominal CT coronal and sagittal sections: A group of local collections in liver segment 4b consistent with abscesses in an area of 5 x 6.5 cm diameter; biggest one was 2.5 cm in diameter. Note that the lesion is extending outside the liver. (c) and (d) Control abdominal CT coronal and sagittal sections: After drainage catheter placement abscess did not drain due to excessive individual compartmentalization.
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There was a 7 x 4 cm heterogenous mass lesion in liver with cystic areas in center which was a multiloculated abscess in abdominal US that was subsequently confirmed with abdominal CT (Figure 2). However, control CT 5 days after catheter placement showed no significant change in the dimensions of abscess (Figure 2).
PMC5259602_02
(a) Chest X-ray: Bilateral extensive infiltrations especially prominent in left upper lobe. (b) and (c) Thorax CT (parenchymal and mediastinal window, resp.): Right upper lobe anterior segment, left upper lobe nearly total consolidations. In particular the consolidation in left upper lobe and right paratracheal, hilar region includes calcifications. (d) Thorax CT (two months later, coronal section): Extensive visceral and parietal lympadenomegalies in mediastinum that reach 3 cm in diameter, some showing central necrosis especially the ones in pericardial neighborhood (*).
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CRP (3 mg/dL) and ESR (60 mm/hr) levels. CXR showed bilateral extensive infiltrations especially prominent in left upper lobe (Figure 3). Thorax CT revealed pneumonic consolidations with calcifications (Figure 3). Extensive lymph node enlargements in mediastinum and around pericardium reaching to 3 cm in diameter, some showing central necrosis, were recorded in the new thorax CT (Figure 3).
Echocardiography: Increased pericardial echogenity, pericardial thickening, localized liquid collections in apex adherent to pericardium (*), and deviation of interventricular septum to left in inspiration (favoring pulmonary hypertension) and diastolic dysfunction due to constrictive pericarditis.
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Echocardiography showed findings compatible with pulmonary hypertension, diastolic dysfunction, and constrictive pericarditis (Figure 4).
(a) Thorax CT coronal section: An abscess of 4.5 x 1.7 cm diameter in left inferior lobe in the neighborhood of cardiac apex (arrow). Parenchymal consolidations with punctate calcifications persevere. (b) Macroscopic appearance of the drainage material.
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fig5
Fever and respiratory distress continued and thorax CT revealed an abscess of 4.5 x 1.7 cm diameter in left lung inferior lobe, two weeks after the pericardiectomy (Figure 5). The abscess was drained and drainage material culture was positive for Aspergillus fumigatus (Figure 5).
(a) Cranial CT: Hypodense area at the level of right basal ganglia compatible with acute ischemic infarction (arrow). (b) Cranial MR: Axial T2 image shows hyperintensity of right caudate nucleus, putamen, and globus pallidus. Contralateral thalamic hyperintensity is also seen (arrows). (c), (d) Diffusion restriction is seen at the level of right basal ganglia at diffusion b 1000 image and ADC map, respectively (arrow). (e), (f) Pre- and postcontrast T1 axial images show many enhancing intra-axial foci in both hemispheres after IV gadolinium administration (arrows). (g) Occlusion of right middle cerebral artery at the level of bifurcation on reconstructed MIP images of 3D TOF MR angiography.
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A hypodense lesion at the level of right basal ganglia was interpreted as acute ischemic infarction in cranial CT (Figure 6). Diffusional restriction consistent with acute ischemia in right basal ganglia and cerebral, cerebellar millimetric enhancing foci consistent with aspergillosis were reported in cranial and diffusion magnetic resonance imaging (MRI) (Figure 6). In MR angiography, right middle cerebral artery was occluded from M2 segment to end which was also associated with Aspergillus infection (Figure 6).
MR examination performed 5 months after the initial examination. (a) Axial T2 image shows the cystic encephalomalacia at the level of right basal ganglia (arrow). (b), (c) Partial resolution of enhancing foci is seen on pre- and postcontrast axial T1 images (arrows).
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fig7
The ischemic lesion in the right basal ganglia showed chronicity and appeared as cystic encephalomalacia; most of the cerebral/cerebellar foci were smaller than before and some disappeared in the control MRI five months after the initial evaluation (Figure 7).