1. Multifocal Consolidation with Halo Sign 경희대학교 의과대학 감염내과 박기호

2. Halo sign Hals sign: mass-like consolidation with peripheral GGO 41-year old neutropenic man who received CTx for AML Invasive Pulmonary Aspergillosis Georgiadou et al. Clin Infect Dis. 2011;52:1144-55

3. Spectrum of pulmonary disease a/w HS Fungal Infections Invasive aspergillosis Mucormycosis Pulmonary candidiasis Cryptococcosis Viral infections Herpes simple virus VZV, RSV, CMV, influenza A Georgiadou et al. Clin Infect Dis. 2011;52:1144-55 Bacterial infections Actinomycosis S. aureus, P. aeruginosa Slow-resolving pneumonia : S. pneumoniae, legionella, Mycoplasma Immunocompromised Immunocompetent

4. Spectrum of pulmonary disease a/w HS Mycobacterial infection M. tuberculosis M. avium-intracellulare Systemic disease Wegener granulomatosis Sarcoidosis Amyloidosis Neoplastic disease Georgiadou et al. Clin Infect Dis. 2011;52:1144-55 Other (steroid Tx) Cryptogenic organizing pneumonia Eosinophilic pneumonia Hypersensitivity pneumonia

5. Halo sign Proportion of halos sign after diagnosis of IPA Day 0: 100%, day 3: 68%, day 7: 28%, day 14: 19% Halo sign is not sensitive or not specific for diagnosing Invasive fungal disease!! Caillot et al. J Clin Oncol. 2001;19:253-9

6. Clinical Experiences of Lung Biopsy 1.Immunocompetent (n =5) or solid cancer (n = 13) 2.Lung biopsy (18 cases) non-diagnostic (n = 13), MSSA (n = 1), MRSA (n = 1), P. aeruginosa (n = 1), Legionella pneumoniae (n = 2) Actinomycosis (?) 3.Empirical regimen: Ampicillin/sulbactam 3.0 gm q 6hr + levofloxacin 750 mg

7. Diagnostic Dillema 1.Halo sign in bacterial infection → Exudate 2. Halo sign in invasive fungal disease → angioinvasion 3. Diagnostic lung biopsy → bleeding risk → diagnostic dillema

8. Probable IFD At least a)1 host criterion AND b)1 clinical criterion AND c)1 microbiological criterion Possible IFD At least a)1 host criterion AND b)1 clinical criterion BUT c)no microbiological criterion

9. Revised EORTC 1.Well-circumscribed lesion with or without halo sign 2.Air-crescent sign 3.Cavity

10. Caillot et al. J Clin Oncol. 2001;19:253-9 Reverse Halo Sign

11. Clinical Features of COP 1.Persistent nonproductive cough (72%) 2.Dyspnea (66%) 3.Fever (51%) 4.Malaise (48%) 5.Weight loss of greater than 10 pounds (57%) 6.Migratory multifocal consolidation King TE Jr. Organizing pneumonia. In: Interstitial lung disease, 5, Schwarz MI, King TE Jr. (Eds), People's Medical Publishing House, Shelton, CT 2011. p.981

12. Take Home Message 1.Various differential diagnosis of multifocal consolidation with or without halo sign 2.Halo sign: not sensitive or not specific for diagnosing invasive fungal disease 3.Host factors: immunocompromised vs. immunocompetent !!