Hemoptysis with a classical radiological sign.

There can be various causes for hemoptysis. We present here a case of hemoptysis in which the chest X-ray helped us to arrive at the diagnosis because of a classical sign. This highlights the need of identifying this finding for prompt recognition of the cause of hemoptysis.

CASE HISTORY

A 45-year-old male, with past history of pulmonary tuberculosis, presented to medicine emergency with history of hemoptysis. His hemodynamic status was normal and respiratory system examination revealed tracheal shift to right with bronchial breath sounds and crepitations in right mammary area. Laboratory parameters were normal including coagulation parameters and oxygen saturation. Sputum for acid-fast bacilli was negative. His chest X-ray [Figure 1] demonstrated a cavity in right upper zone with a gravity dependant ball and a curvilinear crescent of lucency along with signs of volume loss on right side and nonhomogeneous opacities on right middle and lower zones.

Figure 1

Monad sign

QUESTION

Q1. What is the diagnosis?

ANSWER

Chest X-ray showing a cavity with a gravity-dependant ball and a curvilinear crescent of lucency is suggestive of aspergilloma. This sign is called “Monad sign”. Patient's sputum smears and culture results were positive for Aspergillus fumigatus. Patient improved after conservative treatment and remains under regular follow-up.

Aspergilloma are masses of fungal mycelia that grow in pre-existing lung cavities, arising due to tuberculosis, endemic fungal infections, sarcoidosis, bullous emphysema or fibrotic lung disease. The vast majority of these “fungal balls” are caused by members of genus Aspergillus. The most important clinical feature of this illness is hemoptysis; however, most patients are stable and they do not progress under observation. Bleeding usually occurs from the bronchial blood vessels. Hemoptysis may be explained by mechanical friction of mycetoma, an endotoxin with hemolytic properties, an anticoagulant factor derived from Aspergillus, local vasculitis and direct vascular invasion in cavity wall vessels.[1] Substantial percentage of the lesions may resolve spontaneously.[2] The diagnosis is usually established radiographically, with presence of a mobile mass within a cavity suggestive of aspergilloma. Sputum culture may confirm the presence of fungus, but may be negative in about 50% of cases.[3] The serum precipitins (IgG antibodies) for Aspergillus are positive in almost 100% of cases except in cases of Aspergilloma due to other Aspergillus species or if the patient is on corticosteroid therapy.[4]

An aspergilloma that is clinically quiescent or causing only minimal symptoms can be observed. The mainstay of therapy in patients with severe hemoptysis is surgical resection, but resection is often limited by the extent of the underlying lung disease.[5] In patients who are actively bleeding, bronchial artery embolization can be a useful temporizing measure.[6] Systemic, inhaled, and intracavitary antifungal agents have all failed to show benefit in the clinical course, morbidity or mortality of aspergillomas, although reduction in size of fungus balls with prolonged itraconazole therapy has been reported.