ct halo sign (part 1)

Dr Mazen QusaibatyMD, DIS

Head Pulmonary and Internist Department Ibnalnafisse Hospital

Ministry of Syrian healthEmail:

Qusaibaty@gmail.com

1. CT halo sign (part 1)

Topic Outline

1. CT halo sign (part 1)

Useful links

http://bjr.birjournals.org

http://radiographics.rsna.org

http://radiology.rsna.org

CT halo sign

Refers to a zone of ground-glass attenuation (the halo) surrounding a pulmonary nodule or mass or consolidation

HRCT of thorax

CT halo sign

Nodular Ground-Glass

Opacity

Ground glass

Alveolar hemorrhage

Ground glass

Alveolar hemorrhage

Infiltration cells

Consolidation

Lesion

Halo sign could be seen in:

A. AspergillosisB. Eosinophilic PneumoniaC. Bronchiolitis Obliterans with Organizing

PneumoniaD. Thoracic EndometriosisE. Focal Traumatic Lung InjuryF. All above

Halo sign could be seen in:

A. AspergillosisB. Eosinophilic PneumoniaC. Bronchiolitis Obliterans with Organizing

PneumoniaD. Thoracic EndometriosisE. Focal Traumatic Lung Injury

F. All above.

Infectious diseases

Aspergillosis

• Aspergillosis may be manifested as areas of nodular ground-glass opacity

http://radiographics.rsna.org/content/27/2/391.full

Photomicrograph of a histologic specimen (original magnification, ×100; hematoxylin-eosin stain) shows an aspergillus colony (arrows) and a surrounding

area of intraalveolar hemorrhage (arrowheads)

http://radiographics.rsna.org/content/27/2/391/F24.expansion.html

High-power photomicrograph (original magnification, ×1000;

hematoxylin-eosin stain) shows fungal hyphae.

Fungal hyphae

High-power photomicrograph (original magnification, ×1000;

hematoxylin-eosin stain) shows fungal hyphae.

The clinicopathologic features and radiologic manifestations of aspergillosis depend on

• Patient immunity

• The presence of structural lung disease

• The virulence of the fungal species involved

• A 50-year-old woman treated with a high dosage of steroids to reduce cerebral edema from anaplastic oligodendroglioma

ي&ات# الد+ب(ق# م/ و1ر1 التغ1ص5ن ل#ي(ل1ة# الق1

InvasivePulmonary Aspergillosis

• A large mass is seen in :A. The RULB. The Middle lobeC. The RLL

• A large mass is seen in RUL localized in:A. Apical SegmentB. Posterior SegmentC. Anterior Segment

• A large mass is seen in the posterior segment of right upper lobe, surrounded by a wide zone of ground-glass attenuation (arrow)

• Demonstrating the halo sign

• A smaller mass (arrowhead) is seen in:A. The LLL.B. The LUL.

• A smaller mass (arrowhead) is seen in LLL:A. Superior SegmentB. Lateral Basal SegmentC. Posterior Basal

Segment

• A smaller mass (arrowhead) is seen in LLL:A. Superior SegmentB. Lateral Basal SegmentC. Posterior Basal

Segment

• A 39-year-old man with acute myelogenous leukaemia and neutropenia

33http://bjr.birjournals.org/cgi/content/full/78/933/862#T1

Thin-section CT at the level of the lung apex

• Shows multiple nodules surrounded by a halo of ground glass opacity in both upper lobes

Invasive pulmonary aspergillosis

• CT shows nodular consolidation associated with a halo of ground-glass opacity (GGO) in both apices resulting from invasive pulmonary aspergillosis

• This halo represents hemorrhage.• When seen in leukemic patients, is highly suggestive of the

diagnosis of invasive pulmonary aspergillosis.

• A 45-year-old woman with rapidly progressive glomerulonephritis.

• Low grade fever + mild cough and dyspnea + a weakness

Thin-section CT of the right lung base

• Multiple tiny nodules (arrows) with the CT halo sign in the right lower lobe

Quiz/ This patient has pneumonia caused by:

A. AdenovirusB. CytomegalovirusC. AspergillosisD. Staphylococcus

aureusE. E.Coli

Quiz/ This patient has pneumonia caused by:

A. AdenovirusB. CytomegalovirusC. AspergillosisD. Staphylococcus

aureusE. E.Coli

Neoplastic diseases

Kaposi sarcoma in a 29-year-old woman with a history of renal transplantation

• Thin-section CT at the level of the carina

• shows multiple nodules with a surrounding halo of ground glass opacity in both lungs

• Flame-shaped lesions

• The classic findings of Kaposi sarcoma.

Quiz / Thin-section CT obtained at the level of the

A. Bronchus superiorB. Bronchus

intermediusC. Bronchus inferior

45 http://bjr.birjournals.org/cgi/content-nw/full/78/933/862/F4

Quiz / Thin-section CT obtained at the level of the

A. Bronchus superiorB. Bronchus

intermediusC. Bronchus inferior

• A peripheral pulmonary nodule with the CT halo sign

What diagnosis that do you expect?

A. Streptococcus pneumonia

B. Bronchioloalveolar carcinoma

C. Kaposi SarcomaD. Pneumocystis

carinii (P. jirovecii) pneumonia

A. Streptococcus pneumonia

B. Bronchioloalveolar carcinoma

C. Kaposi SarcomaD. Pneumocystis carinii

(P. jirovecii) pneumonia

Non-neoplastic and non-infectious diseases

Eosinophilic PneumoniaEosinophilic lung disease may occur in various

conditionsParasitic infection

Idiopathic pulmonary fibrosis

Sarcoidosis

Collagen vascular disease

Hypereosinophilic syndrome

Drug reactions

HayakawaH, Sato A, Toyoshima M, Imokawa S, Taniguchi M. A clinical study of idiopathic eosinophilic pneumonia. Chest 1994; 105:1462–1466.

Halo sign / Eosinophilic Pneumonia

Eosinophilic lung disease

Parasitic infection (Loeffler syndrome)

Hypereosinophilic syndrome

HayakawaH, Sato A, Toyoshima M, Imokawa S, Taniguchi M. A clinical study of idiopathic eosinophilic pneumonia. Chest 1994; 105:1462–1466.

Histologically

Ground-glass opacity

Intraalveolar exudates Fibrotic change Eosinophilic infiltration

in the interstitium

KimY, Lee KS, Jung KJ, Han J, Kim JS, Suh JS. Halo sign on high resolution CT: findings in spectrum of pulmonary diseases with pathologic correlation. J Comput Assist Tomogr 1999; 23: 622–626.

Histologically

Solid portion

A neutrophilic abscess

KimY, Lee KS, Jung KJ, Han J, Kim JS, Suh JS. Halo sign on high resolution CT: findings in spectrum of pulmonary diseases with pathologic correlation. J Comput Assist Tomogr 1999; 23: 622–626.

Thin-section CT

• Shows multiple small nodules (arrows) in RLL

with a surrounding halo of ground glass opacity in the right lower lobe

55http://bjr.birjournals.org/cgi/content/full/78/933/862/F6

A. SarcoidosisB. Idiopathic

pulmonary fibrosisC. Drug reactionsD. Loeffler syndrome

A. SarcoidosisB. Idiopathic

pulmonary fibrosisC. Drug reactionsD. Loeffler syndrome

Simple pulmonary eosinophilia (Loeffler syndrome)

• In a 42-year-old man with peripheral eosinophilia

• 53.5% of eosinophils in the peripheral blood

Thin-section CT image at the level of the aortic arch

59 http://radiographics.rsna.org/content/27/2/391/F26.expansion.html

An ill-defined area of nodular ground-glass opacity in the upper lobe of the right lung

What diagnosis that do you expect in a 36-year-old man?

A. SarcoidosisB. Eosinophilic

pneumonia C. Idiopathic

pulmonary fibrosisD. Drug reactionsE. Lupus

What diagnosis that do you expect in a 36-year-old man?

A. SarcoidosisB. Eosinophilic

pneumonia C. Idiopathic

pulmonary fibrosisD. Drug reactionsE. Lupus

Please don’t forget

Quiz Ground-glass opacity at the level of

A. The left upper lobar bronchus

B. The left lower lobar bronchus

Quiz Ground-glass opacity at the level of

A. The left upper lobar bronchus

B. The left lower lobar bronchus

Quiz Ground-glass opacity at the level of the left upper lobar

bronchus

A. Apical Posterior Segment

B. Anterior SegmentC. Lingula Superior

SegmentD. Lingula Inferior

Segment

Quiz Ground-glass opacity at the level of the left upper lobar

bronchus

A. Apical Posterior Segment

B. Anterior SegmentC. Lingula Superior

SegmentD. Lingula Inferior

Segment

Spur LUL

Lingula Inferior Segment

Lingula Superior Segment

Apical Posterior Segment

Anterior Segment

• Thin-section CT shows a pulmonary nodule with the CT halo sign in the left lower lobe (thick arrow).

70http://bjr.birjournals.org/cgi/content-nw/full/78/933/862/F5

Note another nodule in without surrounding ground glass opacity (thin arrow) in the:

A. Right middle lobeB. Right upper lobeC. Right lower lobe

Note another nodule in without surrounding ground glass opacity (thin arrow) in the:

A. Right middle lobeB. Right upper lobeC. Right lower lobe

A. SarcoidosisB. Wegener's

granulomatosisC. Idiopathic

pulmonary fibrosisD. Drug reactionsE. Loeffler syndrome

A. SarcoidosisB. Wegener's

granulomatosisC. Idiopathic

pulmonary fibrosisD. Drug reactionsE. Loeffler syndrome

Reverse halo sign

Reverse halo sign: Wegener's granulomatosis

• Many nodules show central areas of ground glass opacity, with surrounding consolidation.

Reverse halo sign: Wegener's granulomatosis

• High-resolution CT scan of the chest shows bilateral nodular opacities with areas of patchy consolidation.

ct halo sign (part 1)

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