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Original Article • Radiol Bras 55 (2) • Mar-Apr 2022 • https://doi.org/10.1590/0100-3984.2021.0055 copy

Radiological patterns of pulmonary fungal infection in pediatric hematology and oncology patients

Padrões radiológicos em infecção fúngica pulmonar em pacientes pediátricos com doenças oncohematológicas

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To describe the radiological findings in pediatric patients with hematological or oncological diseases who also have an invasive fungal infection (IFI).

Materials and Methods:

This was a retrospective study of all patients with IFI admitted to a pediatric hematology and oncology hospital in Brazil between 2008 and 2014. Clinical and demographic data were collected. Chest computed tomography (CT) scans of the patients were reviewed by two independent radiologists.

Results:

We evaluated the chest CT scans of 40 pediatric patients diagnosed with an IFI. Twenty-seven patients (67.5%) had nodules with the halo sign, seven (17.5%) had cavities, two (5.0%) had nodules without the halo sign, and seven (17.5%) had consolidation. The patients with the halo sign and cavities were older (123 vs. 77 months of age; p = 0.03) and had less severe disease (34% vs. 73%; p = 0.04). Ten patients had a proven IFI: with Aspergillus sp. (n = 4); with Candida sp. (n = 5); or with Fusarium sp. (n = 1).

Conclusion:

A diagnosis of IFI should be considered in children and adolescents with risk factors and abnormal CT scans, even if the imaging findings are nonspecific.

Keywords:
Mycoses/diagnostic imaging; Child; Adolescent; Immunocompromised host; Tomography; X-ray computed

Characteristic	Chest CT findings
Characteristic	Typical (n = 29)	Atypical (n =11)	P-value
Sex, n (%)			0.48
Female	13 (45)	7 (64)
Male	16 (55)	4 (36)	ND
Underlying condition, n (%)
Acute lymphoblastic leukemia	9 (31)	3 (27)
Acute myeloid leukemia	13 (45)	4 (36)
Refractory to treatment or relapsed	11 (38)	2 (18)
Autologous bone marrow transplant	2 (7)	1 (9)
Allogeneic bone marrow transplant	1 (3)	1 (9)
Other^* * Neuroblastoma (n = 4); osteosarcoma (n = 2); astrocytoma (n = 1); hemangioendothelioma (n = 1); sarcoma (n = 1); pineoblastoma (n = 1); and retinoblastoma (n = 1).	7 (24)	4 (36)
Age (months), median	123	77	0.03
Age group, n (%)			ND
≤ 6 years	8 (2)	6 (55)
7–12 years	9 (31)	5 (45)
≥ 13 years	12 (41)	0
Neutropenia, n (%)	28 (97)	9 (82)	0.17
Days with neutropenia before
diagnosis, median	15	11	0.04
Broad-spectrum antibiotics, n (%)	29 (100)	11 (100)	ND
Corticosteroid therapy, n (%)	6 (21)	5 (45)	0.13
Chemotherapy, n (%)	28 (97)	9 (82)	0.07
Invasive devices, n (%)	23 (79)	10 (91)	0.65
Mucositis, n (%)	23 (79)	6 (55)	0.13
Signs and symptoms, n (%)
Fever	29 (100)	10 (91)	0.27
Respiratory distress	16 (55)	6 (55)	1
Pleuritic pain	1 (3)	0 (0)	1
Hemodynamic instability	6 (21)	6 (55)	0.03
Skin lesions	0 (0)	1 (9)	0.27
Duration (days) of fever, median	9.0	5.5	0.30
Intensive care unit admission	10 (34)	8 (73)	0.04
Antifungal prophylaxis	17 (59)	6 (55)	ND
Fluconazole	2 (7)	1 (9)
Itraconazole	7 (24)	0
Voriconazole	3 (10)	1 (9)
Micafungin	5 (17)	4 (36)
Antifungal treatment			ND
Duration (days), median	21 days	22 days	0.60
Agent, n (%)
Fluconazole	1 (3)	0
Voriconazole	5 (17)	0
Amphotericin B	12 (41)	9 (82)
Amphotericin B + fluconazole	0	1 (9)
Amphotericin B + voriconazole	11 (38)	1 (9)
Outcome			0.59
Cure	14 (48)	7 (64)
Death from IFI	3 (10)	2 (18)
Death from other causes	9 (31)	2 (18)
Loss to follow-up	3 (10)	0
Chest CT findings^† † 1 finding (n = 4); 2 findings (n = 5); or ≥ 3 findings (n = 31). ND, no data.
Halo sign	27 (93)	0 (0)	0.00
Consolidation	12 (41)	8 (72)	0.15
Cavity	7 (24)	0	0.15
Nodules	1 (3)	2 (18)	0.17
Ground-glass opacity	19 (65)	10 (91)	0.23
Pleural effusion	10 (34)	5 (45)	0.71
Other	24 (82)	8 (72)	0.66

Patient	Sex	Age (years)	Underlying condition	IFI status	Fungal isolate	Site(s) of detection	Symptoms	CT findings
1	Male	6	Acute lymphoblastic leukemia	Proven	Aspergillus sp.	Lung (biopsy)	Fever and respiratory distress	Halo sign; ground-glass opacities; bronchial wall thickening
2	Male	14	Acute myeloid leukemia refractory or relapsed	Proven	Aspergillus sp.	Lung (biopsy)	Fever	Halo sign
3	Female	6	Acute myeloid leukemia	Proven	Aspergillus sp.	Lung (biopsy)	Fever, shock and respiratory distress	Halo sign; consolidation; pleural effusion; ground-glass opacities; mosaic attenuation pattern; bronchial wall thickening
4	Female	6	Acute myeloid leukemia	Proven	Candida parapsilosis	Central venous catheter	Fever and shock	Nodule
5	Female	1	Acute lymphoblastic leukemia	Proven	Aspergillus sp.	Lung (biopsy)	Fever and respiratory distress	Halo sign
6	Male	8	Neuroblastoma + autologous bone marrow transplant	Proven	Candida haemulonii	Central venous catheter; peripheral blood (culture)	Fever	Halo sign; cavity; bronchial wall thickening
7	Female	1	Hemangioendothe- lioma	Proven	Candida parapsilosis	Peripheral blood (culture); peritoneal cavity (ascitic fluid analysis)	Fever without neutropenia, shock and respiratory distress	Nodule; consolidation; cavity; ground- glass opacities; mosaic attenuation pattern; bronchial wall thickening
8	Female	5	Acute lymphoblastic leukemia refractory or relapsed	Proven	Candida albicans	Peripheral blood (culture); urine (culture); lung (bronchoalveolar lavage)	Fever, shock and respiratory distress	Consolidation; pleural effusion; ground-glass opacities; bronchial wall thickening
9	Female	11	Acute lymphoblastic leukemia refractory or relapsed	Proven	Fusarium sp.	Skin (biopsy)	Fever, respiratory distress and skin lesion	Consolidation; pleural effusion; ground-glass opacities
10	Male	3	Retinoblastoma	Proven	Candida parapsilosis	Peripheral blood (culture)	Fever, shock and respiratory distress	Consolidation; ground-glass opacities; bronchial wall thickening
11	Female	17	Acute lymphoblastic leukemia	Probable	Aspergillus sp.	Lung (bronchoalveolar lavage)	Fever and shock	Halo sign; consolidation; cavity; ground glass opacities; bronchial wall thickening

CT finding^* * 1 finding (n = 4); 2 findings (n = 5); or ≥ 3 findings (n = 31).	Proven/probable aspergillosis (n = 5)	Proven candidiasis (n = 5)	Proven fusariosis (n = 1)	Possible IFI (n = 29)
Halo sign, n (%)	5 (100)	1 (20)	0 (0)	21 (72)
Consolidation, n (%)	2 (40)	3 (60)	1 (100)	14 (48)
Cavity, n (%)	2 (40)	2 (40)	0 (0)	3 (10)
Nodules, n (%)	0 (0)	2 (40)	0 (0)	1 (3)
Ground-glass opacity, n (%)	3 (60)	3 (60)	1 (100)	22 (75)
Pleural effusion, n (%)	1 (20)	1 (20)	1 (100)	12 (41)

Chest CT finding	Interobserver agreement
	First round^* * Review of all CT scans.		Second round^† † Review of only the CT scans for which there were differences in interpretation in the first round.
	Kappa	P-value	Kappa	P-value
Halo sign	0.609	< 0.001	0.762	< 0.001
Consolidation	0.609	< 0.001	0.921	< 0.001
Cavity	0.860	< 0.001	0.860	< 0.001
Nodules	0.649	< 0.001	0.782	< 0.001
Ground-glass opacity	0.813	< 0.001	0.865	< 0.001
Pleural effusion	0.900	< 0.001	0.966	< 0.001

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E-mail: radiologiabrasileira@cbr.org.br

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