JAMA Surgery Clinical Challenge

Pulmonary Air Crescent Sign

Image of Figure 1

Figure. After treatment with an antifibrinolytic agent, a ball-like mass with an air crescent sign in the left upper lobe was noted.

Kai-Ling Lee, MD
Hung-Hua Liang, MD
Chi-Li Chung, MD
Shi-Hsin Hsiao, MD
Chung-Hung Shih

A 62-year-old man was admitted to our hospital with a concern of productive cough, profuse hemoptysis, and intermittent breathlessness for about 5 months. He had a 60-year history of cigarette smoking and had stopped smoking 5 months prior to being seen.

When the symptom of hemoptysis occurred 5 months earlier, chest radiography and computed tomography (CT) revealed a ground-glass opacity in the left upper lobe. The patient was treated with an antifibrinolytic agent (tranexamic acid), and the hemoptysis gradually improved and follow-up chest radiography showed resolution of the lesion (Figure). However, about 1 month later, hemoptysis reoccurred and increased volume and frequency over the following 4 months.

On physical examination, sonorous rhonchi were audible in the bilateral lungs. Chest CT revealed a cavitary lesion with a central contrast-enhanced ball-like mass at the site of the prior ground-glass lesion. Sputum examinations for acid-fast bacilli smear and culture, fungal culture, and cytology showed negative results. Fiberoptic bronchoscopy revealed blood clots over the orifice of the left upper lobe bronchus, but no endobronchial lesion was detected.

The chest CT finding, characteristic of a fungus ball-like shadow with an air crescent sign, highly suggested a pulmonary aspergilloma. However, the contrast enhancement was present within the mass, and lung malignancy could not be excluded. Because of persistent massive hemoptysis, the patient underwent left exploratory thoracotomy. A whitish, firm nodule about 2 cm was noted in a cavity in the left upper lung.

See the full article for an explanation and discussion.

Author Affiliations: Lee, Chung, Hsiao, and Shih (b8501133@tmu.edu.tw) are affiliated with the Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, and Liang is affiliated with the Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan, and the Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.