Author
Hima Venigandla, DO, Pichapong Tunsupon, MD
Department of Internal Medicine
Division of Pulmonary and Critical Care Medicine
University of Florida, Gainesville, FL
Case
Introduction
A previously healthy 18-year-old woman presents to the Emergency Department with a complaint of coughing up blood over the past nine months. She describes coughing up approximately 1-2 nickel sized blood clots every morning. She has no further coughing for the rest of the day. She does not have any other associated symptoms and denies chest pain, shortness of breath, wheezing, upper respiratory symptoms, sinus congestion, fevers, chills, rashes, and hematuria. She has not traveled recently. She denies illicit drug use or medication use. She denies any family history of similar symptoms.
She was recently seen by a local pulmonologist for her hemoptysis and underwent an unremarkable bronchoscopy with bacterial, viral, and fungal cultures that returned negative for infection. Notably, the right upper lobe bronchoalveolar lavage (BAL) cell count was composed of 44% neutrophils, 26% lymphocytes, 25% eosinophils, and 4% monocytes. Cytology showed predominantly blood elements with scattered eosinophils and scant pulmonary macrophages, without evidence of malignancy. She underwent extensive serologic testing which was most remarkable for a positive c-ANCA titer of 1:80 as well as a positive anti-proteinase 3 antibody titer of 28. Comprehensive metabolic panel, complete blood count with differential, HIV antibodies, ANA, CRP, Quantiferon, BAL aspergillus antigen, and urinalysis were all negative. She was empirically treated with a 5-day course of oral azithromycin without improvement. Axial and coronal images of her CT chest are shown below.
Images
Question
What is the radiologic finding on the CT chest?
A. Signet ring sign
B. Reversed Halo sign
C. Comet tail sign
D. Crazy paving sign