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Case 224


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Male 63 years old kidney transplanted patient admitted with fever and productive, persistent cough for about a month, despite appropriate empiric treatment with levofloxacin. Were found during examination: light rhonchi at the right base and bibasilar crackles on auscultation. SpO2 = 88 % with nasal catheter to 4L / min. Were requested radiograph, computed tomography, and bronchoscopy with bronchoalveolar lavage (BAL), which presented the following result : negative search for acid-fast bacilli, bacteria not seen in Gram and culture for fungi in progress. Positive serum galactomannan.

Considering the clinical history and images, which is the most likely diagnosis?

a) Bacterial pneumonia


b) Fungal pneumonia


c) Viral Pneumonia


d) Post-primary Tuberculosis


Image analysis

Image 1: Chest radiograph, posteroanterior view. Presence of alveolar consolidations with little defined limits in the upper 2/3 of the lungs (yellow lines). Peribronchovascular infiltration in the right lung base (red line). Mild thickening and / or small pleural effusion within the right costophrenic angle (arrow). Uniformly elongated aorta.


Image 2: Computed tomography ( CT) scan of the chest without contrast, at the level of the trachea. Pulmonary window. Presence of alveolar consolidations in the upper left lobe surrounded by attenuation frosted glass halo (halo sign- yellow line). It is also clear a cuneiform consolidation stretching from the pleura on the right lung upper lobe (red line) and sparse bilateral pulmonary ground-glass opacities.


- Fungal pneumonia is common and severe in immunocompromised patients , requiring early diagnosis and treatment.;

- The patient's clinical context is very important, because the symptoms manifested by the disease are common to other lung infections;

- Galactomannan is a wall polysaccharide of Aspergillus sp, which contributes as a diagnostic marker of infection;

- The combination of antigen markers , plain radiographs and CT of the chest is sufficient to establish diagnosis and treatment institution.


- Uchoa SMP. Capítulo 5 - Aspergilose: do diagnóstico ao tratamento. J. bras.pneumol.  [Internet]. 2009  Dec [cited  2016  Apr  04] ;  35( 12 ): 1238-1244. Disponível em: 

- Silva, C.; Isabela, S.; et al. Tórax. Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. Rio de Janeiro: Elsevier. 2010.


Débora Faria Nogueira, 5th year medical student at UFMG.

E-mail: deborafarianog[at]


Alexandre Valente Tobias, 4th year medical student at UFMG

E-mail: tobias.a94[at]


Brunno Freitas da Costa, 4th year medical student at UFMG

E-mail: fc_brunno[at]


Thiago Andrade dos Santos, 4th year medical student at UFMG

E-mail: thiago.tas92[at]


José Nelson Mendes Vieira, Radiologist, Professor of the Anatomy and Image Department at UFMG.

E-mail: zenelson.vieira[at]


Fabio M. Satake, Cairo Mendes, Raíra Cezar, André Guimarães, Laio Bastos and Professor Viviane Parisotto.

Translated by

Rafael Fusaro Aguiar Oliveira, 5th year medical student at UFMG.

E-mail: rafusaro[at]


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