Pulmonary Air Crescent Sign

Abstract

A62-year-oldmanwas admitted to our hospital with a concern of productive cough, profuse hemoptysis, and intermittent breathlessness for about 5 months. He had a 50-year history of cigarette smoking and had stopped smoking 5months 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. Thepatientwas treatedwithanantifibrinolytic agent (tranexamicacid), and thehemoptysisgradually improved and follow-up chest radiography showed resolution of the lesion (Figure 1). However, about 1 month later, hemoptysis reoccurred and increased volume and frequency over the following 4months. 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 bloodclotsover theorificeof the left upper lobebronchus, butnoendobronchial lesionwas detected. The chest CT finding, characteristic of a fungus ball-like shadow with an air crescent sign, highly suggestedapulmonary aspergilloma.However, the contrast enhancementwas present within the mass, and lung malignancy could not be excluded. Because of persistent massive hemoptysis, the patient underwent left exploratory thoracotomy. Awhitish, firm nodule about 2 cmwas noted in a cavity in the left upper lung. H