CTICasesAngio-Invasive Aspergillosis with Air Crescent Sign (Doll's Eyes)
Imaging findings
Chest radiograph in a liver transplant recipient with febrile illness shows multiple pulmonary nodules. CT confirms nodules with surrounding ground-glass halos consistent with angio-invasive infection. Follow-up radiograph approximately one week later shows cavitation of the nodules with central structures (necrotic lung) visible within the cavities, producing the air crescent sign. On CT these are described as doll's eyes: the central necrotic or cavitated lung ball within the surrounding cavity shell, also called the true air crescent sign (as opposed to the Monad sign of aspergilloma in pre-existing cavity). The organism is Aspergillus.
Key takeaways
Angio-invasive Aspergillus infection progresses from nodules with halos (early phase, from hemorrhagic infarction) to cavitation with air crescent signs as the patient's immune system recovers and neutrophil counts improve. The air crescent sign with central necrotic lung or fungal ball (doll's eyes) was historically most common in neutropenic stem cell transplant patients during neutrophil recovery, but can be seen in any immunosuppressed patient including solid organ transplant recipients. The incidence of this finding has decreased as aggressive early antifungal therapy (voriconazole) prevents progression to this stage.
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