CTICasesPulmonary Mucormycosis ("Bird's Nest" Sign) in Neutropenic Leukemia
Imaging findings
A neutropenic patient with leukemia and failed remission after chemotherapy had a radiograph showing a new right upper lung nodule that progressed within 12 days to a large right upper lung consolidation with a lesion showing central lucency; CT at that time demonstrated a characteristic "bird's nest" pattern in the upper lung despite the patient being on anti-Aspergillus prophylaxis. Bronchoalveolar lavage confirmed Mucorales (mucormycosis) rather than Aspergillus, with a similar early bird's-nest pattern developing on the contralateral side; despite treatment with amphotericin, the disease progressed with larger bilateral consolidation, decreasing lung volumes, and increasing pleural effusion as the patient's neutropenia could not be corrected.
Key takeaways
The "bird's nest" pattern on CT is a strong discriminator favoring pulmonary mucormycosis over Aspergillus, particularly in a neutropenic patient already receiving anti-Aspergillus prophylaxis, and clearance of mucormycosis is very difficult to achieve without recovery of the patient's white cell count, since the disease can progress despite appropriate antifungal therapy in persistently neutropenic hosts and can involve both lungs rather than remaining a single focal infarct-like mass.
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