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British Journal of Radiology (2007) 80, 849-850
© 2007 British Institute of Radiology
doi: 10.1259/bjr/61353689
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Correspondence

Another cause of reverse halo sign: Wegener's granulomatosis

Dear Editor — Sir,

We read with interest the article "Reversed halo sign in lymphomatoid granulomatosis" by Benamore et al [1] in the August issue of the BJR, in which the authors describe a case of lymphomatoid granulomatosis associated with reverse halo sign. The other causes of reversed halo sign described in the literature include pulmonary tuberculosis [2], pulmonary zygomycosis [3] and pulmonary small vessel vasculitis [4]. Herein, we wish to report a further cause of reversed halo sign on CT — Wegener's granulomatosis.

A 28-year-old male presented to the Chest Clinic with history of fever, cough and chest pain of 1 months' duration. The patient also complained of anorexia, weight loss and epistaxis. There were no arthralgias, oliguria, or neurological or skin involvement. A chest radiograph showed bilateral extensive areas of patchy consolidation. Biochemical investigations revealed normal liver function tests but serum creatinine was 3.8 mg dL–1. Complete blood count showed evidence of mild anaemia with thrombocytosis. Urine microscopy revealed 50–60 red blood cells per high power field, and 24-h urinary protein was 1.2 g. A provisional diagnosis of systemic vasculitis was considered. A high-resolution CT scan showed widespread nodular opacities, with some of the nodules demonstrating the reversed halo sign (Figure 1Go); areas of consolidation were also seen. Renal biopsy was performed, which was suggestive of necrotizing vasculitis with crescentic glomerulonephritis; immunofluorescence microscopy revealed pauci-immune IgG deposits. Anti-neutrophil cytoplasmic antibodies, detected by indirect immunofluorescence, displayed a diffuse granular cytoplasmic pattern. A diagnosis of Wegener's granulomatosis was made and the patient was started on bolus intravenous methylprednisolone (1 g day–1) for three consecutive days followed by oral prednisolone (60 mg day–1). Simultaneously oral cyclophosphamide at a dose of 150 mg day–1 was also started. The patient showed significant response and at 3 months the chest radiograph and urine analysis was completely normal. Oral cyclophosphamide was stopped after 3 months and the patient was started on oral azathioprine (150 mg day–1). Prednisolone was tapered, and at 6 months the dose was maintained at 7.5 mg day–1. The patient has continued to be on low-dose prednisolone and oral azathioprine for the past 2 years.


Figure 1
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  		Figure 1. High-resolution CT scan of the chest shows bilateral nodular opacities with areas of patchy consolidation. Many nodules show central areas of ground glass opacity, with surrounding consolidation.

 
The reverse halo sign initially thought to be specific for cryptogenic organizing pneumonia [5] has also been described in other disorders including pulmonary zygomycosis [3], pulmonary paracoccidioidomycosis [6], pulmonary tuberculosis [2], lymphomatoid granulomatosis [1] and small vessel vasculitis (Wegener's granulomatosis), as seen in this case. One previous report [4] has also described a case of Wegener's granulomatosis associated with reverse halo sign; however, this patient had hypereosinophilia and raised serum IgE, which suggests Churg-Strauss syndrome rather than Wegener's granulomatosis. The reverse halo sign thus seems to be a non-specific sign encountered in various pulmonary disorders.

R Agarwal, A N Aggarwal and D Gupta

Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research Chandigarh, India. E-mail: ritesh{at}indiachest.org; riteshpgi{at}gmail.com

Received for publication September 5, 2007. Revision received September 10, 2007. Accepted for publication September 17, 2007.

References

  1. Benamore RE, Weisbrod GL, Hwang DM, Bailey DJ, Pierre AF, Lazar NM, et al. Reversed halo sign in lymphomatoid granulomatosis. Br J Radiol 2007;80:e162–6.[Abstract/Free Full Text]
  2. Ahuja A, Gothi D, Joshi JM. A 15-year-lld boy with "reversed halo". Indian J Chest Dis Allied Sci 2007;49:99–101.
  3. Geronemus A, Coppage L, Hazelton T, editors. The Reversed Halo Sign: A non-specific finding on CT of the thorax. RSNA; 2004: 2441EP-CH-e
  4. Choi YH, Im J-G, Park CK. Notes from the 2001 Annual Meeting of the Korean Society of Thoracic Radiology. J Thorac Imaging 2002;17:170–5.[CrossRef]
  5. Kim SJ, Lee KS, Ryu YH, Yoon YC, Choe KO, Kim TS, et al. Reversed halo sign on high-resolution CT of cryptogenic organizing pneumonia: diagnostic implications. AJR Am J Roentgenol 2003 May;180:1251–4.[Abstract/Free Full Text]
  6. Gasparetto EL, Escuissato DL, Davaus T, de Cerqueira EM, Souza AS Jr, Marchiori E, et al. Reversed halo sign in pulmonary paracoccidioidomycosis. AJR Am J Roentgenol 2005;184:1932–4.[Abstract/Free Full Text]




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