Letters to the Editor
The reversed halo sign extending the spectrum of atypical radiological manifestations in sarcoidosis
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Marchiori E, Zanetti G, Meirelles GS, Escuissato DL, Souza AS Jr, Hochhegger B. The reversed halo sign on high-resolution CT in infectious and noninfectious pulmonary diseases. AJR Am J Roentgenol 2011;197:W69-75. Marchiori E, Zanetti G, Mano CM, Hochhegger B, Irion KL. The reversed halo sign: Another atypical manifestation of sarcoidosis. Korean J Radiol 2010;11:251-2. Marchiori E, Zanetti G, Hochhegger B, Irion KL. Re: Reversed halo sign: Nodular wall as criterion for differentiation between cryptogenic organizing pneumonia and active granulomatous diseases. Clin Radiol 2010;65:770-1. Access this article online Quick Response Code:
Sir, We read with great interest the well-written pictorical essay by Al-Jahdali et al.,[1] which reviews the wide spectrum of atypical thoracic manifestations of sarcoidosis on imaging methods, emphasizing the importance of understanding the radiological manifestations in making a proper diagnosis. In order to contribute to this excellent review, we would like to include another atypical tomographic aspect of sarcoidosis, which is the reversed halo sign (RHS). RHS is defined as a focal, round area of ground-glass attenuation surrounded by a partial or complete rim of consolidation. This sign was initially described as a relatively specific of cryptogenic organizing pneumonia. However, subsequent publications identified this sign in a wide spectrum of diseases, including infectious and non-infectious conditions, among them pulmonary sarcoid is included.[2,3] Although the RHS must be regarded as a non-specific sign that is encountered in various pulmonary diseases, in cases of sarcoidosis the sign has distinctive morphological characteristics. In patients with sarcoidosis, the ring or the inner area of the reversed halo is nodular in appearance. Furthermore, small nodules within the central ground-glass region of the RHS were seen. Histopathologic analysis of such specimens has revealed the presence of granulomas within the ring portion of the RHS and/or inside the RHS.[4,5] The same aspect was seen in active granulomatous infectious diseases, particularly tuberculosis.[5] In conclusion, the RHS with nodular pattern should be included in the spectrum of parenchymal abnormalities that are observed on high resolution computed tomography in patients with sarcoidosis.
Edson Marchiori, Gláucia Zanetti, Marcos Duarte Guimarães1, Bruno Hochhegger Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, 1Hospital A.C. Camargo, São Paulo, Brazil E-mail: [email protected]
References 1.
2.
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Al-Jahdali H, Rajiah P, Koteyar SS, Allen C, Khan AN. Atypical radiological manifestations of thoracic sarcoidosis: A review and pictorial essay. Ann Thorac Med 2013;8:186-96. Marchiori E, Zanetti G, Escuissato DL, Souza AS Jr, Meirelles GS, Fagundes J, et al. Reversed halo sign: High-resolution CT scan findings in 79 patients. Chest 2012;141:1260-6.
Website: www.thoracicmedicine.org
DOI: 10.4103/1817-1737.124445
Reply to the editor Sir, We thank Dr. Marchiori for his interest in our article. In our review[1] we described the atypical radiological features that are unique and may help in the diagnosis of sarcoidosis. We agree with Dr. Marchiori that reversed halo sign (RHS) has been described in patients with glanulomatous disease. However, the RHS is not specific for sarcoidosis and has a wide differential and as such is not very useful in achieving a specific diagnosis particularly sarcoidosis.
Reference 1. Al-Jahdali H, Rajiah P, Koteyar SS, Allen C, Khan AN. Atypical radiological manifestations of thoracic sarcoidosis: A review and pictorial essay. Ann Thorac Med. 2013;8(4):186-196.
Hamdan Al-Jahdali
Department of Medicine, Division of Pulmonology, Sleep Disorders Center, King Saud University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia. Email: [email protected] Access this article online Quick Response Code:
Website: www.thoracicmedicine.org
Annals of Thoracic Medicine - Vol 9, Issue 1, January-March 2014
Copyright of Annals of Thoracic Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
The reversed halo sign extending the spectrum of atypical radiological manifestations in sarcoidosis
3.
4.
5.
Marchiori E, Zanetti G, Meirelles GS, Escuissato DL, Souza AS Jr, Hochhegger B. The reversed halo sign on high-resolution CT in infectious and noninfectious pulmonary diseases. AJR Am J Roentgenol 2011;197:W69-75. Marchiori E, Zanetti G, Mano CM, Hochhegger B, Irion KL. The reversed halo sign: Another atypical manifestation of sarcoidosis. Korean J Radiol 2010;11:251-2. Marchiori E, Zanetti G, Hochhegger B, Irion KL. Re: Reversed halo sign: Nodular wall as criterion for differentiation between cryptogenic organizing pneumonia and active granulomatous diseases. Clin Radiol 2010;65:770-1. Access this article online Quick Response Code:
Sir, We read with great interest the well-written pictorical essay by Al-Jahdali et al.,[1] which reviews the wide spectrum of atypical thoracic manifestations of sarcoidosis on imaging methods, emphasizing the importance of understanding the radiological manifestations in making a proper diagnosis. In order to contribute to this excellent review, we would like to include another atypical tomographic aspect of sarcoidosis, which is the reversed halo sign (RHS). RHS is defined as a focal, round area of ground-glass attenuation surrounded by a partial or complete rim of consolidation. This sign was initially described as a relatively specific of cryptogenic organizing pneumonia. However, subsequent publications identified this sign in a wide spectrum of diseases, including infectious and non-infectious conditions, among them pulmonary sarcoid is included.[2,3] Although the RHS must be regarded as a non-specific sign that is encountered in various pulmonary diseases, in cases of sarcoidosis the sign has distinctive morphological characteristics. In patients with sarcoidosis, the ring or the inner area of the reversed halo is nodular in appearance. Furthermore, small nodules within the central ground-glass region of the RHS were seen. Histopathologic analysis of such specimens has revealed the presence of granulomas within the ring portion of the RHS and/or inside the RHS.[4,5] The same aspect was seen in active granulomatous infectious diseases, particularly tuberculosis.[5] In conclusion, the RHS with nodular pattern should be included in the spectrum of parenchymal abnormalities that are observed on high resolution computed tomography in patients with sarcoidosis.
Edson Marchiori, Gláucia Zanetti, Marcos Duarte Guimarães1, Bruno Hochhegger Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, 1Hospital A.C. Camargo, São Paulo, Brazil E-mail: [email protected]
References 1.
2.
48
Al-Jahdali H, Rajiah P, Koteyar SS, Allen C, Khan AN. Atypical radiological manifestations of thoracic sarcoidosis: A review and pictorial essay. Ann Thorac Med 2013;8:186-96. Marchiori E, Zanetti G, Escuissato DL, Souza AS Jr, Meirelles GS, Fagundes J, et al. Reversed halo sign: High-resolution CT scan findings in 79 patients. Chest 2012;141:1260-6.
Website: www.thoracicmedicine.org
DOI: 10.4103/1817-1737.124445
Reply to the editor Sir, We thank Dr. Marchiori for his interest in our article. In our review[1] we described the atypical radiological features that are unique and may help in the diagnosis of sarcoidosis. We agree with Dr. Marchiori that reversed halo sign (RHS) has been described in patients with glanulomatous disease. However, the RHS is not specific for sarcoidosis and has a wide differential and as such is not very useful in achieving a specific diagnosis particularly sarcoidosis.
Reference 1. Al-Jahdali H, Rajiah P, Koteyar SS, Allen C, Khan AN. Atypical radiological manifestations of thoracic sarcoidosis: A review and pictorial essay. Ann Thorac Med. 2013;8(4):186-196.
Hamdan Al-Jahdali
Department of Medicine, Division of Pulmonology, Sleep Disorders Center, King Saud University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia. Email: [email protected] Access this article online Quick Response Code:
Website: www.thoracicmedicine.org
Annals of Thoracic Medicine - Vol 9, Issue 1, January-March 2014
Copyright of Annals of Thoracic Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
