CRA60 “CHEERIOS” IN MY LUNGS? UNBELIEVABLE BUT TRUE

Nur Liyana Maryam Binti Zaini, Shivaanand, Noor Izyani Binti Zakaria, Jen Lye Wan

Respiratory Department, Selayang Hospital, Selangor

Background
“Cheerio sign” is a rare radiological finding on computed tomography (CT) thorax characterized by a central lucency surrounded by a ring-like or nodular opacity, resembling a breakfast cereal ring. The sign is usually misinterpreted as benign cystic or cavitary lung disease causing the delay in more malignant diagnosis. This case report highlights a rare instance of the Cheerio sign in a patient ultimately diagnosed with pulmonary adenocarcinoma.

Case presentation
A 72-year-old man, active smoker of 40-packed years presented with a chronic coughing and weight loss for over three months. Upon presentation, he was hemodynamically stable despite abnormal chest radiograph. Patient was treated for community-acquired pneumonia with antibiotic and discharged home. However, he returned with worsening symptoms a week later. He was empirically treated for pulmonary tuberculosis while awaiting CT thorax. Despite on antituberculosis, the patient deteriorated clinically and radiologically. Bronchial washing for cultures and blood investigation yielded no evidence of infection. However, tumour markers are marked elevated for CA-125 455U/mL and CA19-9 885U/mL. CT thorax revealed extensive bilateral lung nodules and cavitary mass with central lucency suggestive of cheerio sign. CT guided biopsy finally performed with a high-risk consent and the result was confirmed as pulmonary adenocarcinoma.

Conclusion
In conclusion, it is very crucial to distinguish between true cavitatory lesion and cheerios nodules which has central lucency, surrounded by a rim of tissue on the open airway. This rare CT sign is a potential indicator of malignancy, warranting immediate intervention. Unfortunately, this patient came at the terminal stage of lung malignancy. Despite diagnosis achieved, he was not fit for further treatment and succumbed to death few days after the biopsy.