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Internal Medicine

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A 62-year-old man comes to the emergency department after "coughing up a 6-ounce cupful of blood." He describes about 3 days of increased yellowish sputum production associated with mild increase in dyspnea on exertion. On the previous 2 days he had slight blood streaking in the sputum. He has no prior history of hemoptysis. He has no fever, chills, weight loss, or night sweats.

His past medical history is significant for HIV and tuberculosis treated 12 years ago with directly observed therapy for 9 months. He is compliant with highly active antiretroviral therapy. He is an ex-IV drug user with a 50-pack-year history of tobacco use.

On examination, the patient is very anxious appearing with mild respiratory distress and some dried blood on his lips.

Pulse is 104/min, respirations are 20/min, and SaO, is 90% on room air. Lung examination shows mild diffuse wheezing. He coughs up an additional 25 cc of blood while being examined.

Laboratory results are as follows:

Hemoglobin 13.6 g/dL

Platelets 166,000/pL

Leukocytes 11,000/pL

International Normalized Ratio (INR) 1.1

Ct scan is shown below:

Which of the following is the most likely diagnosis?

  • Bronchogenic Carcinoma

  • Chronic Bronchitis

  • Aspergilloma

  • Tuberculosis recurrence


The Monod sign refers to the presence of gas surrounding a mycetoma, typically an aspergilloma, within a pre-existing pulmonary cavity. It is a distinct radiographic feature indicating a freely mobile mass within the cavity that can move when the patient's position changes, optimally observed when images are acquired in a prone position to allow the mass to shift to a gravity-dependent location. This sign should not be confused with the air crescent sign, which is associated with the recovery phase of angioinvasive aspergillosis and indicates an improvement in the patient's condition. Despite the specific implications of the Monod sign, in clinical practice, the term is not widely recognized, and the gas pattern around the mycetoma is often crescent-shaped. Consequently, the term air crescent sign is frequently used interchangeably to describe both phenomena, although they represent different pathological processes.


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