Cheerios in the lung: A rare but characteristic radiographic sign

Aktuerk D, Lutz M, Rosewarne D, Luckraz H

Abstract

A 52-year-old woman presented with a three-month history of right pleuritic chest pain and recent night sweats. In terms of premedical history, she had a 30 pack-year smoking history, but denied any environmental exposure. There was no evidence of tuberculosis exposure or a positive tuberculin test in the past. She denied weight loss and her travel history included visits only to European countries. Physical examination showed no evidence of jaundice, anaemia, cyanosis, clubbing or lymphadenopathy. On auscultation the chest was clear with bilateral free air entry and there were no cardiac murmurs. A chest x-ray obtained on presentation was normal and did not show any lung pathology. A computed tomography (CT) scan revealed multiple cavitary nodules within the lung bilaterally especially in the right upper lobe. The so-called "Cheerios" in the lung appear on CT images as one or multiple nodules of variable sizes with hypodense centers. Thus, they received their name after the "O"-shaped breakfast cereal "Cheerios". They usually present as a small, hoop like and fairly uniform shadowing embedded in normal surrounding lung. The "Cheerios" in the lung have their origin in the peribronchiolar proliferation of malignant as well as non-malignant cells. Thus, the differential diagnosis includes bronchioloalveolar carcinoma, metastatic adenocarcinoma, metastatic sarcoma, metastatic squamous cell carcinoma and lymphoma, but there are also documented findings in systemic inflammatory conditions such as cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) vasculitis and pulmonary Langerhans cell histiocytosis (PLCH). © The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.