A reversed halo sign (RHS) is defined as the presence of a focal ring-shaped area of ground-glass opacity within a peripheral rim of consolidation. Although originally described in patients with cryptogenic organizing pneumonia, it has been described with several other noninfectious and infectious diseases, including fungal infections. Thus, it is imperative that a proper diagnosis be established before initiating treatment. In this article, we systematically review the literature (PubMed and Embase) for the associations of the RHS. We have also proposed a diagnostic algorithm for an approach to a patient with an RHS.
VoloudakiAE, BourosDE, FroudarakisME, DatserisGE, ApostolakiEG, GourtsoyiannisNC. Crescentic and ring-shaped opacities. CT features in two cases of bronchiolitis obliterans organizing pneumonia (BOOP). Acta Radiol, 1996; 37(6):889–892.
2.
KimSJ, LeeKS, RyuYH, YoonYC, ChoeKO, KimTS, SungKJ. Reversed halo sign on high-resolution CT of cryptogenic organizing pneumonia: diagnostic implications. AJR Am J Roentgenol, 2003; 180(5):1251–1254.
3.
MarlowTJ, KrapivaPI, SchabelSI, JudsonMA. The “fairy ring”: a new radiographic finding in sarcoidosis. Chest, 1999; 115(1):275–276.
4.
ZompatoriM, PolettiV, BattistaG, DiegoliM. Bronchiolitis obliterans with organizing pneumonia (BOOP), presenting as a ring-shaped opacity at HRCT (the atoll sign). A case report. Radiol Med, 1999; 97(4):308–310.
5.
KondoH, FujitaJ, InoueT, HoriuchiN, NakaoK, IwataM, et al. [Minocycline-induced pneumonitis presenting as multiple ring-shaped opacities on chest CT, pathologically diagnosed bronchiolitis obliterans organizing pneumonia (BOOP)]. Nihon Kokyuki Gakkai Zasshi, 2001; 39(3):215–219. Article in Japanese.
6.
FujiiM, IdaM, EnomotoN, NogimuraH, NakamuraY, ChidaK, NakamuraH. [A case of sarcoidosis manifesting as annular opacities after multiple nodular shadows]. Nihon Kokyuki Gakkai Zasshi, 2002; 40(12):970–974. Article in Japanese.
7.
ChoiYH, ImJG, ParkCK. Notes from the 2001 Annual Meeting of the Korean Society of Thoracic Radiology. J Thorac Imaging, 2002; 17(2):170–175.
8.
GasparettoEL, EscuissatoDL, DavausT, de CerqueiraEM, SouzaASJr, MarchioriE, MüllerNL. Reversed halo sign in pulmonary paracoccidioidomycosis. AJR Am J Roentgenol, 2005; 184(6):1932–1934.
9.
HataY, UeharaH. [A case where herbal medicine sho-seiryu-to induced interstitial pneumonitis]. Nihon Kokyuki Gakkai Zasshi, 2005; 43(1):23–31. Article in Japanese.
10.
Bravo SoberónA, Torres SánchezMI, García RíoF, Sánchez AlmarazC, Parrón PajaresM, Pardo RodríguezM. [High-resolution computed tomography patterns of organizing pneumonia]. Arch Bronconeumol, 2006; 42(8):413–416. Article in Spanish.
11.
AgarwalR, AggarwalAN, GuptaD. Another cause of reverse halo sign: Wegener's granulomatosis. Br J Radiol, 2007; 80(958):849–850.
12.
AhujaA, GothiD, JoshiJM. A 15-year-old boy with “reversed halo”. Indian J Chest Dis Allied Sci, 2007; 49:99–101.
13.
AraiT, InoueY, AndoS, InoueK, TsuyuguchiK, SuzukiK, et al. [A case of cryptogenic organizing pneumonia showing reversed halo sign on computed tomography of the chest]. Nihon Kokyuki Gakkai Zasshi, 2007; 45(8):621–626. Article in Japanese.
KanajiN, BandohS, NagamuraN, Soo ChangS, IshikawaS, YokomiseH, et al. Lipoid pneumonia showing multiple pulmonary nodules and reversed halo sign. Respir Med Extra, 2007; 3(3):98–101.
17.
OkuboT, MiyazakiE, UeoM, OkuboF, AndoM, FukamiT, KumamotoT. [A case of psittacosis with wandering infiltrates developing to acute respiratory distress syndrome]. Nihon Kokyuki Gakkai Zasshi, 2007; 45(5):419–423. Article in Japanese.
18.
SakaiF, TokudaH, GotoH, TatedaK, JohkohT, NakamuraH, et al. Computed tomographic features of Legionella pneumophila pneumonia in 38 cases. J Comput Assist Tomogr, 2007; 31(1):125–131.
19.
UedaS, InoueR, TanakaK, MizumoriY, KawamuraT, NakaharaY, et al. [A case of nonspecific interstitial pneumonia with reversed halo sign on chest HRCT]. Nihon Kokyuki Gakkai Zasshi, 2007; 45(3):248–252. Article in Japanese.
BräunlichJ, SeyfarthHJ, GessnerC, GradistanacT, WirtzH. Lymphomatoid granulomatosis: a short description of an unusual case of the disease. Pneumologie, 2009; 63(12):697–701.
22.
KumazoeH, MatsunagaK, NagataN, KomoriM, WakamatsuK, KajikiA, et al. “Reversed halo sign” of high-resolution computed tomography in pulmonary sarcoidosis. J Thorac Imaging, 2009; 24(1):66–68.
23.
TzouvelekisA, KoutsopoulosA, OikonomouA, FroudarakisM, ZarogoulidisP, SteiropoulosP, et al. Acute fibrinous and organising pneumonia: a case report and review of the literature. J Med Case Rep, 2009; 3:74.
24.
BurkeL, JacobBK. Reversed halo sign in cryptogenic organising pneumonia. BMJ Case Rep, 2010. doi:10.1136/bcr.03.2010.2824.
GodbertB, Clement-DuchêneC, RegentD, MartinetY. [Do all cryptogenic organizing pneumonias require lung biopsy and steroid treatment?]. Rev Mal Respir, 2010; 27(5):509–514. Article in French.
27.
ItoT, SuginoK, SatohD, MuramatsuY, SanoG, SatoK, et al. Bird fancier's lung which developed in a pigeon breeder presenting organizing pneumonia. Intern Med, 2010; 49(23):2605–2608.
28.
MaimonN. A 47-year-old female with shortness of breath and “reversed halo sign”. Eur Respir Rev, 2010; 19(115):83–85.
29.
MarchioriE, GrandoRD, Simões Dos SantosCE, Maffazzioli Santos BalzanL, ZanettiG, ManoCM, GutierrezRS. Pulmonary tuberculosis associated with the reversed halo sign on high-resolution CT. Br J Radiol, 2010; 83(987):e58–60.
30.
MarchioriE, ZanettiG, ManoCM, HochheggerB, IrionKL. The reversed halo sign: another atypical manifestation of sarcoidosis. Korean J Radiol, 2010; 11(2):251–252.
31.
OteraH, TadaK, SakuraiT, HashimotoK, IkedaA. Reversed halo sign in pneumocystis pneumonia: a case report. BMC Med Imaging, 2010; 10:26.
TzilasV, BastasA, ProvataA, KotiA, TzoudaV, TsoukalasG. The “reversed halo” sign in pneumonococcal pneumonia: a review with a case report. Eur Rev Med Pharmacol Sci, 2010; 14(5):481–486.
34.
WalshSL, RobertonBJ. Images in thorax. The atoll sign. Thorax, 2010; 65(11):1029–1030.
35.
AnaiS, KumazoeH, WakamatsuK, NagataN, NakanishiY, KajikiA. [Reversed halo sign in organizing pneumonia secondary to Sjogren syndrome]. Nihon Kokyuki Gakkai Zasshi, 2011; 49(9):707–712. Article in Japanese.
GudavalliR, Diaz-GuzmanE, ArrossiAV, ChapmanJT, MehtaAC. Fleeting alveolar infiltrates and reversed halo sign in patients with breast cancer treated with tangential beam irradiation. Chest, 2011; 139(2):454–459.
38.
HongSH, KangEY, ShinBK, ShimJJ. Reversed halo sign on thin-section CT in a patient with non-specific interstitial pneumonia. Br J Radiol, 2011; 84(1001):e103–e105.
39.
InoueY, YoshimuraN, ShimadaH, SaitoH, ShimizuK, KurataK, et al. [Clinical features of reversed halo sign in cryptogenic organizing pneumonia]. Nihon Kokyuki Gakkai Zasshi, 2011; 49(2):75–80. Article in Japanese.
40.
MangoVL, NaidichDP, GodoyMCB. Reversed halo sign after radiofrequency ablation of a lung nodule. J Thorac Imaging, 2011; 26(4):W150–W152.
41.
MarchioriE, MeloSM, ViannaFG, MeloBS, MeloSS, ZanettiG. Pulmonary histoplasmosis presenting with the reversed halo sign on high-resolution CT scan. Chest, 2011; 140(3):789–791.
42.
MehtaH, PaolettiL, PastisN, JudsonM. Fairy ring sign on high resolution computed tomography in a patient with cryptogenic organizing pneumonia. Chest, 2011; 140(4):109A.
43.
MukaiN, TokuyasuH, IzumiH, TakedaK, HikinoH, ShimizuE. [A case of organizing pneumonia with a reversed halo sign following postoperative irradiation for breast cancer]. Nihon Kokyuki Gakkai Zasshi, 2011; 49(5):393–398. Article in Japanese.
44.
BuscaA, LimeruttiG, LocatelliF, BarbuiA, De RosaFG, FaldaM. The reversed halo sign as the initial radiographic sign of pulmonary zygomycosis. Infection, 2012; 40(1):77–80.
45.
KimuraM, AraokaH, UchidaN, OhnoH, MiyazakiY, FujiiT, et al. Cunninghamella bertholletiae pneumonia showing a reversed halo sign on chest computed tomography scan following cord blood transplantation. Med Mycol, 2012; 50(4):412–416.
MarkosM, TakekoshiD, JooM. Rare cresentic shaped radiographic findings of organizing pneumonia associated with cutaneous T-cell lymphoma. Chest, 2012; 142(4):554A.
48.
ValenteT, LassandroF, MarinoM, SquillanteF, AlipertaM, MutoR. H1N1 pneumonia: our experience in 50 patients with a severe clinical course of novel swine-origin influenza A (H1N1) virus (S-OIV). Radiol Med, 2012; 117(2):165–184.
49.
CasulloJ, SemionovA. Reversed halo sign in acute pulmonary embolism and infarction. Acta Radiol, 2013; 54(5):505–510.
50.
ChooJY, ParkCM, LeeHJ, LeeCH, GooJM, ImJG. Sequential morphological changes in follow-up CT of pulmonary mucormycosis. Diagn Interv Radiol, 2014:20(1);42–46.
51.
FreemanMD, GrajoJR, KaramsadkarND, SteffensenTS, HazeltonTR. Reversed halo sign on computed tomography as a presentation of lymphocytic interstitial pneumonia. J Radiol Case Rep, 2013; 7(10):51–56.
52.
GoshimaH, HiromiT, NishioC, FujiiH, KatsuyamaE. Reversed halo sign in pulmonary infarction with tumor emboli: a case report. Respir Invest, 2013 [Epub ahead of print]. doi:10.1016/j.resinv.2013.08.004.
53.
MadanK, GuleriaR. Reverse halo sign. Lung India, 2013; 30(1):72–73.
54.
OkuboY, IshiwatariT, IzumiH, SatoF, AkiK, SasaiD, et al. Pathophysiological implication of reversed CT halo sign in invasive pulmonary mucormycosis: a rare case report. Diagn Pathol, 2013; 8:82.
55.
StewartJI, D'AlonzoGE, CiccolellaDE, PatelNB, DurraH, ClaussHE. Reverse halo sign on chest imaging in a renal transplant recipient. Transpl Infect Dis, 2014; 16(1);115–118.
56.
SuzukiK, SeyamaK, HayashiT, YamashiroY, ShiraishiA, KuwatsuruR. Reversed halo sign in tuberous sclerosis complex. Case Rep Radiol, 2013; 2013:428501.
57.
YüksekkayaR, ÇelikyayF, YılmazA, İnönüH, KöseoğluD, SadeR. Reversed halo sign in hypersensitivity pneumonia: a diagnostic difficulty. Respir Case Rep, 2013; 2(3):112–116.
58.
ZhanX, WangZ, ZhangL, JinML, LiuM, ChenWH, DaiHP. Clinical and pathological features of adult pulmonary tuberculosis with reversed halo sign. Int J Tuberc Lung Dis, 2013; 17(12):1621–1625.
59.
MoonS, RyuYH, KimS, ChoeKO, LeeJ, SungK. Reversed halo sign: a new supplementary CT finding in confident diagnosis of BOOP. Radiology, 2000; 217(S):335.
60.
HansellDM, BankierAA, MacMahonH, McLoudTC, MüllerNL, RemyJ. Fleischner Society: glossary of terms for thoracic imaging. Radiology, 2008; 246(3):697–722.
61.
MaromEM, KontoyiannisDP. Imaging studies for diagnosing invasive fungal pneumonia in immunocompromised patients. Curr Opin Infect Dis, 2011; 24(4):309–314.
62.
GeorgiadouSP, SipsasNV, MaromEM, KontoyiannisDP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. Clin Infect Dis, 2011; 52(9):1144–1155.
63.
MarchioriE, ZanettiG, IrionKL, NobreLF, HochheggerB, MançanoAD, EscuissatoDL. Reversed halo sign in active pulmonary tuberculosis: criteria for differentiation from cryptogenic organizing pneumonia. AJR Am J Roentgenol, 2011; 197(6):1324–1327.
64.
MarchioriE, ZanettiG, HochheggerB, IrionKL. Re: Reversed halo sign: nodular wall as criterion for differentiation between cryptogenic organizing pneumonia and active granulomatous diseases. Clin Radiol, 2010; 65(9):770–771.
65.
MarchioriE, MaromEM, ZanettiG, HochheggerB, IrionKL, GodoyMC. Reversed halo sign in invasive fungal infections: criteria for differentiation from organizing pneumonia. Chest, 2012; 142(6):1469–1473.
