Medical Image of the Month: Idiopathic Right Lower Lobe Pulmonary Vein Thrombus

Figure 1. CT angiogram chest sagittal view: showing low density filling defect consistent with pulmonary vein thrombus (yellow arrow).

Figure 2. A: CT angiogram chest axial view showing right lower lobe pulmonary vein thrombus. B: the vein (red arrow) is well differentiated by his lower contrast than the adjacent artery (blue arrows).

A 62-year-old man with a medical history notable only for a seasonal allergy, presented to the emergency department with complaints of shortness of breath with productive cough for 2 months which were worsening for the last 2 weeks. CTA chest revealed low density filling defect in the RLL vein consistent with RLL vein thrombus (Figures 1 and 2). After a comprehensive work up to rule out malignancy and hypercoagulable disorders, a diagnosis of idiopathic pulmonary vein thrombosis was made. The patient received heparin and was discharged with rivaroxaban.

Pulmonary vein thrombosis is a rare disease but can be fatal, usually patient presents with non-specific symptoms such as cough and shortness of breath (1). The etiology in most of cases is hypercoagulable disorders, malignancies, atrial fibrillation, post lung operations such as lobectomy and lung transplantation, or could be idiopathic as in our patient.

Timothy Jon Rolle MD¹ and Mohammad Abdelaziz Mahmoud MD, DO^2
1Department of Radiology and the ²Internal Medicine Residency

Midwestern University Arizona College of Osteopathic Medicine

Canyon Vista Medical Center
Tucson, AZ USA

Reference

1. Chaaya G, Vishnubhotla P. Pulmonary vein thrombosis: a recent systematic review. Cureus. 2017 Jan 23;9(1):e993. [CrossRef] [PubMed]

Cite as: Rolle TJ, Mahmoud MA. Medical image of the month: idiopathic right lower lobe pulmonary vein thrombus. Southwest J Pulm Crit Care. 2020;20(1):7-8. doi: https://doi.org/10.13175/swjpcc048-19 PDF

Medical Image of the Week: Saddle Pulmonary Embolism

Figure 1. Thoracic axial computed tomography angiogram (CTA) demonstrating saddle embolism within bilateral pulmonary arteries with extension into sub-segmental branches.

Figure 2. Coronal CTA.

A 66-year-old woman with recent history of left knee surgery and L2-L5 spinal fusion within the past month presented to the Emergency Department (ED) with pleuritic chest pain and shortness of breath for three days. On admission, reported crushing diffuse substernal chest pain worsened to 10/10 on the pain scale on the day of presentation. In the ED, physical examination was remarkable for tachycardia, tachypnea, diaphoresis and hypotension. Initial electrocardiogram was significant for sinus tachycardia with S1Q3T3 pattern. thoracic computed tomography angiogram (CTA) showed saddle pulmonary embolus (PE) with extension into segmental vasculature, right greater than left (Figures 1 and 2). A bedside echocardiogram demonstrated diastolic and systolic bowing of the intraventricular septum into the left ventricle. An emergent trans-thoracic echocardiogram confirmed flattened septum consistent with right ventricle pressure overload with right ventricular systolic pressure of 55 mmHg + central venous pressure (CVP) and reduced left ventricular ejection fraction of 38%. Her hemodynamic condition was stabilized by administering intravenous norepinephrine infusion. Interventional radiology was contacted for an emergent catheter directed thrombolysis. Ten milligrams of tissue plasminogen activator (tPA) was injected into the pulmonary artery with subsequent removable inferior vena cava filter placement. Vasoactive medications were titrated down and stopped four hours following tPA administration and anticoagulation with intravenous heparin was commenced. The patient was discharged from the hospital after initiation of rivaroxaban.

Saddle pulmonary embolism (SPE) is a form of large pulmonary thromboembolism that straddles the main pulmonary arterial branch at the bifurcation. The incidence of SPE is found in about 2.6% of the PE cases (1). The choice of diagnostic testing for PE is CTA based on multiple studies demonstrating CTA was both sensitive and specific for PE especially in moderate to high clinical probability PE (2,3). Suspicion for PE in our patient included sedentary status following knee replacement surgery, tachycardia, S1Q3T3 pattern on EKG, evidence for right ventricular strain on echocardiography, and no other diagnosis more likely thus lead to high clinical suspicion of pulmonary embolism with a Well’s score for PE of 6.

Faraz Jaffer, MD¹ See Wei Low, MD¹ and Sairam Parthasarathy, MD²

¹Department of Internal Medicine, Banner - University Medical Center

²Department of Allergy, Pulmonary, Critical Care and Sleep Medicine

Banner-University Medical Center

Tucson, AZ USA

References

1. Ryu JH, Pellikka PA, Froehling DA, Peters SG, Aughenbaugh GL. Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome. Respir Med. 2007 Jul;101(7):1537-42. [CrossRef] [PubMed]
2. Van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006 Jan 11;295(2):172-9. [CrossRef] [PubMed]
3. Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006 Jun 1;354(22):2317-27. [CrossRef] [PubMed] 

Cite as: Jaffer F, Low SW, Parthasarathy S. Medical image of the week: saddle pulmonary embolism. Southwest J Pulm Crit Care. 2016 May;12(5):192-3. doi: http://dx.doi.org/10.13175/swjpcc024-16 PDF

Medical Image of the Week: Atherosclerotic Aneurysm of Aortic Arch and Descending Thoracic Aorta

Figure 1.  Chest radiograph displays mild CHF, prominent vascular markings, and a large thoracic aneurysm.

Figure 2. Panel A: Computerized tomography angiography (CTA) with contrast displays an aneurysm of the aortic measuring 6.8 cm with eccentric thrombi. Panel B: CTA also shows an aneurysm of the descending aorta measuring 6 cm across with eccentric thrombi. Panel C: CTA demonstrates a tortuous descending aorta displayed by the curving of the descending aorta as it transitions to the abdominal aorta.

A 94-year-old Spanish-speaking woman presented to the hospital with intermittent episodes of dyspnea and abdominal pain for one week. Her past medical history was notable for 30 pack-year smoking history and hypertension, which was reportedly controlled with medical therapy.  Physical exam showed trace peripheral edema bilaterally, intact peripheral pulses, and a mild abdominal bruit. Work up at the emergency department revealed a non-ST elevation myocardial infarction with troponin T of 0.34 ng/mL but no ST-wave abnormality on electrocardiography. Chest x-ray displayed an incidental thoracic aneurysm (Figure 1). Chest computed tomography with contrast demonstrated a continuous aneurysm of the aortic arch and descending thoracic aorta with diameters measuring 6.8 cm and 6 cm, respectively (Figure 2A and 2B). Eccentric thrombi are noted in the aortic arch and the descending aorta. Interestingly, the distal descending thoracic aorta curves as it transitions to the abdominal aorta, which is evidence of a tortuous descending aorta (Figure 2C). The patient declined both invasive and non-invasive treatment and left the hospital against medical advice one day after admission.     

Melvin Parasram MS¹, Lea McKinnon MD², Iwan Nyotowidjojo MD³, and Kareem Ahmad MD⁴

¹Midwestern University: Arizona College of Osteopathic Medicine, Glendale, AZ USA

²Departments of Radiology, ³Internal Medicine and ⁴Pulmonary and Critical Care, Banner University Medical Center - Tucson, Tucson, AZ USA

Cite as: Parasram M, McKinnon L, Nyotowidjojo I, Ahmad K. Medical image of the week: atherosclerotic aneurysm of aortic arch and descending thoracic aorta. Southwest J Pulm Crit Care. 2016;12(2):46-7. doi: http://dx.doi.org/10.13175/swjpcc155-15 PDF