December 2022 Medical Image of the Month: Bronchoesophageal Fistula in the Setting of Pulmonary Actinomycosis

Figure 1. Axial (A) and sagittal (B) reconstructions from a contrast-enhanced chest CT demonstrates an ill-defined low-attenuation subcarinal mass (*) which causes deformity of the left mainstem bronchus (LMSB) (arrow). Axial reconstruction from a repeat contrast-enhanced CT performed 6 days later (C) demonstrates a gas-filled fistulous tract between the LMSB and esophagus through the mass (arrowheads).  An esophogram (D) performed 24 hours after esophageal stent placement demonstrates occlusion of the fistula.

A 65-year-old woman, never smoker with hypothyroidism, hypertension, anxiety, and depression disorders, initially presented to the emergency department with progressive nonspecific chest discomfort for two days. She had CT Angio, which was negative for PE but showed a 4.6 cm subcarinal centrally necrotic nodal mass (Figure 1A-B). She was subsequently advised to follow up with her primary care physician. A week later, she attended our emergency department again with a new intermittent cough and one episode of non-bloody emesis. She reported a sensation of drowning with the intake of liquids and subsequent intractable coughing. Otherwise, she did not have other associated symptoms such as shortness of breath, abdominal pain, fever, sweats, or chills.

Vital signs and physical exam were unremarkable. A repeat chest CT was performed, which demonstrated internal cavitation of the subcarinal mass with fistulous communication between the lumen of the midthoracic esophagus and the proximal left mainstem bronchus posteriorly, suggestive of broncho-esophageal fistula (Figure 1C). She subsequently underwent bronchoscopy, which revealed areas of friable bronchial mucosal nodularity along the posterior membrane of the mid to distal left mainstem bronchus. Despite a thorough airway inspection, no clear fistula was observed, and no gastric or bilious material was seen within the airway. She underwent endobronchial ultrasound (EBUS) with transbronchial nodal aspiration (TBNA) of the mediastinal lymphadenopathy, which showed extensive necrotic debris and granulomatous inflammation; however, Giemsa stain was negative and no sulfur granules were observed. An upper endoscopy was performed in tandem with the bronchoscopy. The EGD identified a cratered esophageal ulcer in the mid esophagus, which was biopsied. As well, a 25 mm fistulous track was found within the ulcerated region, and thus, an esophageal stent was placed. An esophagogram performed the next day showed no evidence of a leak (Figure 1D), which is suggestive of successful occlusion of the fistula. The esophageal biopsy was negative for malignancy though it also revealed ulcerated squamous mucosa with marked acute and chronic inflammation with reactive granulation tissue.

Infectious workup included Legionella urinary antigen, Streptococcus pneumoniae urinary antigen, MRSA nasal screen, serum Aspergillus antigen, coccidiomycosis  IgG/IgM (by EIA and CF/ID), QuantiFERON TB gold, and beta-D-glucan, all of which were negative. Histoplasma urinary antigen, Histoplasma and Blastomyces serum antibodies were also negative. Anaerobic cultures from lymph node aspirate later grew Actinomycetes.

Infectious disease was consulted, and the patient was started on ceftriaxone 2 g IV daily for three weeks, for pulmonary actinomyces infection, with a plan to transition to oral amoxicillin 750 mg three times a day for six months. She had a clinic follow-up appointment in eight weeks, in which she reported complete resolution of her symptoms.

Actinomycetes are branching gram-positive anaerobic bacteria and rarely cause infection, with only about 1 in 300,000 cases reported per year (1). Infections can involve any organ system, with pulmonary actinomycosis being the third most common location, representing around 15 % of the total disease cases (2). Actinomyces species are part of normal flora found in the mouth and gastrointestinal tract; therefore, it is hypothesized that pulmonary actinomycosis is caused by aspiration (3).

Diagnosis by clinical features alone can be challenging as it shares many symptoms associated with chronic infections like a low-grade fever, sputum production, cough and malaise. Therefore, it may be wrongfully diagnosed as tuberculosis, lung abscess and fungal infection. It can also often be confused with malignancy. Mabeza et al. (4) reported that around a quarter of cases with thoracic actinomyces were initially thought to have carcinoma.

Image findings of pulmonary actinomyces are also quite diverse. A retrospective study of 94 patients diagnosed with pulmonary actinomycosis pathologically over ten years in Korea revealed that the most common chest CT finding was consolidation (74.5%), mediastinal or hilar lymph node enlargement (29.8%), atelectasis (28.7%), cavitation (23.4%), ground-glass opacity (14.9%), and pleural effusion (9.6%) (5). Actinomyces can spread from the lung to the pleura, mediastinum, and chest wall. It is hypothesized that the mechanism behind their ability to travel through these anatomical barriers is due to their ability to produce proteolytic enzymes (6). Given its indolent presentation, proper diagnosis and treatment may be delayed leading to the involvement of adjacent structures and potentially life-threatening complications, including massive hemoptysis or bronchoesophageal fistula formation.

Detection of ‘sulfur’ granules histologically has been previously described as the hallmark for the diagnosis; however, they can also be found in other infections like nocardiosis (7), and they are only observed in 50% of cases; therefore, their absence does not exclude actinomycosis. Culture confirmation is typically clinically difficult because of inadequate anaerobic conditions, prior antibiotic therapy, or overgrowth of concomitant organisms (2). 

The principal treatment for pulmonary actinomycosis has been penicillin; however, there are no well-established guidelines regarding the duration of antibiotic therapy. High-dose intravenous penicillin is usually used for four to six weeks, followed by six to twelve months of oral amoxicillin in most cases (9). Surgery is typically reserved for pulmonary actinomycosis complicated by abscesses, empyemas, discharging fistulas and sinuses, life-threatening hemoptysis, exclusion of malignancy, and for patients who do not respond to antibiotic therapies (10).

John Fanous MD¹, Nikita Ashcherkin MD², Michael Gotway MD³, Kenneth Sakata, MD¹ and Clinton Jokerst MD³

Division of Pulmonology¹, Department of Internal Medicine², and Department of Radiology³

Mayo Clinic Arizona, Scottsdale, AZ USA

References

1. Gajdács M, Urbán E, Terhes G. Microbiological and Clinical Aspects of Cervicofacial Actinomyces Infections: An Overview. Dent J (Basel). 2019 Sep 1;7(3):85. [CrossRef] [PubMed]
2. Han JY, Lee KN, Lee et al. An overview of thoracic actinomycosis: CT features. Insights Imaging. 2013 Apr;4(2):245-52. [CrossRef] [PubMed]
3. Park HJ, Park KH, Kim SH, Sung H, Choi SH, Kim YS, Woo JH, Lee SO. A Case of Disseminated Infection due to Actinomyces meyeri Involving Lung and Brain. Infect Chemother. 2014 Dec;46(4):269-73. [CrossRef] [PubMed]
4. Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003 Mar;21(3):545-51. [CrossRef] [PubMed]
5. Kim SR, Jung LY, Oh IJ, et al. Pulmonary actinomycosis during the first decade of 21st century: cases of 94 patients. BMC Infect Dis. 2013 May 14;13:216. [CrossRef] [PubMed]
6. Heo SH, Shin SS, Kim JW, Lim HS, Seon HJ, Jung SI, Jeong YY, Kang HK. Imaging of actinomycosis in various organs: a comprehensive review. Radiographics. 2014 Jan-Feb;34(1):19-33. [CrossRef] [PubMed]
7. Brown JR. Human actinomycosis. A study of 181 subjects. Hum Pathol. 1973 Sep;4(3):319-30. [CrossRef] [PubMed]
8. Zhang AN, Guss D, Mohanty SR. Esophageal Stricture Caused by Actinomyces in a Patient with No Apparent Predisposing Factors. Case Rep Gastrointest Med. 2019 Jan 2;2019:7182976. [CrossRef] [PubMed]
9. Valour F, Sénéchal A, Dupieux C, et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014 Jul 5;7:183-97. [CrossRef] [PubMed]
10. LoCicero J 3rd, Shaw JP, Lazzaro RS. Surgery for other pulmonary fungal infections, Actinomyces, and Nocardia. Thorac Surg Clin. 2012 Aug;22(3):363-74. [CrossRef] [PubMed]

Cite as: Fanous J, Ashcherkin N, Gotway M, Sakata K, Jokerst C. December 2022 Medical Image of the Month: Bronchoesophageal fistula in the Setting of Pulmonary Actinomycosis. Southwest J Pulm Crit Care Sleep. 2022;25(6):97-100. doi: https://doi.org/10.13175/swjpccs047-22 PDF 

February 2022 Imaging Case of the Month: Between A Rock and a Hard Place

Michael B. Gotway MD

Department of Radiology, Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona USA

Clinical History: A 46-year-old woman presented to her primary care physician with longstanding complaints of difficulty with aerobic exercise, near syncope, headache, poor sleep, and pain in both legs and arms, exacerbated when flying in commercial aircraft. The patient had also complained of several gastrointestinal disturbances recently that prompted evaluation, revealing a normal colonoscopy. The patient was diagnosed with probable food intolerance by breath testing showing fructose intolerance, managed with a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet with positive results.

PMH, SH, FH: The patient’s past medical history was remarkable for a history of Raynaud’s phenomenon and head trauma at age 16. She noted that her presenting complaints have been present since childhood to some extent. Her poor sleep was characterized as frequent awakenings, daytime somnolence, mouth dryness, and waking up with severe headaches. The patient had been diagnosed with COVID-19 4 months earlier, with her presenting complaints all exacerbated and accompanied by shortness of breath, but she recovered uneventfully. The patient denied other significant past medical history and had no surgical history. Her family history was remarkable for a sister diagnosed with obstructive sleep apnea, diabetes, and thyroid carcinoma, and hypertension in a number of her 13 siblings. The patient’s mother had been diagnosed with colonic malignancy and her father died of melanoma. The patient’s social history was remarkable for abuse during childhood by a male sibling. The patient denied tobacco, alcohol, and illicit drug use.

Physical Examination: The patient’s physical examination showed her to be slender and in no distress although anxious, afebrile, pulse rate= 73, normal respiratory rate, with a blood pressure of 116/95 mmHg. Her cardiovascular, pulmonary, musculoskeletal, and neurologic examinations were within normal limits.

Results from prior outside examinations, including funduscopic, abdominal MRI, and brain MRI and MRA were within normal limits. An outside audiology consultation when the patient complained of hearing loss several months after her SARS-CoV-2 infection showed normal findings. Her complete blood count, coagulation parameters, electrolytes, and liver panel showed no abnormal values. A frontal chest radiograph from an outside institution (Figure 1) from 4 months prior to her primary care appointment, around the time when the patient was diagnosed with COVID-19.

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Figure 1. Frontal (A) and lateral (B) chest radiography obtained around the time the patient was diagnosed with COVID-19.

Which of the following represents an appropriate interpretation of her frontal chest radiograph? (Click on the correct answer to be directed to the second of 11 pages)

1. Frontal chest radiography shows findings typical for coronavirus (SARS-CoV-2) pulmonary infection
2. Frontal chest radiograph shows bilateral peribronchial lymphadenopathy
3. Frontal chest radiography shows focal consolidation
4. Frontal chest radiography shows multiple lung nodules
5. Frontal chest radiography shows pleural effusion

Cite as: Gotway MB. February 2022 Imaging Case of the Month: Between A Rock in a Hard Place. Southwest J Pulm Crit Care Sleep. 2022;24(2): 12- . doi: https://doi.org/10.13175/swjpccs004-22  PDF

November 2019 Imaging Case of the Month: A 56-Year-Old Woman with a Rash

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 56-year-old post-menopausal woman with a remote history of asthma and asymptomatic uterine fibroids presented with a macular-papular rash over the upper chest, upper medial left forearm, and medial legs, without scaling that has intermittently recurred over the previous few years. The rash is unaccompanied by fever, chills, rigors, abdominal pain, cough, conjunctivitis, urethritis, or any other mucocutaneous lesions. The patient did not note any seasonal relationships or association with food, and the rash regresses promptly with H₁ or H₂-blocker therapy.

The patient’s past medical history was otherwise unremarkable. Her surgical history was positive only for a laparoscopic left inguinal hernia repair 7 years earlier. The patient indicated she was neither a smoker nor a drinker. Her medications included an as-needed albuterol inhaler, a steroid inhaler, a nasal steroid spray, a multivitamin, and a topical steroid.

The patient’s physical examination showed normal vital signs, although her pulse rate was 95 beats / minute. The physical examination was otherwise entirely within normal limits aside from her presenting complaint of rash; in particular, her lungs were clear to auscultation. 

About 2 weeks later, the patient began to complain of myalgias and some wheezing in addition to her rash, with some mild fatigue as well. She denied other complaints, such as coryza, cough, nasal drainage, ear pain, and neck pain or stiffness. At repeat physical examination, her lungs remained clear to auscultation; no wheezing was noted. A dermatology consult suggested that the rash was most consistent with atopic dermatitis, for which a topical steroid was prescribed.

Basic laboratory data showed a white blood cell count in the normal range, mild anemia (hemoglobin / hematocrit = 11.5 mg/dL / 34.7%), a normal platelet count, normal serum chemistries and renal function parameters, and normal liver function tests aside from a mildly elevated alkaline phosphatase level of 145  U/L147 (normal, 35 – 104 U/L). A C-reactive protein level was elevated at 38.5 mg/L (normal, ≤8 mg/L). The patient was referred for chest radiography (Figure 1).

Figure 1.  Frontal chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to be directed to the second of twelve pages)

1. The chest radiograph shows mediastinal and peribronchial lymph node enlargement
2. The chest radiograph shows bilateral consolidation
3. The chest radiograph shows cavitary lung disease
4. The chest radiograph shows findings suggesting increased pressure pulmonary edema
5. The chest radiograph shows numerous small nodules

Cite as: Gotway MB. November 2019 imaging case of the month: a 56-year-old woman with a rash. Southwest J Pulm Crit Care. 2019;19(5):127-43. doi: https://doi.org/10.13175/swjpcc065-19 PDF 

January 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: An 81-year-old woman with little significant past medical history complained of a dry cough for the previous 1.5 years, but without hemoptysis or shortness of breath. The patient’s past medical history was remarkable only for hypothyroidism, for which she was taking levothyroxine. She smoked for 1 year only, at age 19. Her past surgical history was negative and she denied any alcohol use. Her only other medications included vitamin D3 supplementation and over-the-counter cough medicine.

Physical examination was remarkable only for coarse, left-greater-than-right basal rales. The patient’s oxygen saturation was 98% on room air. The patient’s vital signs were within normal limits and she was afebrile.

Laboratory evaluation showed a normal complete blood count, electrolyte panel, and liver function tests. Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to proceed to the second of eleven pages)

1. Chest radiography shows basilar fibrosis
2. Chest radiography shows left lower lobe consolidation
3. Chest radiography shows mediastinal and peribronchial lymphadenopathy
4. Chest radiography shows multiple small nodules
5. Chest radiography shows normal findings

Cite as: Gotway MB. January 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(1):16-27. doi: https://doi.org/10.13175/swjpcc001-18 PDF 

Medical Image of the Week: Chemotherapy-Induced Diffuse Alveolar Hemorrhage

Figure 1. Panel A: Chest X-ray on admission consistent showing some pulmonary edema and effusions at the bases. Panel B: Chest X-ray after initiation of chemotherapy showing diffuse bilateral infiltrates and consolidation.

Figure 2. CT scan of the chest after initiation of chemotherapy showing patchy ground glass consolidation throughout the lung fields bilaterally. Large bilateral pleural effusions can also be seen.

A 65-year-old man presented with relapse of his acute myeloid leukemia (AML). On admission he was seen to have a reduced ejection fraction at 40-50%. His chest X-ray showing pulmonary edema and bilateral pleural effusions (Figure 1A). He was diuresed to his dry weight to improve his clinical status. The decision was made to re-induce him for his AML with fludarabine and cytarabine without idarubicin (due to his reduced ejection fraction). After 2 doses of each the fludarabine and cytarabine the patient showed worsening respiratory distress, had increasing oxygen requirements and started having hemoptysis. Repeat imaging of his chest showed bilateral infiltrates in his lungs on both chest x-ray (Figure 1B) and chest CT (Figure 2). Infectious causes for the changes were sought and ruled out. He was transferred to the ICU where he was put on high flow oxygen and received methylprednisolone 1000 mg IV daily for 3 days. During this period his blood hemoglobin also dropped from 8.2 g/dl to 6.8 g/dl requiring transfusion of 1 unit of packed red blood cells. After 3 days of supportive care he was transferred back out of the ICU on oxygen by nasal cannula with progressive improvement in his lung function. Pulmonary toxicity is a known side effect resulting from both fludarabine and cytarabine and can present in a variety of forms. Their prompt recognition is important due to the steroid responsive nature of many of these once infectious causes have been ruled out.

Saud Khan, MD and Huzaifa A. Jaliawala, MD

Department of Internal Medicine

University of Oklahoma Health Sciences Center

Oklahoma City, OK USA

References

1. Helman DL Jr, Byrd JC, Ales NC, Shorr AF. Fludarabine-related pulmonary toxicity: a distinct clinical entity in chronic lymphoproliferative syndromes. Chest. 2002 Sep;122(3):785-90. [CrossRef] [PubMed]
2. Rudzianskiene M, Griniute R, Juozaityte E, Inciura A, Rudzianskas V, Emilia Kiavialaitis G. Corticosteroid-responsive pulmonary toxicity associated with fludarabine monophosphate: a case report. Turk J Haematol. 2012 Dec;29(4):392-6. [CrossRef] [PubMed]
3. Forghieri F, Luppi M, Morselli M, Potenza L.Cytarabine-related lung infiltrates on high resolution computerized tomography: a possible complication with benign outcome in leukemic patients. Haematologica. 2007 Sep;92(9):e85-90. [CrossRef] [PubMed]

Cite as: Khan S, Jaliawala HA. Medical image of the week: chemotherapy-induced diffuse alveolar hemorrhage. Southwest J Pulm Crit Care. 2017;15(5):219-20. doi: https://doi.org/10.13175/swjpcc131-17 PDF

Medical Image of the Week: Typical Pulmonary CT Findings Following Radiotherapy

Figure 1. Panel A: CT chest, lung windows, demonstrating a spiculated nodule, biopsy proven adenocarcinoma in the right lower lobe (arrow). Panel B: Eight months post stereotactic radiation therapy, there has been development of focal consolidation, with air bronchograms, involving the right middle and lower lobes. Notice the volumetric appearance. The primary malignancy is no longer identified as such. Panel C: Thirteen months later the consolidation has evolved into an area of volume loss, containing bronchiectasis, and sharp contours as a result of organized fibrosis.

Radiation-induced lung disease (RILD) commonly develops in patients treated with radiation for intrathoracic and chest wall malignancies.

There are two distinct radiographic patterns:

1. Radiation pneumonitis which occurs within 4-12 weeks after completion of therapy, and is characterized by development ground-glass opacities and/or consolidation in and around the treated lesion. A somewhat nodular or patchy appearance may occur. Typically, the affected tissue conforms to the radiation ports and may cross fissures/lobes. There may be milder similar changes in the contralateral lung.
2. A chronic phase, known as radiation fibrosis, is noticeable about 6-12 months post treatment and may progress up to 2 years, after which the findings tend to stabilize. In this stage, the areas of consolidation undergo volume loss, architectural distortion and may contain traction bronchiectasis. Linear and band scarring may also be seen. In this phase, sharper demarcation between normal and irradiated lung parenchyma is commonly seen.

Special attention to the typical radiological characteristics and timeline, in most cases allows to distinguish RILD from potential superimposed infection, subacute inflammatory diseases, locally recurrent neoplasm and radiation-induced neoplasms.

Andrew Erickson MS IV¹, Berndt Schmidt MD², Veronica Arteaga MD², Diana Palacio MD²

¹Midwestern University – Arizona College of Osteopathic Medicine

²Division of Thoracic Radiology, Department of Medical Imaging. University of Arizona, Tucson (AZ)

Reference

1. Choi YW, Munden RF, Erasmus JJ, Joo Park K, Chung WK, Jeon SC, Park CK. Effects of radiation therapy on the lung: radiologic appearances and differential diagnosis. Radiographics. 2004 Jul;24(4):985-97. [CrossRef] [PubMed]

Cite as: Erickson A, Schmidt B, Arteaga V, Palacio D. Medical image of the week: typical pulmonary CT findings following radiotherapy. Southwest J Pulm Crit Care. 2017;15(3):120-1. doi: https://doi.org/10.13175/swjpcc112-17 PDF

Medical Image of the Week: The Atoll Sign in Cryptogenic Organizing Pneumonia

Figure 1. Portable chest X-ray shows bilateral airspace opacities (yellow arrows) and possible trace pleural effusion (blue arrow).

Figure 2. Computed tomography of the chest showing (A) patchy ground glass opacity in the upper lungs with additional scattered circular areas of opacity in a reverse halo configuration (blue arrows, atoll sign) and (B) extensive bibasilar consolidation with air bronchograms.

A 54-year-old woman presented to the emergency department with cough and worsening shortness of breath. Her cough began approximately 1 month prior to presentation, at which time she was diagnosed with pneumonia by her primary care physician based on a chest X-ray at an outside institution. She tried and failed courses of azithromycin, doxycycline, and levofloxacin.

The patient had an oxygen saturation of 55% and hyperpyrexia to 101.7 F in the emergency department. An initial chest X-ray was suggestive of moderate multifocal pneumonia with pleural effusion (Figure 1). Subsequent chest computed tomography (CT; Figure 2) revealed findings consistent with cryptogenic organizing pneumonia (COP) including multiple upper lobe atoll signs. Infectious and autoimmune workups were negative and the patient experienced a rapid recovery with pulse steroids, providing further evidence for the diagnosis of COP.

CT is the best imaging modality for evaluation of potential COP. Features include consolidations and nodules, bronchial wall thickening or dilatation, and ground glass opacities (1). The atoll sign, consisting of a central ground glass opacity and surrounding consolidation which may also be called a reverse halo sign, is highly specific but not sensitive for organizing pneumonia (2). Definitive diagnosis requires lung biopsy, although the disease is often managed based on a presumptive diagnosis (3).

Joseph Frankl, BS¹ and Veronica A. Arteaga, MD²

¹University of Arizona College of Medicine and ²Department of Medical Imaging

Banner University Medical Center Tucson

Tucson, AZ USA

References

1. Lee JW, Lee KS, Lee HY, Chung MP, Yi CA, Kim TS, Chung MJ. Cryptogenic organizing pneumonia: serial high-resolution CT findings in 22 patients. AJR Am J Roentgenol. 2010 Oct;195(4):916-22. [CrossRef] [PubMed]
2. Davidsen JR, Madsen HD, Laursen CB. Reversed halo sign in cryptogenic organising pneumonia. BMJ Case Rep. 2016 Feb 8;2016. pii: bcr2015213779. [CrossRef] [PubMed]
3. Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax. 2008 Sep;63 Suppl 5:v1-58. [CrossRef] [PubMed]

Cite as: Frankl J, Artega VA. Medical image of the week: the atoll sign in cryptogenic organizing pneumonia. Southwest J Pulm Crit Care. 2017;15(2):92-3. doi: https://doi.org/10.13175/swjpcc100-17 PDF

August 2017 Imaging Case of the Month

Brandon T. Larsen, MD, PhD¹

Michael B. Gotway, MD²

Departments of Pathology¹ and Radiology²

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 67-year-old man with a 23 pack-year history of smoking, stopping 6 years earlier, presented with a year-long history of intermittent hemoptysis consisting of small specs of blood particularly in the morning after he awoke. No sputum discoloration was reported and the patient denied shortness of breath, fever, shortness of breath, and chills. The patient also denied rash, joint pain, and night sweats. His past surgical history was remarkable only for an appendectomy, tonsillectomy, and repair of an ankle fracture, all as a young man. The patient did report some asbestos exposure in the past. He takes a multivitamin and occasional over-the counter pain relievers, but was not taking prescription medications.

Physical examination: unremarkable and the patient’s oxygen saturation was 98% on room air.

Laboratory evaluation: largely unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative. An outside otolaryngology examination was reported to show no abnormalities. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of nine pages)

1. The chest radiograph shows a mediastinal mass
2. The chest radiograph shows multifocal consolidation and pleural effusion
3. The chest radiograph shows multifocal smooth interlobular septal thickening
4. The chest radiograph shows a possible focal air space opacity
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Larsen BT, Gotway MB. August 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(2):69-79. doi: https://doi.org/10.13175/swjpcc098-17 PDF

November 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 38-year-old man presented to his primary care physician with complaints of pruritus, jaundice, and poor appetite. The patient had been diagnosed with hypertension one year earlier and was treated with hydrochlorothiazide and an angiotensin-converting enzyme inhibitor, but evidently did not tolerate the regimen well, and developed “tea-colored” urine following initiation of this therapy. He was also recently diagnosed with diabetes mellitus and also complained of intermittent right upper quadrant pain.

Laboratory data, including white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 99%.

Frontal and lateral chest radiographs (Figure 1) were performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven pages)

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows a focal, poorly defined right base opacity
3. Frontal and lateral chest radiography shows bilateral peribronchial and mediastinal lymph node enlargement
4. Frontal and lateral chest radiography shows cardiomegaly
5. Frontal and lateral chest radiography shows upper lobe bilateral linear and reticular abnormalities

Cite as: Gotway MB. November 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(5):207-15. doi: http://dx.doi.org/10.13175/swjpcc112-16 PDF 

September 2011 Case of the Month

Michael B. Gotway, M.D.
Associate Editor, Imaging

Reference as: Gotway MB. September 2011 case of the month. Southwest J Pulm Crit Care 2011;3:58-63. Click here for PDF version

Clinical History

A 44-year-old man presents for chest radiography for pre-operative screening prior to surgical repair of a meniscal tear in his right knee. An abnormality was noted on this study. 

Figure 1A and B: Frontal (A) and lateral (B) chest radiography.

What abnormality is seen on the chest X-ray? (Depending on your computer settings, you may need to enlarge the chest x-ray with your browser to identify the abnormality.)

1. Right lower lobe consolidation
2. Left lower lobe consolidation
3. Right lower lobe nodule
4. Left upper lobe nodule
5. Left lower lobe nodule