Medical Image of the Week: Idiopathic Pulmonary Hemosiderosis

Figure 1. Representative axial high-resolution CT (HRCT) scan sections demonstrating increased attenuation of the lungs due to diffuse groundglass opacification with subpleural and scattered clustered cysts most evident in the upper lung zones.

The patient is a 40 year-old man who was diagnosed with Idiopathic Pulmonary Hemosiderosis (IPH) at the age of three. He has recurrent episodes of hemoptysis several times a year that are controlled with increased doses of prednisone. He is chronically on 10 mg daily which usually control his symptoms. A HRCT scan of the chest shows predominantly upper lung cystic changes both subpleural and clustered with a honeycomb appearance superimposed on a background of diffuse ground glass opacification.

Typical HRCT findings include patchy scattered areas of ground glass opacity and consolidation that usually involve the perihilar and lower aspects of the lungs. However, case reports of rare findings of multiple honeycomb cystic changes have been reported that are thought to be a result of progressive fibrotic changes from hemosiderin deposition in the interstitium (1). These honeycomb cysts may represent sites of more severe and recurrent alveolar hemorrhage in adults with IPH and are probably related to a traction phenomenon secondary to interstitial fibrosis following recurrent episodes of alveolar hemorrhage.

Nathaniel Reyes MD^*, Linda Snyder MD^*, Veronica Arteaga MD⁺
Department of Medicine, Division of Pulmonary and Critical Care Medicine*
Department of Radiology⁺

University of Arizona, Tucson, Arizona

Reference

1. Harte S, McNicholas WT, Donnelly SC, Dodd JD. Honeycomb cysts in idiopathic pulmonary haemosiderosis: high-resolution CT appearances in two adults. Br J Radiol. 2008;81(972):e295-8. [CrossRef] [PubMed] 

Reference as: Reyes N, Snyder L, Arteaga V. Medical image of teh week: idiopathic pulmonary hemosiderosis. Southwest J Pulm Crit Care. 2014;9(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc092-14 PDF

Medical Image of the Week: Metastatic Melanoma with Hemorrhage

Figure 1. Axial image of CT Chest with contrast showing pulmonary metastatic masses and alveolar opacities consistent with pulmonary hemorrhage.

Figure 2. Coronal image of CT Chest with contrast showing innumerable pulmonary nodules and masses along with ground-glass alveolar opacities representing alveolar hemorrhage.

A 62 year-old gentleman presented with right leg swelling due to an extensive DVT in the right femoral vein.  He was found to have a right groin mass attributed to metastatic malignant melanoma.  Chest X-ray and CT revealed multiple bilateral pulmonary nodules.  He was started on warfarin 3mg daily for acute DVT and referred to Oncology.  2 weeks later he developed hemoptysis and was found to be hypoxemic.  He was admitted to our MICU.  His INR upon admission was 8.2 and hemoglobin 6.4.  CT Chest showed innumerable bilateral pulmonary nodules and ground-glass alveolar opacities with thickening and nodularity of intra-lobular septa adjacent to the nodules.  Warfarin was held and packed RBC and FFP transfusions were given with progressive improvement in hemoptysis and pulmonary status.

Tauseef Afaq Siddiqi, MD; Abdulmajid Eddib, MD; Phillip Factor, DO; and Steven Knoper, MD

Department of Medicine

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ 85724, USA

Reference as: Siddiqi TA, Eddib A, Factor P, Knoper S. Medical image of the week: metastatic melanoma with hemorrhage. Southwest J Pulm Crit Care. 2013;6(6):287-8. http://dx.doi.org/10.13175/swjpcc079-13 PDF

Ground-Glass Opacities

Reference as: Gopal V, Robbins RA. Ground-glass opacities. Southwest J Pulm Crit Care 2011;2:67-70. (Click here for PDF version)

A 54-year-old male was admitted to the medical intensive care unit complaining of abdominal pain, nausea, and vomiting for 2 days. He had a past medical history of pancreatitis in 2009, treated as outpatient, and asthma treated with albuterol inhaler as needed. His medication list included gemfibrizol, gabapentin, and amitriptyline. He drank 6-8 beers per day and smoked 1 pack-per-day for the past 40 years.

On physical examination is the patient was afebrile, his lungs are clear to auscultation, but tenderness was present in both lower quadrants. The remainder of the physical examination was normal.

Laboratory examination revealed a normal complete blood count and normal basic metabolic panel. Abnormal laboratory values included an elevated total bilirubin of 2.7 mg/dL (normal 0.2-1 mg/dL); alkaline phophatase 169 U/L (normal 10-40 U/L);  alanine aminotransferase 286 U/L (normal 10-35 U/L); amylase 468 U/L (normal 25-125 U/L), and lipase 1580 U/L (normal 8-78 U/L). Arterial blood gasmeasurements showed PaO_{2 =} 91 mm Hg, PaCO₂ = 26 mm Hg, pH = 7.52, and oxygen saturation = 98% while breathing room air.

Chest radiography (Figure 1, Panel A) was interpreted as showing a “right upper lobe infiltrate which could represent an acute pneumonia”.  No distinct abnormalities were identified on abdominal radiographs (Figure 1, Panel B).

 Figure 1. Panel A. Frontal chest radiography.  Panel B. Abdominal radiography.

To further evaluate the possibility of a right upper lobe abnormality at chest radiography, thoracic CT was performed and as showing patchy ground-glass opacities throughout the lungs bilaterally (Figure 2).

Figure 2. Representative images from thoracic CT.

Question 1. What’s the most likely diagnosis?

1. Hypersensitivity pneumonitis
2. Acute inhalational injury secondary to “huffing”.
3. Drug-induced lung disease
4. Valley Fever
5. Ground-glass opacities associated with pancreatitis

Question 2. What would you do next?

1. Hypersensitivity panel
2. Bronchoscopy with bronchoalveolar lavage
3. Begin Diflucan
4. Broaden his antibiotic coverage
5. Repeat the thoracic CT scan in 3-4 days.

The thoracic CT was repeated four days later and the ground-glass opacities seen previously had largely resolved (Figure 3).

Figure 3.  Representative images from thoracic CT performed four days following the initial study Figure 2).

These ground-glass opacities likely represent subclinical non-cardiogenic pulmonary edema in the setting of acute pancreatitis. Ground-glass opacities are foci of increased lung attenuation that do not obscure underlying vessels or bronchial margins (1). Ground-glass opacities often represent parenchymal abnormalities below the spatial resolution of high-resolution CT of the lung. Although the differential diagnosis of ground-glass opacities at high-resolution CT is large, these etiologies may be broadly divided into acute or chronic causes. Table 1 lists some of the more common causes of ground-glass opacities at high-resolution CT.

Table 1: Common Etiologies for Ground-Glass Opacity at Thoracic CT

Acute	Chronic
Pulmonary edema (cardiogenic or non-cardiogenic)	Interstitial diseases (hypersensitivity pneumonitis, desquamative interstitial pneumonia, respiratory bronchiolitis-interstitial lung disease, nonspecific interstitial pneumonia, sarcoidosis, others)
Infectious pneumonitis (PJP, CMV, HSV, RSV, others)	Bronchoalveolar carcinoma
Noninfectious pneumonitis (hypersensitivity pneumonitis, acute inhalational exposures, drug-induced lung diseases)	Other causes (drug toxicity, pulmonary alveolar proteinosis, organizing pneumonia, chroic eosinophilic pneumonia, others)

Our patient had no apparent cause, other than subclinical non-cardiogenic pulmonary edema secondary to pancreatitis. Pulmonary edema is a well known complication of pancreatitis and can be severe (2). It seems likely that, as more sensitive methods for the detection of pulmonary abnormalities, such as thoracic CT, are increasingly applied to patients with pancreatitis, that subclinical pulmonary injury may be increasingly detected.

Venu Gopal, M.D.

Chief, Infectious Disease, Phoenix VA Medical Center

Richard A. Robbins, M.D.

Chief, Pulmonary and Critical Care, Phoenix VA Medical Center

Slide Set

References

1. Miller WT Jr, Shah RM.  Isolated diffuse ground-glass opacity in thoracic CT: causes and clinical presentations.  AJR Am J Roentgenol 2005;184:613-22.
2. Raghu MG, Wig JD, Kochhar R, Gupta D, Gupta R, Yadav TD, Agarwal R, Kudari AK, Doley RP, Javed A. Lung complications in acute pancreatitis. JOP. 2007;8:177-85.