Imaging

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.

The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Mediastinal Lipomatosis

Figure 1. Chest X-ray showing right sided mediastinal mass.

 

Figure 2. Coronal (A) and axial (B) CT Images showing a right paratracheal homogenously fat-enhancing mass.

 

A 61-year-old man presented to the pulmonary clinic for evaluation of a chronic cough of 6 months’ duration.  Other medical problems included class three obesity, obstructive sleep apnea on CPAP therapy, and hypertension.  Chest X-Ray (Figure 1) revealed a right mediastinal mass which then prompted a chest CT to be performed. The chest CT (Figure 2) demonstrated a homogenously enhancing, well circumscribed and fat-attenuating 8 x 5 cm mass in the right paratracheal region without invasion or compression into surrounding structures.

Mediastinal lipomatosis was diagnosed.  This is a benign soft tissue tumor made of mature adipocytes that can be seen with obesity, chronic corticosteroid use, and Cushing’s syndrome.  They are thought to represent up to 2.3% of all primary mediastinal tumors (1).  They are occasionally associated with compression of surrounding structures which can cause superior vena cava syndrome, dry cough, dysphagia, and occasionally arrhythmias (2).  Management is typically conservative with weight loss encouraged unless mass effect is present that significantly affects quality of life, in which case surgical options may be explored. 

Although this patient’s cough could be due to this lipoma, he also had symptoms of cough possibly exacerbated by severe gastroesophageal reflux disease which was not yet managed.  A trial of a proton pump inhibitor was pursued with follow-up arranged to determine if further intervention is necessary.

Bryan Borg MD and James Knepler MD

Department of Medicine

Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Arizona

Tucson, AZ USA

References

  1. Gaerte SC, Meyer CA, Winer-Muram HT. Fat-containing lesions of the chest. Radiographics. 2002;22:61-78. [CrossRef] [PubMed]
  2. Cutilli T, Schietroma M, Marcelli VA, Ascani G, Corbacelli A. Giant cervico-mediastinal lipoma. A clinical case. Minerva Stomatol. 1999 Jan-Feb;48(1-2):23-8. [PubMed]

Cite as: Borg B, Knepler J. Medical image of the week: mediastinal lipomasosis. Southwest J Pulm Crit Care. 2018;16:228-9. doi: https://doi.org/10.13175/swjpcc046-18 PDF 

Read More
Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Increased Liver Attenuation

Figure 1. Coronal (A) and axial (B) CT scan without contrast demonstrating diffuse increase in hepatic density.

An 86-year old man had a non-contrast thoracic CT for evaluation of a chest x-ray abnormality. Incidentally, the CT scan showed diffuse increase in liver density with Hounsfield units of 105. The normal unenhanced attenuation value is between 55-65 Hounsfield units in a normal liver on CT scan without contrast (1).   Hepatic attenuation is reflected in Hounsfield values and depends on combinations of factors including the presence or absence (as well as phase) of IV contrast administration.

The patient had no known underlying liver disease and liver function studies were within normal limits.  Figure 1 shows coronal and axial views of the CT scan of the patient.

There are several intrinsic liver pathologies leading to diffuse changes in liver attenuation including (2):

  • Deposits of certain metals seen in hemochromatosis, hemosiderosis, and Wilson’s disease.
  • Glycogen storage disease(es)
  • Medications/drugs including amiodarone and gold therapy (3-7).
  • Previous Thorotrast administration – Thorotrast is a contrast agent used between 1930-1950 and was found to be carcinogenic and can cause hepatic angiosarcoma, cholangiocarcinoma, and hepatocellular carcinoma. It is retained in the reticulo-endothelial system for long periods of time (8).

After reviewing the patient’s case he had been on chronic amiodarone therapy and had not had exposures or clinical history related to any of the other above causes of increased hepatic density. Based on imaging and history it is suspected that patient’s diffuse increase in liver density is secondary to iodine infiltration from chronic amiodarone usage.

Allen Thomas MD, Sandra Till DO, and Jeremy Patterson RT

Phoenix VA Medical Center

References

  1. Boll DT, Merkle EM. Diffuse liver disease: strategies for hepatic CT and MR imaging. Radiographics. 2009;29:1591-614. [CrossRef] [PubMed]
  2. Weerakkody Y. Hepatic attenuation on CT. Radiopaedia. Available at: http://radiopaedia.org/articles/hepatic-attenuation-on-ct (accessed 2/6/14).
  3. Markos J, Veronese ME, Nicholson MR, McLean S, Shevland JE. Value of hepatic computerized tomographic scanning during amiodarone therapy. Am J Cardiol. 1985;56(1):89-92. [CrossRef] [PubMed]
  4. Nicholson AA, Caplin JL, Steventon DM. Measurement of tissue-bound amiodarone and its metabolites by computed tomography. Clin Radiol. 1994;49(1):14-8. [CrossRef] [PubMed]
  5. De Maria M, De Simone G, Laconi A, Mercadante G, Pavone P, Rossi P. Gold storage in the liver; appearance on CT scans. Radiology. 1986;159(2):355-6. [PubMed] 
  6. Goldman IS, Winkler ML, Raper SE, Barker ME, Keung E, Goldberg HI, Boyer TD. Increased hepatic density and phospolipidosis due to amiodarone. AJR Am J Roentgenol. 1985;144(3):541-6. [CrossRef] [PubMed] 
  7. Kojima S, Kojima S, Ueno H, Takeya M, Ogawa H. Increased density of the liver and amiodarone-associated phospholipidosis. Cardiol Res Pract. 2009;2009:598940. [CrossRef] [PubMed]
  8. Weber E, Laarbaui F, Michel L, Donckier J. Abdominal pain: do not forget Thorotrast! Postgrad Med J. 1995;71(836):367-8. [CrossRef] [PubMed] 

Reference as: Thomas AR, Till S, Patterson J. Medical image of the week: increased liver attenuation. Southwest J Pulm Crit Care. 2014;8(2):105-7. doi: http://dx.doi.org/10.13175/swjpcc011-14 PDF

Read More