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.
Medical Image of the Week: Elemental Mercury Poisoning
Figure 1. Panel A: Abdominal x-ray showing radiopaque matter. Panel B: Repeat x-ray after colonoscopy.
A 34-year-old woman presented to the Emergency department with abdominal pain after ingestion of an unknown liquid that family felt might be poisonous. The patient had a past history of prior suicide attempts, as well as a history of polysubstance and alcohol abuse. The patient was confused, tangential and a difficult historian. The patient had a heart rate of 72, was normotensive, and had an oxygen saturation of 100% on room air. She was confused and answered questions intermittently. The remainder of her physical examination including her neurological exam was normal. The initial serum chemistry, anion gap, lactate, liver function tests were normal. Urine drug screen was positive for benzodiazepines, for which the patient was prescribed. An abdominal x-ray was performed showing a radiopaque substance in the abdomen (Figure 1A). It was eventually determined she ingested elemental mercury. Blood levels were elevated, and she did eventually have hematochezia. Colonoscopy was performed which removed some of the metallic liquid mercury (Figure 1B).
Mercury in any form is poisonous, with mercury toxicity most commonly affecting the neurologic, gastrointestinal (GI) and renal organ systems (1). Poisoning can result from mercury vapor inhalation, mercury ingestion, mercury injection, and absorption of mercury through the skin.
Elemental mercury is poorly absorbed after ingestion but easily vaporizes at room temperature and is well absorbed (80%) through inhalation. Once absorbed elemental mercury is mostly converted to an inorganic divalent or mercuric form by catalase in the erythrocytes. This inorganic form has similar properties to inorganic mercury (e.g., poor lipid solubility, limited permeability to the blood-brain barrier, and excretion in feces).
Treatment of mercury toxicity consists of removal of the patient from the source of exposure, supportive care, and chelation therapy. Our patient had limited symptoms, and for this reason, chelation therapy was not performed. She made an uneventful recovery after discharge to psychiatry. Her blood levels eventually returned to normal in a few months.
Michel A. Boivin, MD
Pulmonary/Critical Care/Sleep Medicine
Department of Internal Medicine
University of New Mexico
Albuquerque, NM USA
Reference
- Olson DA. Mercury poisoning. Medscape. August 14, 2017. Available at: https://emedicine.medscape.com/article/1175560-overview (accessed 5/22/18).
Cite as: Boivin M. Medical image of the week: Elemental mercury poisoning. Southwest J Pulm Crit Care. 2018;16(5):287-8. doi: https://doi.org/10.13175/swjpcc067-18 PDF
Medical Image of the Week: Coffee Bean and Whirlpool Signs
Figure 1. Supine abdominal x-ray demonstrating a large dilated loop of bowel and coffee bean sign (red circle).
Figure 2. Contrast CT abdomen (coronal section) showing markedly dilated sigmoid loop with the swirling mesentery (whirlpool sign) (red circle).
A 79-year-old woman with a history of Parkinson’s disease presented with altered mental status, poor oral intake, and multiple episodes of nausea and vomiting. An abdominal x-ray demonstrated dilated loops of bowel and the coffee bean sign concerning for sigmoid volvulus (Figure 1). The coffee bean sign occurs when a thick “inner wall” represents the double wall thickness of opposed loops of bowel while the thinner outer walls due single thickness. A contrast CT abdomen showed dilated sigmoid loop and whirlpool sign confirming sigmoid volvulus (Figure 2). She underwent a total colectomy with ileorectal anastomosis and full recovery.
Brittany Bartolome MS31, Choua Thao MD2, Yaser Dawod MD2, and Carmen Luraschi MD3
1University of Nevada School of Medicine, Reno, NV USA
2Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV USA
3Division of Pulmonary and Critical Care, University of Nevada School of Medicine, Las Vegas, NV USA
Cite as: Bartolome B, Thao C, Dawod Y, Luraschi C. Medical image of the week: coffee bean and whirlpool signs. Southwest J Pulm Crit Care. 2016;12(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc002-16 PDF