Medical Image of the Week: Mucous Plugs Forming Airway Casts

Figure 1. Bronchoscopic view of the mucous plug.

Figure 2. Cast removed with cryo-adhesion probe.

A 64 -year-old man with a recent diagnosis of acute lymphocytic leukemia (ALL) on chemotherapy presented with acute hypoxic respiratory failure, multifocal pneumonia, neutropenic fever and septic shock. The patient was intubated and required vasopressors for septic shock. His blood and sputum cultures grew Pseudomonas aeruginosa. Chest computed tomography demonstrated extensive consolidation of the left lung mainly the left lower lobe with extensive endobronchial mucus plugs. The patient underwent bronchoscopy after noninvasive measures failed to resolve the left lung atelectasis. After multiple attempts to retrieve the mucus plugs (Figure 1) with suction failed, a cryo-adhesion probe was used to freeze and retrieve the mucus plug. The plug formed a cast taking the shape of the airway (Figure 2).

Flexible bronchoscopy is warranted in patients who have persistent atelectasis or pneumonia that is either of unknown cause or suspected of being due to airway obstruction (1). The use of cryo-adhesion and extraction has been particularly useful in the management of airway obstruction caused by foreign bodies especially mucus plugs and blood clots that are not easily extracted by more standard means such as suction or forceps (2).

Huthayfa Ateeli, MBBS and Cameron Hypes MD, MPH

Division of Pulmonary, Critical Care, Sleep and Allergy Medicine

University of Arizona, Tucson, AZ USA

References

1. Feinsilver SH, Fein AM, Niederman MS, Schultz DE, Faegenburg DH. Utility of fiberoptic bronchoscopy in nonresolving pneumonia. Chest. 1990 Dec;98(6):1322-6. [CrossRef] [PubMed]
2. Strausz J, Bolliger CT. Interventional pulmonology. Sheffield: European Respiratory Society; 2010: 165.

Cite as: Ateeli H, Hypes C. Medical image of the week: mucous plugs forming ariway casts. Southwest J Pulm Crit Care. 2017;15(6):278-9. doi: https://doi.org/10.13175/swjpcc147-17 PDF 

Medical Image of the Week: Ascaris Lumbricoides

Figure 1. 23 cm adult Ascaris lumbricodes recovered from patient's feces.

A 25 year-old man was admitted to the ICU with acute renal failure and acute respiratory failure from fluid overload after attempting to cross the border. The patient was successfully extubated after five days of mechanical ventilation and renal replacement therapy. Following extubation, the patient had a bowel movement and passed a 23cm adult Ascaris lumbricoides. He was treated with a single dose of albendazole 400 mg.

Ascariasis is a very common helminthic infection, particularly in pediatric populations, and affects mostly the gastrointestinal tract. When infective eggs are swallowed by the host, larvae hatch in the GI tract. The larvae invade the GI mucosa and then are brought into the lungs via portal circulation. The larvae can then move up the tracheobronchial tree and then are swallowed into the GI tract where the mature worms form (1).

While our patient had a simple gastrointestinal infection, several pulmonary complications of ascariasis have been reported (2). Adult worms can cause largyngospasm as well as mechanical obstruction of the airway which can result in cardiac arrest (3,4). This migration of worms from the stomach to the trachea may be related to the use of anesthetics and the subsequent relaxation of the lower esophageal sphincter. Ascaris larvae have been implicated in Loeffler’s syndrome, also described as simple pulmonary eosinophilia, characterized by transient pulmonary infiltrates and eosinophilia with a usually benign course.

Candy Wong¹; Aaron Fernandes², Jennifer Huang², and Sachin Chaudhary¹

¹Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine.

² Department of Medicine

University of Arizona

Tucson, AZ

References

1. Centers for Disease Control and Prevention. Parasites – Ascariasis. Biology. Available at: http://www.cdc.gov/parasites/ascariasis/biology.html (accessed 1/13/2015).
2. Li QY, Zhao DH, Qu HY, Zhou CN. Life-threatening complications of ascariasis in trauma patients: a review of the literature. World J Emerg Med. 2014;5(3):165-70. [CrossRef] [PubMed]
3. Maletin M, Veselinović I, Stojiljkovic GB, Vapa D, Budakov B. Death due to an unrecognized ascariasis infestation: two medicolegal autopsy cases. Am J Forensic Med Pathol. 2009;30(3):292-4. [CrossRef] [PubMed]
4. Husain SJ, Zubairi AB, Sultan N, Beg MA, Mehraj V. Recurrent episodes of upper airway blockage associated with Ascaris lumbricoides causing cardiopulmonary arrest in a young patient. BMJ Case Rep. 2009;2009. pii: bcr01.2009.1415. [CrossRef] [PubMed]

Reference as: Wong C, Fernandes A, Huang J, Chaudhary S. Medical image of the week: ascaris lumbridoies. Souhtwest J Pulm Crit Care. 2015;10(2):81-2. doi: http://dx.doi.org/10.13175/swjpcc008-15 PDF

Medical Image of the Week: Granulation Tissue

Figure 1. Subglottic space showing the presence of granulation tissue (arrows).

Figure 2. Argon Plasma Coagulation of the granulation tissue

A 57 year old woman presented with a tickling sensation in the back of throat and intermittent bleeding from the healing stoma one month after decannulation of her tracheostomy tube. On bronchoscopy a granuloma with surrounding granulation tissue was present in the subglottic space (Figure 1). Argon plasma coagulation (APC) was performed to cauterize the granulation tissue (Figure 2).

Formation of granulation tissue after tracheostomy is a common complication which can result in tracheal stenosis. APC and electrocautery using flexible bronchoscopy has been shown to safely and effectively remove the granulation tissue.

Aarthi Ganesh, MBBS and  James Knepler, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona

Tucson, AZ

Reference

1. Epstein SK. Late complications of tracheostomy. Respir Care. 2005;50(4):542-9. [PubMed] 

Reference as: Ganesh A, Knepler J. Medical image of the week: granulation tissue. Southwest J Pulm Crit Care. 2014;8(3):192-3. doi: http://dx.doi.org/10.13175/swjpcc029-14 PDF

October 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 65-year-old non-smoking woman presented with a history of cough, exertional dyspnea, and occasional wheezing. Frontal chest radiography (Figure 1) was performed.

Figure 1. Admission chest x-ray.

 Which of the following statements regarding the chest radiograph is most accurate?

1. The frontal chest radiograph is normal
2. The frontal chest radiograph is non-specifically abnormal
3. The frontal chest radiograph shows numerous small nodules, consistent with a “miliary” pattern
4. The frontal chest radiograph shows significant right lung volume loss, suggesting endobronchial obstruction
5. The frontal chest radiograph shows diffuse fibrotic lung disease

Reference as: Gotway MB. October 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:186-92. PDF