August 2021 Imaging Case of the Month: Unilateral Peripheral Lung Opacity

Michael B. Gotway, MD

Department of Radiology, Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

Clinical History: A 56-year-old post-menopausal woman was referred to endocrinology after a routine screening bone densitometry scan suggested osteoporosis. She had undergone this testing after she developed back pain following a pulled muscle for which she saw a chiropractor. The patient had no significant past medical history and she was actively involved in exercise. She denied use of alcohol, drugs, and smoking. She had no allergies and was not taking any medications. Her past surgical history included Lasik surgery, breast augmentation 15 years earlier, and surgery for a deviated septum. 

Physical examination showed a thin patient, afebrile, with a largely normal physical exam, although her pulse was intermittently irregular. Her blood pressure was 130 / 80 mmHg with a normal respiratory rate. Pulse oximetry showed a room air saturation of 98%.

When asked about her irregular pulse, the patient recalled that she had episodes of “heart racing” for which she had undergone evaluation several years earlier by an outside cardiologist. These records were subsequently located and showed supraventricular tachycardia with interventricular conduction delay superimposed on a normal baseline sinus rhythm with occasional premature atrial contractions. The patient indicated that her “heart racing” episodes were often accompanied by nausea, fatigue, and sometimes dizziness, and that they would come and go, starting about 7 years earlier, not necessarily precipitated by exercise. The patient refused further evaluation of this issue and over the next year, continued to intermittently experience these same complaints. When she re-presented to her primary care physician, she had undergone repeat assessment with an outside cardiologist who again performed a 24-hour ambulatory cardiac monitor which disclosed intermittent atrial fibrillation. The patient was tried on flecainide and metoprolol, which she did not tolerate. She expressed interest in an electrophysiology consolation, but did not flow up.

Approximately 2 years later, the patient again presented to her primary care physician after experiencing abrupt onset of cough productive of sputum a small amount of blood associated with a burning sensation in the chest, starting about one month earlier, for which she had been treated by an outside cardiologist with doxycycline for presumed pneumonia. She completed that therapy 8 days prior to re-presentation and indicated her symptoms had improved, but not resolved. She has remained afebrile throughout the entire course of this illness. The patient’s complete blood count and serum chemistries showed entirely normal values. The patient had undergone frontal and lateral chest radiography (Figure 1) at the outside institution at the recommendation of her cardiologist and chiropractor.

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

Which of the following represents an appropriate interpretation of her frontal chest radiograph? (Click on the correct answer to be directed to page 2 of 10 pages)

1. Frontal chest radiography shows cardiomegaly and increased pressure pulmonary edema
2. Frontal chest radiograph shows left upper and lower lobe consolidation and a left pleural effusion
3. Frontal chest radiography shows multiple small nodules
4. Frontal chest radiography shows mediastinal lymphadenopathy
5. Frontal chest radiography shows a pneumothorax

Cite as: Gotway MB. August 2021 imaging case of the month: unilateral peripheral lung opacity. Southwest J Pulm Crit Care. 2021;23(2):36-48. doi: https://doi.org/10.13175/swjpcc031-21 PDF

Medical Image of the Week: Bilateral Atrial Appendage Thrombi

Figure 1. Panel A: Right atrial appendage (RAA) thrombus (red arrow) on chest computerized tomorgraphy angiogram (CTA). Panel B: Left atrial appendage (LAA) thrombus (yellow arrow) on chest CTA. Panel C: RAA thrombus (red arrow) on transesophageal echocardiography (TEE). Panel D: LAA thrombus (yellow arrow) on TEE.

A 63-year-old man with a past history significant for hypertension, low back pain and polysubstance abuse (tobacco and marijuana) presented with shortness of breath and hemoptysis for the last 8 days prior to admission. His initial exam showed elevated jugular venous pressure and bilateral basal crackles with reduced air entry on the right lower lung zone.

The patient was found to be in atrial fibrillation with a rapid ventricular response. His initial chest X-ray showed a moderate right-sided pleural effusion. Immediate bedside echo was concerning for bilateral ventricular dysfunction with concerns of right-sided heart pressure and volume overload. A chest CT angiogram was obtained and showed acute lower lobe pulmonary embolism, with possible distal infarct, moderate right sided pleural effusion, and filling defects in both atrial appendages concerning for thrombi (Figure 1, Panels A & B).

The patient was started on therapeutic anticoagulation and underwent therapeutic thoracentesis, gentle diuresis, and rate control for his atrial fibrillation. A few days later, a trans-esophageal echo confirmed the bilateral atrial thrombi (Figure 1, Panels C & D).

Huthayfa Ateeli MBBS¹, Andrew Kovoor MD¹, Hem Desai MBBS¹, Alana Stubbs MD², Tam Nguyen MD³

¹Department of Medicine, ²Radiology Department, and ³Cardiology Division

University of Arizona and Southern Arizona VA Health Care System

Tucson, AZ

References

1. Kim YY, Klein AL, Halliburton SS, Popovic ZB, Kuzmiak SA, Sola S, Garcia MJ, Schoenhagen P, Natale A, Desai MY. Left atrial appendage filling defects identified by multidetector computed tomography in patients undergoing radiofrequency pulmonary vein antral isolation: a comparison with transesophageal echocardiography. Am Heart J. 2007;154(6):1199-205. [CrossRef] [PubMed]
2. Shapiro MD, Neilan TG, Jassal DS, Samy B, Nasir K, Hoffmann U, Sarwar A, Butler J, Brady TJ, Cury RC. Multidetector computed tomography for the detection of left atrial appendage thrombus: a comparative study with transesophageal echocardiography. J Comput Assist Tomogr. 2007;31(6):905-9. [CrossRef] [PubMed] 

Reference as: Ateeli H, Kovoor A, Desai H, Stubbs A, Nguyen T. Medical image of the week: bilateral atrial appendange thrombi. Southwest J Pulm Crit Care. 2015;10(1):54-5. doi: http://dx.doi.org/10.13175/swjpcc006-15 PDF

Medical Image of the Week: Massive Spontaneous Intra-Abdominal Bleeding

Figure 1. CT scan of the abdomen and pelvis showing diffuse intra-abdominal bleeding.

A 67 year-old female with RA, on anti-TNF and steroids, was admitted to the ICU with severe shock, likely hemorrhagic. She was on Coumadin for atrial fibrillation. She was found to have severe coagulopathy and diffuse spontaneous abdominal bleeding (Figure 1). She also developed left popliteal artery thrombosis, with compartment syndrome requiring surgical intervention. DIC was the final diagnosis.

Mohammed Alzoubaidi MD, Carmen Luraschi-Monjagatta MD, Sridhar Reddy MD, Robert McAtee MD.

Departments of Pulmonary and Critical Care, Internal Medicine and Emergency Medicine

South Campus

Tucson, Arizona

Reference as: Alzoubaidi M, Luraschi-Monjagatta C, Reddy S, McAtee R. Medical image of the week: massive spontaneous intra-abdominal bleeding. Southwest J Pulm Crit Care. 2014;8(2):135. doi: http://dx.doi.org/10.13175/swjpcc018-14 PDF