May 2024 Medical Image of the Month: Hereditary Hemorrhagic Telangiectasia in a Patient on Veno-Arterial Extra-Corporeal Membrane Oxygenation

Figure 1.  Preoperative nasopharyngoscopic direct visualization of telangiectasia of the nasal turbinate.

Figure 2.  Noncontrast head CT on postoperative day 3 demonstrates extensive multifocal areas of low attenuation consistent with early signs of infarction involving much of the cerebral hemispheres, most prominently involving the left parietal lobe.

A 54-year-old man with a complex cardiac history, including Tetralogy of Fallot requiring Blalock-Taussig shunt in infancy, infundibular patch repair at age 7, and bioprosthetic tricuspid valve replacement at age 52, had ongoing frequent hospitalizations with decompensated right ventricular heart failure secondary to native pulmonary valve mixed stenosis plus regurgitation and left pulmonary artery stenosis. His case was further complicated by his history of hereditary hemorrhagic telangiectasia (HHT) with recurrent epistaxis and recent GI bleeds with multiple angiodysplastic lesions throughout the stomach, duodenum, and descending colon which were previously treated with argon plasma coagulation.

The patient was admitted to our hospital in NYHA class IV heart failure receiving a continuous dopamine infusion and aggressive diuresis. Upon admission, a right heart catheterization demonstrated severe pulmonary valve regurgitation, left pulmonary artery stenosis, and systemic hypoxemia suggestive of an intrapulmonary shunt. Admission transthoracic echocardiogram demonstrated normal left ventricular ejection fraction of 55-60%, a severely enlarged right ventricle, moderately reduced right ventricular systolic function, severe pulmonary valve regurgitation, and moderate pulmonary valve stenosis.

A multidisciplinary team including congenital cardiology, pulmonary hypertension, interventional pediatric cardiology, and congenital cardiovascular surgery was consulted and after extensive discussions the patient consented to surgical intervention. Prior to his operative date, he underwent cauterization of his bilateral nasal cavity telangiectasias by Otolaryngology (Figure 1). On hospital day sixteen, he underwent a fourth time redo median sternotomy, pulmonary valve replacement with St. Jude Epic 27-mm porcine bioprosthesis, and repair of left pulmonary artery stenosis. Intraoperative transesophageal echocardiogram at the end of the surgical case demonstrated severe right ventricular dilation, severe right ventricular systolic dysfunction, normal pulmonary valve prosthesis, and left ventricular ejection fraction of 55%. The case was technically challenging requiring a cardiopulmonary bypass time of 178 minutes, and massive transfusion (including twelve units packed red blood cells, two packs of platelets, 4 units fresh frozen plasma, and 10 units cryoprecipitate) for a total estimated blood loss of 3.9 L.

Postoperatively, he had persistent right ventricular systolic dysfunction and diffuse mediastinal hemorrhage. By postoperative day two, a repeat transesophageal echocardiogram revealed worsening right ventricular dilation and severe right ventricle systolic dysfunction. The multidisciplinary care team recommended central venoarterial extracorporeal membrane oxygenation (VA ECMO) support for both worsening hypoxemia and continuing severe right ventricular failure.  The aorta was cannulated with a 22 French Bio-Medicus cannula (Medtronic, Minneapolis, USA) and the right atrium cannulated with a 36 French venous cannula (Medtronic, Minneapolis, USA), and full ECMO support was initiated using a Cardiohelp console with a HLS 7.0 oxygenator (Getinge, Goteborg, Sweden) reaching ECMO blood flows of 6 L/minute (an indexed ECMO blood flow of 2.6 L/minute/m²).

On POD 3, bronchoscopy was performed and revealed diffuse thin bloody secretions in the distal airways without a focal source, which was cleared with suction but quickly reaccumulated. Due to the pulmonary hemorrhage and recent mediastinal hemorrhage, systemic anticoagulation was not started at that time. Due to a lack of awakening during a sedation vacation, computed tomography (CT) imaging of his head was obtained and demonstrated a large ischemic stroke affecting the majority of the left MCA territory and part of the right parietal lobe (Figure 2).

HHT (also known as Osler-Weber-Rendu disease) is an autosomal dominant genetic disease with various vascular manifestations (1). In addition to the more common mucocutaneous and gastrointestinal tract telangiectasias, some patients with HHT also have pulmonary arteriovenous malformations (AVMs) with right-to-left shunt that can cause hypoxemia with resultant polycythemia. Cerebral AVMs present a risk of intracranial hemorrhage, ischemia, and hydrocephalus, which correlate with the size of the vascular defect. Given the presence of AVMs and hemorrhagic complications related to telangiectasias, the use of extracorporeal membrane oxygenation (ECMO) in patients with HHT is a potentially high-risk situation.

This case highlights the risks of ECMO in patients with HHT. The causes of this patient’s hemorrhagic and thrombotic events were most likely multifactorial, including contributions from a dilutional and consumptive coagulopathy after cardiopulmonary bypass and hemorrhage, initiation of ECMO, kidney failure, and his underlying HHT. The timing and precise cause of our patient’s cerebral infarction are unclear. However, patients with HHT and clinically significant intrapulmonary AVMs may have an increased risk of paradoxical thromboembolic stroke (2). The international HHT expert guidelines assert that even though HHT is a hemorrhagic disorder, it provides no protection against thrombosis (3). In addition, patients with HHT may  levels of von Willebrand factor and factor VIII, which would potentially increase their risk of thrombosis (4). This case exemplifies the substantial risks of hemorrhagic and thrombotic complications associated with ECMO for patients with HHT. Further study is needed to help determine whether HHT should be considered a contraindication to ECMO.

Theodore O. Loftsgard, APRN, CNP^1,2; Kari A. Wilson, APRN, CNP^1,2; John K. Bohman, MD^2,3

¹Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN

²Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN

³Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN

References

1. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2011 Feb;48(2):73-87. [CrossRef] [PubMed]
2. Dittus C, Streiff M, Ansell J. Bleeding and clotting in hereditary hemorrhagic telangiectasia. World J Clin Cases. 2015 Apr 16;3(4):330-7. [CrossRef] [PubMed]
3. Faughnan ME, Mager JJ, Hetts SW, et al. Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia. Ann Intern Med. 2020 Dec 15;173(12):989-1001. [CrossRef] [PubMed]
4. Shovlin CL, Sulaiman NL, Govani FS, Jackson JE, Begbie ME. Elevated factor VIII in hereditary haemorrhagic telangiectasia (HHT): association with venous thromboembolism. Thromb Haemost. 2007 Nov;98(5):1031-9. [PubMed]

Cite as: Loftsgard TO, Wilson KA, Bohman JK. May 2024 Medical Image of the Month: Hereditary Hemorrhagic Telangiectasia in a Patient on Veno-Arterial Extra-Corporeal Membrane Oxygenation. Southwest J Pulm Crit Care Sleep. 2024;28:68-70. doi: https://doi.org/10.13175/swjpccs015-24 PDF

Medical Image of the Month: Coccidioidal Pneumatocele Complicated by Pulmonary Hemorrhage

Figure 1. Axial CT of the chest without contrast 12 years prior to this hospitalization demonstrates an irregularly-marginated right upper lobe cyst measuring 1.5 x 1.6 cm (red arrow).

Figure 2. Axial CT of the chest without contrast obtained 4 months prior to this admission demonstrated a cavitary lesion now measuring 6.3 x 8.2 cm, thin-walled, with small internal air-fluid level and adjacent small pleural effusion without any internal debris (red arrow).

Figure 3. An axial CT angiogram of the chest in lung windows demonstrated a right upper lobe pulmonary cavitary lesion increased in size to 10.5 cm in largest dimension with almost complete opacification (red star) concerning for a superimposed infection.

A 77-year-old man with emphysema, hypertension, hypothyroidism, and diabetes mellitus presented with two days of worsening cough that progressed to massive hemoptysis. His hemoptysis included clots the size of golf balls and multiple episodes of frank blood, measuring half a cup each. His symptoms included dyspnea at rest, fatigue, and a 15-20-pound weight loss in three weeks. He denied fevers, night sweats, chest pain, hematemesis, and prior hemoptysis. Additionally, he had a history of coccidioidomycosis complicated by a cavitary lung lesion. Per chart review, 12 years prior to this hospitalization the patient had an irregularly-marginated right upper lobe cyst measuring 1.5 x 1.6 cm (Figure 1). A CT scan obtained 4 months prior to admission showed the cavity to be 6.3 x 8.2 cm thin-walled and clear of debris (Figure 2) – consistent with a pneumatocele. The patient was referred to thoracic surgery for possible resection at that time but was lost to follow up.

Admission labs showed a decrease in hemoglobin to 13.4 from a baseline of 15.1 g/dL and white blood cells of 10,300 cells/µL. Blood cultures were negative. CT angiography now demonstrated an increase in the right upper lobe pulmonary cavitary lesion to 10.5 cm in largest dimension with almost complete opacification of the lesion - concerning for a superimposed infection. Imaging also showed tree-in-bud nodules in right middle and lower lobes without evidence of a pulmonary embolism (Figure 3). Coccidioidomycosis serologies by EIA showed a non-reactive IgM with reactive IgG. Acid fast bacilli staining of the sputum was negative. Bronchoscopy performed in the hospital showed fresh blood present in the trachea and in the visualized tracheobronchial tree. Active bleeding was noted only from the posterior segment of the right upper lobe. A bronchoalveolar lavage was performed confirming alveolar hemorrhage centered in the right upper lobe. Lidocaine with epinephrine was instilled to stop bleeding. No endobronchial lesion was seen.

The case was evaluated by an interventional radiologist and cardiothoracic surgeon at our institution. They both felt the patient would benefit from transfer to a larger medical center for definitive management of his hemorrhage. He was transferred to a tertiary academic center for a right upper lobectomy, which he tolerated well.  Surgical pathology and bronchoscopy cultures ultimately grew coccidioides immitis and the patient was discharge on a treatment course of oral fluconazole.

Pulmonary pneumatoceles are thin-walled, air-filled cystic structures. Most pneumatoceles are encountered in infancy; however, they can appear at any age (1). Pneumatoceles are known sequelae of pneumonia but can also occur due to blunt thoracic injury or as a rare side effect of chemotherapy (2,3). While the mechanism of pneumatocele formation is unclear, several theories have been postulated including check-valve bronchial obstruction and narrowing or from parenchymal necrosis with accompanying focal collections of air within the interstitial tissue (5). Such cases are typically asymptomatic and do not require intervention as they resolve within weeks to months (6). While many pneumatocele resolve on their own without additional intervention, complex pneumatoceles may result in uncontrolled hemorrhage, as portrayed in this case, or infected lesions unresponsive to antibiotics - necessitating surgical intervention (7). Other complications of pneumatoceles are rare and may include a tension pneumatocele with cardiorespiratory compromise or pneumothorax (8). 

Staphylococcal pneumonia is frequently complicated by pneumatocele development, with pneumatoceles thought to occur in 61% of cases of staphylococcal pneumonia (9). However, the literature of pneumatocele development following cocci infection is scant. In immunocompetent hosts, infections from coccidiosis are transient, with pulmonary complications (often nodules and self-limited thin-walled cavities) occurring in less than 10% of patients (10).  Complications from coccidiosis infection are usually brief fatigue, dyspnea, cough, and arthritis, with chronic infection or severe complication being rare. Here, we report a case of a gradually enlarging pneumatocele in the setting of cocci infection that eventually eroded into the pulmonary vasculature. The resulting massive hemoptysis was refractory to epinephrine injection and not amenable to catheter embolization. Upper lobectomy was required for definite treatment of the pulmonary hemorrhage.

Sylvester Moses MD, Gregory Gardner MD, Ella Starobinska MD, and Arthur Wolff MD

Department of Internal Medicine

University of Arizona

Tucson, AZ USA

References

1. Flaherty RA, Keegan JM, Sturtevant HN. Post-pneumonic pulmonary pneumatoceles. Radiology. 1960;74:50-3. [CrossRef] [PubMed]
2. Aissaoui O, Alharrar R. Traumatic pulmonary pseudocyst: a rare complication of blunt thoracic injury. Pan Afr Med J. 2019 Apr 11;32:180. [CrossRef] [PubMed]
3. Sangro P, Bilbao I, Fernández-Ros N, Iñarrairaegui M, Zulueta J, Bilbao JI, Sangro B. Pneumatocele during sorafenib therapy: first report of an unusual complication. Oncotarget. 2017 Dec 22;9(5):6652-6. [CrossRef] [PubMed]
4. Quigley MJ, Fraser RS. Pulmonary pneumatocele: pathology and pathogenesis. AJR Am J Roentgenol. 1988 Jun;150(6):1275-7. [CrossRef] [PubMed]
5. Zuhdi MK, Spear RM, Worthen HM, Peterson BM. Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. Crit Care Med. 1996 Feb;24(2):330-3. [CrossRef] [PubMed]
6. Kaira K, Ishizuka T, Yanagitani N, Sunaga N, Hisada T, Mori M. Pulmonary traumatic pneumatocele and hematoma. Jpn J Radiol. 2009 Feb;27(2):100-2. [CrossRef] [PubMed]
7. Kesieme EB, Kesieme CN, Akpede GO, Okonta KE, Dongo AE, Gbolagade AM, Eluehike SU. Tension pneumatocele due to Enterobacter gergoviae pneumonia: a case report. Case Rep Med. 2012;2012:808630. [CrossRef] [PubMed]
8. Dines DE. Diagnostic significance of pneumatocele of the lung. JAMA. 1968 Jun 24;204(13):1169-72. [CrossRef] [PubMed]
9. Nayeemuddin M, Jankowich MD, Noska A, Gartman EJ. A strange case of coccidioidomycosis: utilization of bronchoscopy to diagnose a chronic cavitary lesion. Am J Resp Crit Care Med. 2018;197:A5427 [Abstract].

Cite as: Moses S, Gardner G, Starobinska E, Wolff A. Medical image of the month: coccidioidal pneumatocele complicated by pulmonary hemorrhage. Southwest J Pulm Crit Care. 2020;20(3):84-6. doi: https://doi.org/10.13175/swjpcc008-20 PDF 

Medical Image of the Week: Bronchial Clot Removal via Cryotherapy

Figure 1. Chest x-ray showing complete opacification of the left hemithorax.

Figure 2. Flexible bronchoscopy with cryotherapy was used to remove clot that formed casts of the bronchial tree. Black arrow: depicts segmental branch of the left upper lobe.

A 38-year-old man with a history of non-ischemic dilated cardiomyopathy presented with decompensated heart failure, acute renal failure, and possible sepsis. He underwent right cardiac catheterization but developed hemoptysis with concern for pulmonary artery rupture. Subsequently, the patient suffered a cardiac arrest but was resuscitated. Emergent bronchoscopy revealed copious amounts of blood and clot that could not be cleared at the time. The patient was then taken to the operating room and placed on A-A ECMO (left ventricle to aorta). The following morning chest x-ray (Figure 1) revealed a completely opacified left lung. Flexible bronchoscopy showed blood clot along the entire left bronchial tree. Initial attempts to remove the clot with suction and endobronchial graspers was unsuccessful. Ultimately, cryotherapy was used to remove the majority of the clot in fragments (Figure 2).

The use of cryotherapies and specifically, in this case, a cryoprobe, has been shown to safely and effectively remove thrombus from the bronchial tree. The basis behind this technique is the use of pressurized nitrous oxide or carbon dioxide to cool a metal probe tip. The probe then freezes any substance it comes in direct contact with, such as a blood clot. Thus, cryoadherence of the probe to the clot allows for effective removal via flexible endoscopy.  Sriratanaviriyakul et al. (1) reported success rates for cryoextraction of blood clots to be >90%.

Cathy V. Ho MD, Ryan Matika MD, and Mimi Amberger MD

¹Division of Trauma, Critical Care, Burn and Emergency Surgery. Department of Surgery

²The Department of Anesthesia

University of Arizona

Tucson, AZ USA

Reference

1. Sriratanaviriyakul N, Lam F, Morrissey BM, Stollenwerk N, Schivo M, Yoneda KY.Safety and clinical utility of flexible bronchoscopic cryoextraction in patients with non-neoplasm tracheobronchial obstruction: a retrospective chart review. J Bronchology Interv Pulmonol. 2015 Oct;22(4):288-93. [CrossRef] [PubMed] 

Cite as: Ho CV, Matika R, Amberger M. Medical image of the week: bronchial clot removal via cryotherapy. Southwest J Pulm Crit Care. 2016;13(5):253-4. doi: https://doi.org/10.13175/swjpcc109-16 PDF 

Medical Image of the Week: Diffuse Gastric Bleeding and ALL

Figure 1. Technetium 99m tagged RBC scan showing abnormal radio tracer accumulation throughout the stomach (Panel A), and subsequently passing into the small bowel (Panel B).

A 26-year-old man with a medical history significant for acute lymphoblastic leukemia (ALL) presented with hypovolemic shock secondary to large volume hematemesis. The patient was diagnosed with ALL and treated with high dose chemotherapy followed by peripheral blood stem cell transplant from a matched unrelated donor one year prior to presentation. His treatment course was complicated by grade 4 acute graft versus host disease (GVHD) and CMV colitis. Blood work on admission showed hemoglobin of 6.4 g/dL and a leukocytosis. Patient was intubated for airway protection, transferred to ICU, and EGD was performed, which revealed diffusely friable mucosa, inflammation, and ulcerations throughout the gastric mucosa with only a few areas of normal appearing mucosa. Additionally, areas of spontaneous bleeding were seen. Selective arteriography within the right gastric and gastroduodenal arteries showed no active extravasation from the stomach or duodenum. However the gastroepiploic and right gastric arteries were prophylactically embolized. Subsequently, a technetium 99m tagged RBC scan demonstrated abnormal radio-tracer accumulation throughout the stomach with subsequent passage into the small bowel (Figure 1). The patient continued to have refractory gastric bleeding even with an increased dose of cyclosporine. Surgical measures including gastrectomy were discussed with the family. However, the family decided on comfort care. The patient died the following day.

Although gastric bleeding is rare in ALL patients in general, it is more commonly associated with certain condition such as GVHD and colitis following allogeneic stem cell transplantation (SCT). One of the retrospective studies with 447 SCT patients showed that 21.1% of study population experienced major GI bleeding, requiring transfusions or surgical intervention. Also, their mortality was shown to be twice higher than patients without bleeding complication, although most cases of bleeding were mild and occurred in the peri-transplant period with concurrent severe thrombocytopenia (1).

Hemorrhagic complications occur predominantly during the first month of post transplant, and bleeding is more commonly associated with allogeneic SCT compared to autologous SCT (2). This is mainly secondary to GVHD with gastrointestinal involvement, which leads to destruction and fragility of the epithelium as well as hyper-perfusion and proliferation of the blood vessels. As such, the risk of hemorrhage in patients with acute and chronic GVHD greater than grade I was 2.9 and 4.2 fold higher, respectively, and these patients had 10.8 fold higher risk of severe bleeding. The risk of bleeding is further increased by CMV infection, which infects vascular endothelial cells, narrows capillary lumens, and leads to ischemia and ulceration of gastric mucosa (3). The combination of GVHD and CMV infection could have synergistically damaged the gastric mucosa leading to severe refractory bleeding in our case.

Onyemaechi Okolo MD¹, Seongseok Yun MD PhD¹, Faiz Anwer MD, FACP²

¹Department of Medicine

²Department of Hematology & Oncology, Blood & Bone Marrow Transplantation Program

University of Arizona

Tucson, AZ, 85721

References

1. Pihusch R, Salat C, Schmidt E, Göhring P, Pihusch M, Hiller E, Holler E, Kolb HJ. Hemostatic complications in bone marrow transplantation: a retrospective analysis of 447 patients. Transplantation. 2002;74(9):1303-9. [CrossRef] [PubMed]
2. Törnebohm E, Lockner D, Paul C. A retrospective analysis of bleeding complications in 438 patients with acute leukaemia during the years 1972-1991. Eur J Haematol. 1993;50(3):160-7. [CrossRef] [PubMed]
3. Cheung AN, Ng IO. Cytomegalovirus infection of the gastrointestinal tract in non-AIDS patients. Am J Gastroenterol. 1993;88(11):1882-6. [PubMed]

Cite as: Okolo O, Yun S, Anwer F. Medical image of the week: diffuse gastric bleeding and ALL. Southwest J Pulm Crit Care. 2016;12(3):108-9. doi: http://dx.doi.org/10.13175/swjpcc010-16 PDF

Medical Image of the Week: Abdominal Compartment Syndrome Due to Massive Upper Gastrointestinal Hemorrhage

Figure 1. Coronal section demonstrating a section of the Minnesota Tube within the stomach (yellow arrow), severe dilatation of the stomach (green arrow) and small bowel (blue arrow) due to intraluminal filling from blood. There is markedly reduced lungs volumes due to superior displacement of the diaphragm.

Figure 2. Saggital section demonstration the Minnesota Tube in place within the esophagus and stomach (yellow arrow) surrounded with intraluminal blood. There is intraluminal filling of the small intestine as well (green arrow).

A 29 year old woman with history of a Whipple procedure for pancreatic cancer and nonalcoholic steatohepatitis cirrhosis presented with a massive upper gastrointestinal bleeding (UGIB) likely from esophageal varices and developed hemorrhagic shock.

Emergent upper endoscopy could not be performed due to hemodynamic instability. Therefore, a Minnesota Tube was placed emergently for balloon tamponade of the bleeding. A transjugular intrahepatic portosystemic shunt was also placed emergently to decrease bleeding by reducing portal pressure. By this time, the patient had received 4 liters of normal saline, 14 units of packed red blood cells, 6 units of platelets, and 4 units of fresh frozen plasma.

The Minnesota tube did control the bleeding somewhat, however, there was continued bloody drainage from the stomach port of the Minnesota tube. The patient’s abdomen became remarkably distended and was dull to percussion throughout. A CT scan of the abdomen and pelvis revealed severe dilatation of the stomach and multiple loops of small bowel filled with mixed density blood (Figures 1 and 2). Intraabdominal bladder pressure was elevated to 34 mmHg. Given the radiographic findings, elevated bladder pressures, worsening lactic acid level and renal function, the patient was diagnosed with abdominal compartment syndrome. She was not a surgical candidate due to her grim prognosis. A large bore tube was placed into the abdominal cavity to drain ascitic fluid in effort to relieve the abdominal pressure.

Aggressive resuscitation including fluids, blood products, and four vasopressors was continued for the next several hours. However, due to patient’s poor prognosis, a decision was made to proceed with comfort care and the patient shortly passed away.

Acute upper gastrointestinal bleeding is a frequently encountered condition in the intensive care unit . Initial management generally consists of airway protection, intravascular resuscitation, correction of any coagulopathies, and acid-suppressive therapy (1). For UGIB with hemodynamic compromise, immediate upper endoscopic evaluation is indicated. The upper endoscopy allows for determination of the specific etiology of UGIB and for interventional therapy. If endoscopy cannot be done, bleeding cannot be controlled with endoscopic interventions or the patient is hemodynamically unstable, balloon tamponade should be considered (2). It is important to note that balloon tamponade is considered a bridge to more definitive therapy. Lastly, a multidisciplinary approach for management of massive UGIB should always be utilized especially in difficult cases.

VuAnh N. Truong, MD

Department of Medicine

Loma Linda University Medical Center

Loma Linda, CA

References

1. Conrad SA. Acute upper gastrointestinal bleeding in critically ill patients: causes and treatment modalities. Crit Care Med. 2002;30(6 Suppl):S365-8. [CrossRef] [PubMed]
2. Chen YI, Dorreen AP, Warshawsky PJ, Wyse JM. Sengstaken-Blakemore tube for non-variceal distal esophageal bleeding refractory to endoscopic treatment: a case report & review of the literature. Gastroenterol Rep (Oxf). 2014; Gastroenterol Rep (Oxf). 2014;2(4):313-5. [CrossRef] [PubMed] 

Reference as: Truong VN. Medical image of the week: abdominal compartment syndrome due to massive upper gastrointestinal hemorrhage. Southwest J Pulm Crit Care. 2014;9(5):284-6. doi: http://dx.doi.org/10.13175/swjpcc133-14 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