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: Pulmonary Arteriovenous Malformations
Figure 1. Cardiac ultrasound showing right to left shunting.
Figure 2. Thoracic CT scan showing arteriovenous malformations (AVM's, arrows).
A 34 year old woman presented to the clinic with exertional dyspnea since childhood. Oxygen saturations in clinic were 92% on room air. On review of systems she admitted to recurrent epistaxis and her daughter also suffered from frequent epistaxis. Bubble contrast echocardiography showed severe right to left shunting without evidence of intracardiac shunt (Figure 1). Computed tomography angiogram of the chest revealed multiple bilateral arteriovenous malformations (AVM’s), the largest measuring 9mm on coronal images (Figure 2). MRI of the brain was negative for AVM’s. She was referred to interventional radiology for microcoil embolization. She met two of four Curaçao criteria for the diagnosis of hereditary hemorrhagic telangiectasia (HHT), giving her “possible HHT”. She was referred for genetic testing to confirm the diagnosis.
Chris Strawter MD and Laura Meinke MD
University of Arizona
Tucson, Arizona
References
- Lacombe P, Lacout A, Marcy PY, et al. Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview. Diagn Interv Imaging. 2013;94:835-48. [CrossRef] [PubMed]
- Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158:643-61. [CrossRef] [PubMed]
- Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2011;48:73-87. [CrossRef] [PubMed]
Reference as: Strawter C, Meinke L. Medical image of the week: pulmonary arteriovenous malformations. Southwest J Pulm Crit Care. 2014;9(4):238-9. doi: http://dx.doi.org/10.13175/swjpcc131-14 PDF
Medical Image of the Week: Pulmonary Arteriovenous Fistula
Figure 1. Panel A: Micro-bubbles appear in the right atrium (RA) and right ventricle (RV) with delayed appearance in the left atrium (LA) and left ventricle (LV). Panels B and C: The density of the micro-bubbles were same in the left and the right cardiac chambers even after 10 cardiac cycles. Panel D: When the injection was stopped, there were micro-bubbles in the left cardiac chambers, but none in the right cardiac chambers.
A 60 year-old man with hepatic cirrhosis, was referred for chest pain, shortness of breath, and progressive cyanosis and an echocardiographic evaluation. PaO2 was 64 mm Hg on room air, but only 74 mm Hg on 100% oxygen. Chest X-ray and pulmonary function testing were normal. A contrast echocardiography using agitated saline (bubble study) was performed. A delayed appearance of a substantial amount of micro-bubbles in the left atrium greater than three cardiac cycles after appearance in the right atrium and ventricle was suggestive of pulmonary arteriovenous fistula (Figure 1A). The delayed appearance and a large amount of micro-bubbles in the left atrium preclude the intracardiac shunting result of a patent foramen ovale (PFO) or atrial septal defect (ASD). Interestingly, the density of micro-bubbles were same in the left and the right cardiac chambers even after 10 cardiac cycles (Figure 1B and 1C). When the injection was stopped, there were micro-bubbles in the left cardiac chambers, but none in the right cardiac chambers (Figure 1D). Although pulmonary angiography remains the gold standard method for definitive diagnosis of the pulmonary arteriovenous malformations, contrast echocardiography can suggest arteriovenous fistula in the setting of unexplained hypoxemia before angiography, especially in hospitals without on-site angiography facilities.
Manisha Bajracharya MD, Madhu Gupta MD, Liping Chen MD PhD
Department of Gynecology and the Cardiovascular Disease Center, Norman Bethune College of Medicine, Jilin University, Changchun, China
Reference
Nanthakumar K, Graham AT, Robinson TI, Grande P, Pugash RA, Clarke JA, Hutchison SJ, Mandzia JL, Hyland RH, Faughnan ME. Contrast echocardiography for detection of pulmonary arteriovenous malformations. Am Heart J. 2001;141(2):243-6. [CrossRef] [PubMed]
Reference as: Bajracharya M, Gupta M, Chen L. Medical image of the week: pulmonary arteriovenous fistula. Southwest J Pulm Crit Care. 2014;8(4): . doi: http://dx.doi.org/10.13175/swjpcc035-14 PDF