February 2021 Imaging Case of the Month: An Indeterminate Solitary Nodule

Prasad M. Panse MD

Clinton E. Jokerst MD

Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Phoenix, Arizona 85054

Clinical History: A 43 -year-old woman with no past medical history presented to the Emergency Room with complaints of right chest wall pain extending into the right upper quadrant. The patient was a non-smoker, denied any allergies, and was not taking any prescription medications.

Physical examination showed the patient to be afebrile with normal heart and respiratory rates and blood pressure = 110/75 mmHg. Her room air oxygen saturation was 99%.

The patient’s complete blood count and serum chemistries showed normal values. Her liver function testing and renal function testing parameters were also within normal limits.

Which of the following represents an appropriate next step for the patient’s management?

1. Perform abdominal ultrasound
2. Perform chest radiography
3. Perform unenhanced chest CT
4. More than one of the above
5. None of the above

Cite as: Panse PM, Jokerst CE, Gotway MB. February 2021 Imaging Case of the Month: An Indeterminate Solitary Nodule. Southwest J Pulm Crit Care. 2020;21(5):41-55. doi: https://doi.org/10.13175/swjpcc006-21 PDF

Medical Image of the Month: Metastatic Pulmonary Calcifications in a Kidney Transplant Recipient

Figure 1. Axial and coronal views of thoracic CT scan showing upper lobe predominant centrilobular ground glass nodules.

Figure 2. Transbronchial biopsy yielded nine tissue fragments, each of which demonstrated moderate to marked interstitial calcification (amorphous purple material) along the alveolar septae, perivascular spaces and within the bronchioles consistent metastatic calcification.  There were secondary changes of mild alveolar fibrosis and interstitial hemosiderin laden macrophages (golden brown pigment).  There was no evidence of an inflammatory response or malignancy to otherwise explain the CT findings in this patient.

A 40-year-old man presented with shortness of breath, cough and abnormal imaging. He had a past medical history of end stage renal disease (ESRD) secondary to Alport syndrome and underwent three kidney transplants in 2004, 2010 and 2016. He was intermittently on dialysis between the transplants. He also had a history of coronary artery disease, congestive heart failure and parathyroidectomy. His CT scan (Figure 1) from 2019 showed diffuse centrilobular ground glass opacities sparing the peripheral lung and lung bases. Pulmonary function testing showed obstruction, with reduced diffusion capacity. Bronchoscopy with bronchoalveloar lavage and transbronchial biopsy of the right upper and middle lobes was consistent with metastatic pulmonary calcification (MPC) (Figure 2).

MPC is a rare metabolic pulmonary disease which is usually found incidentally or on autopsy. It occurs with chronically elevated calcium and phosphorus levels (1). It is very commonly associated with ESRD and rarely in primary hyperparathyroidism, osteoporosis, sarcoidosis, renal and liver transplant and hematological malignancies (2-5). CT shows diffuse, nodular areas of ground-glass opacity or consolidation seen in the upper lung zones with pleural sparing. Diagnosis is made on histopathology. There is no definitive treatment for MPC. MPC should be considered with radiological nodular ground glass opacities, particularly in the context of chronic kidney disease or kidney transplant.

Nikhil Madan¹ MD FCCP, Vipul Patel¹ MD, Christine Minerowicz² MD, Harpreet Greewal¹ MD, and Thomas Kaleekal MD FCCP

¹Division of Pulmonary and Critical Care and Transplant

Newark Beth Israel Medical Center

Newark, NJ USA

²Department of Pathology and Laboratory Medicine

Rutgers Robert Wood Johnson Medical School

New Brunswick, NJ USA 

References

1. Chan ED, Morales DV, Welsh CH, McDermott MT, Schwarz MI. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med. 2002 Jun 15;165(12):1654-69. [CrossRef] [PubMed]
2. Kuhlman JE, Ren H, Hutchins GM, Fishman EK. Fulminant pulmonary calcification complicating renal transplantation: CT demonstration. Radiology. 1989; 173:459e60. [CrossRef] [PubMed]
3. Bendayan D, Barziv Y, Kramer MR. Pulmonary calcifications: a review. Respir Med. 2000; 94:190e3. [CrossRef] [PubMed]
4. Izadyar M, Mahjoub F, Ardakani SN, Ahmadi J. Pulmonary metastatic calcification in a leukemic patient: a case report. J Pediatr Hematol Oncol. 2010;32:e108e10. [CrossRef] [PubMed]
5. Surani SR, Surani S, Khimani A, Varon J. Metastatic pulmonary calcification in multiple myeloma in a 45-year-old man. Case Reports Pulmonol. 2013; 2013:341872. [CrossRef] [PubMed]

Cite as: Madan N, Patel V, Minerowicz C, Greewal H, Kaleekal T. Medical image of the month: metastatic pulmonary calcifications in a kidney transplant recipient. Southwest J Pulm Crit Care. 2020;20(2):71-2. doi: https://doi.org/10.13175/swjpcc001-20 PDF

Medical Image of the Week: Asbestos Related Pleural Disease

Figure 1. Chest radiograph demonstrates bilateral coarse calcification, most elongated and vertically oriented in nature (white arrows). Also note coarse calcification outlining the hemidiaphragms (dark arrows). Editor's note: the patient's only chest x-ray was two different AP views which are merged above.

Figure 2.  Holly leaf. Its shape is similar to the irregular thickened nodular edges of pleural plaques on chest radiograph, referred to as “the holly leaf sign”.

Figure 3. Thoracic CT shown in soft tissue (A: top) and lung (B: bottom) windows clearly localizes the calcifications to the parietal pleura.

Pleural plaques are strongly associated with inhalational exposure to asbestos (1). The lesions may take up to thirty years to develop. Plaques are typically bilateral, involve the parietal pleura, commonly along the sixth through ninth ribs and are usually absent at the lung apices and costophrenic sulci (Figures 1 and 3). On chest radiograph, the “holly leaf sign” refers to the shape of the calcifications with thickened rolled and nodular edges (Figure 2). The plaques per se are benign in nature. However, they can potentially impair lung function, resulting in restriction.  They are also markers of the individual’s greater risk of developing a lung cancer or mesothelioma.

Wesley Hunter MS IV¹, Veronica Arteaga MD², and Diana Palacio MD²

¹College of Medicine and ²Department of Medical Imaging

University of Arizona

Tucson, AZ USA

Reference

1. Norbet C, Joseph A, Rossi SS, Bhalla S, Gutierrez FR. Asbestos-related lung disease: a pictorial review. Curr Probl Diagn Radiol. 2015 Jul-Aug;44(4):371-82. [CrossRef] [PubMed] 

Cite as: Hunter W, Arteaga V, Palacio D. Medical image of the week: asbestos related pleural disease. Southwest J Pulm Crit Care. 2017;15(3):116-7. doi: https://doi.org/10.13175/swjpcc104-17 PDF

January 2017 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 35-year-old woman presented with complaints of increasing shortness of breath and a non-productive cough. She had no significant past medical history.

Laboratory data, including a white blood cell count, coagulation profile, and serum chemistries, were within normal limits. Oxygen saturation on room air was normal.

Frontal and lateral chest radiographs (Figure 1) were performed.

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

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven pages)

1. Frontal and lateral chest radiography shows abnormal mediastinal contours
2. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
3. Frontal and lateral chest radiography shows multifocal pleural thickening
4. Frontal and lateral chest radiography shows numerous small nodules
5. Frontal and lateral chest radiography shows upper lobe, bilateral perihilar masses

Cite as: Gotway MB. January 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(1):16-23. doi: https://doi.org/10.13175/swjpcc001-17 PDF

Medical Image of the Week: Subcutaneous Calcification in Dermatomyositis

Figure 1. Thoracic CT scan in lung windows showing non-specific interstitial disease secondary to dermatomyositis.

Figure 2. Pelvic CT scan showing subcutaneous calcifications (encircled).

A 36-year old woman was referred to our Interstitial Lung Disease (ILD) clinic for evaluation of dyspnea. A high-resolution CT scan of the chest showed perivascular reticular and ground glass opacities with air trapping, consistent with non-specific interstitial pneumonitis (Figure 1). She was diagnosed with connective tissue associated ILD. On review of previous images extensive subcutaneous calcifications were seen (Figure 2).

Calcinosis is an uncommon manifestation of dermatomyositis in adults (1). It is usually seen around areas of frequent trauma like the hands and elbows. In her case, a pelvic inflammatory disease may have been a trigger for this calcinosis. Calcinosis is a difficult complication to treat with some success seen with diltiazem, aluminum hydroxide, and even alendronate in children. Surgical excision may be required in some cases.

Bhupinder Natt MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson (AZ)

Reference

1. Chander S, Gordon P. Soft tissue and subcutaneous calcification in connective tissue diseases. Curr Opin Rheumatol. 2012 Mar;24(2):158-64. [CrossRef] [PubMed]

Cite as: Natt B. Medical image of the week: subcutaneous calcification in dermatomyositis. Southwest J Pulm Crit Care. 2016;13(6):317-8. doi: https://doi.org/10.13175/swjpcc130-16 PDF 

Medical Image of the Week: Tracheobronchopathia Osteochondroplastica

Figure 1: Panels (A and B) show the lumpy, bumpy nodules of tracheobronchopathia osteochondroplastica affecting the anterior tracheal wall with sparing of the posterior membrane. In this patient, copious amounts of white secretions can be seen in the distal trachea and the posterior membrane from her current MRSA pneumonia. 

Tracheobronchopathia osteochondroplastica (TO) is a rare, idiopathic tracheobronchial abnormality that is seen during 0.7% of bronchscopies. It is usually diagnosed in the 5th to 6th decades of life with a male preponderance (1,2)^. Here, we present the case of a 62-year-old woman with history of bronchial asthma with recurrent exacerbations who was admitted with pneumonia and a new mass-like consolidation on imaging. She underwent bronchoscopy for further work up and was found to have methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Incidental nodules were found in her trachea during the bronchoscopy (Figure 1). Most patients with TO are asymptomatic but can rarely present with cough, shortness of breath, and even non-massive hemoptysis due to ulceration of nodular mucosa. Secondary airway narrowing has also been reported. The lumpy, bumpy nodules typically are 3-8 mm in size, localize in the sub-mucosa of the trachea, and are difficult to biopsy due to their cartilaginous or osseous nature. Diagnosis can be made by chest CT or bronchoscopy. A very important distinctive feature is sparing of the posterior membranous wall of the trachea, differentiating it from other nodular airway diseases. TO is a benign disease that generally doesn’t need any specific treatment or intervention (1,2).

Huthayfa Ateeli, MBBS, Elaine Cristan, MD, and Afshin Sam, MD.

Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine

University of Arizona, Tucson, AZ USA

References

1. Lundgren R, Stjernberg NL. Tracheobronchopathia osteochondroplastica. A clinical bronchoscopic and spirometric study. Chest. 1981 Dec;80(6):706-9. [CrossRef] [PubMed]
2. Prince JS, Duhamel DR, Levin DL, Harrell JH, Friedman PJ. Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation. Radiographics. 2002 Oct;22 Spec No:S215-30. [CrossRef] [PubMed] 

Cite as: Ateeli H, Cristan E, Sam A. Medical image of the week: tracheobronchopathia osteochondroplastica. Southwest J Pulm Crit Care. 2016;13(3):131-2. doi: http://dx.doi.org/10.13175/swjpcc067-16 PDF

August 2011 Case of the Month

Michael B. Gotway, M.D.

Associate Editor, Imaging

Reference as: Gotway MB. August 2011 case of the month. Southwest J Pulm Crit Care 2011;3:54-7. Click here for PDF version

Clinical History

A 60-year-old woman with no significant previous medical history complains of shortness of breath. Chest radiography was performed (Figure 1).

Point to the lesion on the chest X-ray on the chest x-ray to proceed.