April 2023 Imaging Case of the Month: Large Impact from a Small Lesion

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

Phoenix, Arizona USA

History of Present Illness: A 65-year-old woman with a history of diabetes mellitus complained of worsening fatigue with a 20 lbs. weight gain over the last year as well as shortness of breath. The patient also complained of bruising without recalling specific injury and complained her complexion had changed recently, becoming “ruddier”, accompanied by increasing growth of facial hair. Her past medical history was remarkable for hypertension, including a previous hospitalization for a hypertensive emergency. The patient’s diabetes had become more difficult to control in recent months, with labile blood glucose levels requiring escalating insulin doses. The patient denied recent changes in sleep, worsening anxiety or depression, or changes in mood.

PMH, SH, FH: The patient’s past medical history was also notable for diastolic dysfunction and hyperlipidemia, and she required oxygen use at night. Her past surgical history was significant for a previous hysterectomy and a knee arthroplasty. Her family history was unremarkable.

Medications: Her medications included insulin, pravastatin, lisinopril, metformin, aspirin, furosemide, felodipine, citalopram, and potassium supplementation.

Physical Examination: The patient’s physical examination showed her to be afebrile with pulse rate and blood pressure within the normal range at 128/75 mmHg. She was obese (113 kg) and her facial complexion was indeed ruddy with a rounded appearance. The patient’s skin appeared somewhat thin and several bruises were noted over her extremities. Her lungs were clear and her cardiovascular examination

was normal.

Laboratory Evaluation:  A complete blood count showed normal findings. The patient’s plasma glucose was elevated at 171 mg/dL (normal, 65-95 mg/dL) Her hemoglobin A1c was 9.4% (normal, 4-5.6%). The white blood cell count was normal with no left shift and her liver function studies were entirely normal. Serum chemistries were completely within normal limits aside from a borderline elevated blood urea nitrogen level of 20 mg/dL (normal, 6-20 mg/dL) serum creatinine was normal.

Radiologic Evaluation: Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography.

Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the next page)

1. Frontal chest radiography shows normal findings
2. Frontal chest radiography shows cardiomegaly
3. Frontal chest radiography shows mediastinal lymphadenopathy
4. Frontal chest radiography shows pleural effusion
5. Frontal chest radiography shows several nodules

Cite as: Gotway MB. April 2023 Imaging Case of the Month: Large Impact from a Small Lesion. Southwest J Pulm Crit Care Sleep. 2023;26(4):48-55. doi: https://doi.org/10.13175/swjpccs014-23 PDF

Medical Image of the Week: Carcinoid at the Carina

Figure 1. Flow-volume loop showing flattening of expiratory loop suggesting variable intra-thoracic obstruction.

Figure 2. CT of the chest showing pedunculated tracheal lesion at the level of main carina.

Figure 3. Bronchoscopic view of endobronchial tumor before (Panel A) and after removal (Panel B).

A 74-year-old woman with history of 30 pack-year smoking, allergic rhinitis and asthma presented to pulmonary clinic with cough and dyspnea on exertion. She was placed on inhaled corticosteroids and long-acting beta-agonist. Pulmonary function test showed moderate obstructive ventilator defect and flow volume loop suggested variable intra-thoracic obstruction (Figure 1). In the meantime, she was hospitalized with complaint of dyspnea and possible COPD exacerbation. Het CT chest revealed an endobronchial 12 mm pedunculated lesion at anterior aspect of main carina (Figure 2). She underwent flexible bronchoscopy and lesion was removed using electro-surgical snare and cryoprobe (Figure 3). Her symptoms improved post-procedure. Pathologic examination of lesion revealed a carcinoid tumor.

Endobronchial tumors are masses confined within the bronchus, and may be associated with atelectasis or pneumonia of the distal parenchyma. These tracheobronchial tumors are classified as malignant or benign. Malignant tumors arising from surface epithelium include squamous cell carcinoma and neuro-endocrine tumors; and those arising from mesenchyme include sarcoma and malignant lymphoma. On the other hand, benign tumors arising from surface epithelium include squamous cell papilloma and mucus gland adenoma; and those arising from mesenchyme include hamartoma, lipoma, fibroma, leiomyoma, and neurogenic tumor. Hamartomas may present as a fatty mass, nodules with calcification, or as soft-tissue-density nodules on CT scans. The lipomas manifested as fat density on CT scans. The other benign tumors were low-attenuating, soft-tissue-density masses without characteristic findings on CT scans.

Tauseef Afaq Siddiqi, MD; Muhammad Alzoubaidi, MD; James Knepler, MD and Kenneth Knox, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ

Reference

1. Ko JM, Jung JI, Park SH, Lee KY, Chung MH, Ahn MI, Kim KJ, Choi YW, Hahn ST. Benign tumors of the tracheobronchial tree: CT-pathologic correlation. AJR Am J Roentgenol. 2006;186(5):1304-13. [CrossRef] [PubMed] 

Reference as: Siddiqi TA, lzoubaidi M, Knepler J, Knox KS. Medical image of the week: carcinoid at the carina. Southwest J Pulm Crit Care. 2015;10(6):341-2. doi: http://dx.doi.org/10.13175/swjpcc052-15 PDF 

December 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 34-year-old non-smoking woman presented to her physician as an outpatient with complaints of intermittent chest pain and intermittent mild hemoptysis. Her previous medical history was otherwise unremarkable.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal 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 6 panels)

1. The chest radiograph shows a circumscribed pulmonary mass
2. The chest radiograph shows asymmetric pulmonary vascularity
3. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
4. The chest radiograph shows mild streaky central opacities, possibly reflecting airway thickening
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. December 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(6):311-9. doi: http://dx.doi.org/10.13175/swjpcc157-14 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

June 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 46 -year-old man presents to the emergency room with hemoptysis. Frontal and lateral chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal and lateral chest radiography shows a lobulated, circumscribed lesion within the left hilum. The right hilum appears normal, no lung consolidation is present, and no pleural abnormalities are seen. There is no evidence of mediastinal lymph node enlargement. There is relative lucency involving the left lung, particularly the left upper lobe, compared with the right side.

Which of the differential diagnostic considerations listed below is the least likely consideration for the appearance of the lesion on the chest radiograph?

1. Bronchogenic carcinoma
2. Adenoid cystic carcinoma
3. Carcinoid tumor
4. Sarcoidosis
5. Allergic bronchopulmonary aspergillosis

 Reference as: Gotway MB. June 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:214-21. (click here for a PDF version of the manuscript)

December 2011 Case of the Month

Clinical History

A 19-year-old woman presents with complaints of cough, with a history of recurrent left pneumonias and abnormalities noted in the left lung on outside facility prior imaging. A frontal and lateral chest radiographic examination (Figures 1A and B) was performed. A chest radiograph (Figure 1C) obtained over one year previously is shown for comparison.

Figure 1.

What is the main finding on the current chest radiograph (Figures 1A and B)? How would you describe the finding?

1. A left upper lobe mass is present
2. A wide mediastinum is present
3. Partial collapse of the left upper lobe is present
4. An extrapulmonary lesion is projected over the left upper thorax
5. A left pleural effusion is present

Reference as: Gotway MB. December 2011 case of the month. Southwest J Pulm Crit Care 2012;4:5-11. (Click here for a PDF version of the manuscript)