November 2017 Imaging Case of the Month

Michael B. Gotway, MD¹

Isabel Mira-Avendano, MD²

¹Mayo Clinic Arizona, Scottsdale AZ USA

²Mayo Clinic Jacksonville, FL USA

Clinical History: A 70-year-old white woman with a remote history of smoking and mild gastroesophageal reflux disease presented with complaints of a dry cough and shortness of breath, present for some time but worsening over the previous 8 months. No hemoptysis was noted and the patient did not complain of chest pain. No history of syncope was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 86% on room air, 90% on 4 L/m by mask. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Enhanced thoracic CT (Figure 1) was performed.

Figure 1. Panels A-D: Representative static images from the thoracic CT scan in lung windows. Lower panel: Video of thoracic CT scan in lung windows.

Which of the following statements regarding the thoracic CT is most accurate? (Click on the correct answer to proceed to the second of eight pages)

1. The thoracic CT shows advanced destructive emphysema
2. The thoracic CT shows bilateral, basal and subpleural predominant reticulation associated with ground-glass opacity, architectural distortion, and traction bronchiectasis
3. The thoracic CT shows multifocal lobular consolidation
4. The thoracic CT shows multifocal small pulmonary cysts
5. The thoracic CT shows small cavitary pulmonary nodules

Cite as: Gotway MB, Mira-Avendano I. November 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(5):199-208. doi: https://doi.org/10.13175/swjpcc134-17 PDF

Medical Image of the Week: Cannon V Waves

Figure 1. Video showing jugular venous distention to earlobes with cannon V waves.

A 66-year-old man experienced recurrent ascites of unknown etiology over six months. He had previously undergone a renal transplant secondary to complications of diabetes and hypertension and had known severe coronary artery disease. His most recent paracentesis revealed an albumin 1.6 g/dL (serum albumin 2.1) and a total protein of 3.8 g/dL. His adenosine deaminase was 11.6 U/L (normal <7.6 U/L), but repeated bacterial and mycobacterial ascites cultures were negative, as were a carcinoembryonic antigen assay and ascites cytology. Computerized tomography of the abdomen showed findings consistent with cirrhosis, but an extensive workup for common causes of cirrhosis was negative.

Physical exam showed jugular venous distention with prominent V waves and a holosystolic murmur at the left lower sternal border (Figure 1). Echocardiography showed a dilated right ventricle, moderate pulmonary and tricuspid regurgitation and an estimated right ventricular systolic pressure of 87 mm Hg. Cardiac catherization confirmed the presence of an elevated right ventricular pressure of 72/10 (22) mm Hg, an elevated pulmonary artery pressure of 75/27 (45) mm Hg and a left ventricular ejection fraction of 20-25%. The right atrial pressure was 20 and the pulmonary artery occlusion pressure was 22 mmHg.  A diagnosis of pulmonary hypertension secondary to left ventricular heart disease (type 2 pulmonary hypertension) with congestive hepatopathy and cardiac ascites was made.

The patient’s physical examination provided an important clue to the etiology of the ascites – cardiac ascites is thought to be due to chronic venous congestion of the liver due to transmission of high central venous pressures. Tricuspid regurgitation can be associated with severe hepatic congestion because of retrograde transmission of right ventricular pressure directly into the hepatic veins. In some patients (although not in this patient), careful examination will reveal that the liver in such patients is palpably pulsatile.

Cardiac ascites is typically characterized by a serum albumin gradient (SAAG) >1.1 g/dL (indicative of portal hypertension) and ascites protein level of >2.5 g/dL (1). We cannot fully explain why this patient’s SAAG was low. A complete workup for infectious and oncological etiologies of low SAAG ascites was negative. It has been noted that in patients with known cirrhosis (as in this patient), the finding of a low SAAG has a low specificity for infectious and oncological etiologies of ascites (2). Serositis which can sometimes manifest as ascites can also be a complication of tacrolimus which the patient was receiving s/p renal transplant. It’s possible that tacrolimus might have changed the nature of the ascites fluid in this patient but this is conjectural. 

Robert A. Raschke, MD

College of Medicine-Phoenix

Phoenix, AZ USA

References

1. Sam AH, James THT. Rapid Medicine. Wiley-Blackwell; 2009: ISBN 1-4051-8323-3.
2. Khandwalla HE, Fasakin Y, El-Serag HB. The utility of evaluating low serum albumin gradient ascites in patients with cirrhosis. Am J Gastroenterol. 2009 Jun;104(6):1401-5. [CrossRef] [PubMed] 

Cite as: Raschke RA. Medical image of the week: cannon V waves. Southwest J Pulm Crit Care. 2017;15(2):90-1. doi: https://doi.org/10.13175/swjpcc095-17 PDF

Medical Image of the Week: Constrictive Pericarditis

Figure 1. A computerized tomography of the chest revealed cardiomegaly, bilateral pleural effusions and pericardial calcification noted diffusely with focal regions of pericardial thickening greater than 4 mm.

A 62-year-old woman, with a past medical history significant for oxygen dependent COPD, paroxysmal atrial fibrillation, and obstructive sleep apnea, presented to the hospital with hypoxemic respiratory failure requiring intubation and mechanical ventilation. A computerized tomography of the chest revealed cardiomegaly, bilateral pleural effusions, and pericardial calcification that was noted diffusely with focal regions of pericardial thickening greater than 4 mm. A cardiac catheterization revealed elevated right-sided pressure; markedly elevated left ventricular end diastolic pressure; equalization of LV-RV diastolic pressures; and sharp Y descent on the right atrial pressure waveform; which is all suggestive of constrictive physiology.  The patient was medically optimized and diuresed and eventually underwent a successful pericardiectomy.

Mohammed Alzoubaidi MD, John Bloom MD, Jarrod Mosier MD, Linda Snyder MD

Department of Pulmonary and Critical Care Medicine, University of Arizona,

Tucson, AZ

Reference as: Alzoubaidi M, Bloom J, Mosier J, Snyder L. Medical image of the week: constrictive pericaditis. Southwest J Pulm Crit Care. 2014;8(5):280. doi: http://dx.doi.org/10.13175/swjpcc042-14 PDF