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: Chronic Pulmonary Histoplasmosis
Figure 1. Chest radiography showing upper lobe fibrosis and cavitation secondary to chronic histoplasmosis.
Histoplasmosis is endemic to the Midwest US and commonly causes an acute infection that presents as a subacute pneumonia. In patients with underlying lung disease, particularly COPD, a subacute pneumonia can evolve into chronic pulmonary histoplasmosis and is characterized by persistent or recurrent pulmonary symptoms, progressive lung infiltrates, fibrosis, and cavitation. Upper lobe infiltrates and cavities are characteristic, resembling the findings in tuberculosis (Figure 1). Progression is manifested by cavity enlargement, increased fibrosis and bronchopleural fistulae. Misdiagnosis delays therapy and can be catastrophic. Histoplasmosis titers and sputum cultures are useful tests. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy for culture may be needed when diagnosis remains elusive.
Kenneth S. Knox, MD1 and Veronica A. Arteaga, MD2
1Professor of Medicine
University of Arizona College of Medicine- Phoenix
Phoenix, AZ USA
2Associate Professor of Medicine
Medical Imaging
University of Arizona College of Medicine- Tucson
Tucson, AZ USA
Cite as: Knox KS, Artega VA. Medical image of the week: chronic pulmonary histoplasmosis. Southwest J Pulm Crit Care. 2017;14(3):88. doi: https://doi.org/10.13175/swjpcc022-17 PDF
Medical Image of the Week: ICU Chest X-Ray
Figure 1. ICU portable chest x-ray. A: cardioversion pads. B: oro-gastric tube. C: right internal jugular dialysis catheter. D: endotracheal tube. E: left internnal jugular central venous catheter, incidentally seen terminating within the azygous vein. F: external EKG lead. G: chest tubes. H: staples along the thoracotomy incision. I: left lower lobe atelectasis and small pleural effusion.
A chest x-ray is probably the most commonly obtained radiographic image in the intensive care unit (ICU). Although not supported by evidence and recommended against, daily chest x-rays, especially in the intubated patients, are done in many ICUs (1,2). Multiple hardware placed for the support of the patient need to be identified for placement, position and potential complications. These can make reading a radiograph challenging specially the mediastinum. The accompanied radiograph serves as an example of an “ICU chest x-ray” with multiple “tube and lines”.
Janet Campion MD and Bhupinder Natt MD
Division of Pulmonary, Allergy, Critical Care and Sleep
Banner-University Medical Center, Tucson (AZ)
References
- Oba Y, Zaza T. Abandoning daily routine chest radiography in the intensive care unit: meta-analysis. Radiology. 2010 May;255(2):386-95. [CrossRef] [PubMed]
- http://www.choosingwisely.org/wp-content/uploads/2015/02/SCCM-Choosing-Wisely-List.pdf
Cite as: Campion J, Natt B. Medical image of the week: ICU chest x-ray. Southwest J Pulm Crit Care. 2017;14(1):39. doi: https://doi.org/10.13175/swjpcc007-17 PDF
Medical Image of the Week: Pericardial Effusion in a Setting of Bacterial Endocarditis
Figure 1. Single portable semi-upright chest radiograph with findings of an enlarged cardiomediastinal silhouette, and indistinctness of the perihilar vasculature.
Figure 2. Axial contrast enhanced computed tomography—soft tissue windows. A large concentric rim (fluid density) surrounds all four chambers of the heart, consistent with a pericardial effusion. Notice how the right ventricle is normal, which can be collapsed in cardiac tamponade.
A 25-year-old man with an extensive history of intravenous drug abuse presents to the hospital with worsening shortness of breath and fevers for two weeks. In the emergency department, he was initially provided breathing treatments including ipratropium/albuterol and methylprednisolone. As the patient still required supplemental oxygen, a chest radiograph was performed to evaluate for an underlying infectious etiology.
However, the chest radiograph portrayed an enlarged cardiomediastinal silhouette in a “water-bottle” appearance and obscuration of the hilar vessels (Figure 1). Given these findings, there was a high concern for a pericardial effusion, and the physicians opted for further cross-sectional imaging. The contrast enhanced computed tomography (CT) images confirmed the aforementioned diagnosis (Figure 2). As blood cultures eventually grew Staphylococcus aureus, and given the patient’s extensive history of intravenous drug abuse, there was a high suspicion for bacterial endocarditis. A subsequent echocardiogram verified several valvular vegetations in keeping with endocarditis. The patient’s vitals remained stable throughout the hospital course, and he was continued on long-term antibiotic therapy.
Chest radiographs are often unreliable in depicting pericardial effusions, as they require at least 200 mL of pericardial fluid to portray an enlarged cardiomediastinal silhouette (1). As fluid continues to accumulate in the pericardial space, the increase in pericardial pressure on the chambers can eventually lead to cardiac tamponade—a form of cardiogenic shock (2). Cardiac tamponade will result in a decrease in stroke volume, decreased blood pressure, and ultimately a diminished cardiac output; all of which require immediate intervention (2). Echocardiography remains the imaging modality of choice given its portability and high sensitivity in diagnosing pericardial fluid (3).
Amrit Hansra, MD
Department of Medical Imaging
University of Arizona
Tucson, AZ
References
- Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007 Nov-Dec;27(6):1595-610. [CrossRef] [PubMed]
- Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003 Aug 14;349(7):684-90. [CrossRef] [PubMed]
- Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modalities, and management. Compr Ther. 1995 Jul;21(7):378-85. [PubMed]
Cite as: Hansra A. Medical image of the week: pericardial effusion in a setting of bacterial endocarditis. Southwest J Pulm Crit Care. 2016 Mar;12(3):110-1. doi: http://dx.doi.org/10.13175/swjpcc009-16 PDF