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 Month: Idiopathic Right Lower Lobe Pulmonary Vein Thrombus

Figure 1. CT angiogram chest sagittal view: showing low density filling defect consistent with pulmonary vein thrombus (yellow arrow).

Figure 2. A: CT angiogram chest axial view showing right lower lobe pulmonary vein thrombus. B: the vein (red arrow) is well differentiated by his lower contrast than the adjacent artery (blue arrows).

A 62-year-old man with a medical history notable only for a seasonal allergy, presented to the emergency department with complaints of shortness of breath with productive cough for 2 months which were worsening for the last 2 weeks. CTA chest revealed low density filling defect in the RLL vein consistent with RLL vein thrombus (Figures 1 and 2). After a comprehensive work up to rule out malignancy and hypercoagulable disorders, a diagnosis of idiopathic pulmonary vein thrombosis was made. The patient received heparin and was discharged with rivaroxaban.

Pulmonary vein thrombosis is a rare disease but can be fatal, usually patient presents with non-specific symptoms such as cough and shortness of breath (1). The etiology in most of cases is hypercoagulable disorders, malignancies, atrial fibrillation, post lung operations such as lobectomy and lung transplantation, or could be idiopathic as in our patient.

Timothy Jon Rolle MD¹ and Mohammad Abdelaziz Mahmoud MD, DO^2
1Department of Radiology and the ²Internal Medicine Residency

Midwestern University Arizona College of Osteopathic Medicine

Canyon Vista Medical Center
Tucson, AZ USA

Reference

1. Chaaya G, Vishnubhotla P. Pulmonary vein thrombosis: a recent systematic review. Cureus. 2017 Jan 23;9(1):e993. [CrossRef] [PubMed]

Cite as: Rolle TJ, Mahmoud MA. Medical image of the month: idiopathic right lower lobe pulmonary vein thrombus. Southwest J Pulm Crit Care. 2020;20(1):7-8. doi: https://doi.org/10.13175/swjpcc048-19 PDF