Medical Image of the Week: Bilateral Atrial Appendage Thrombi

Figure 1. Panel A: Right atrial appendage (RAA) thrombus (red arrow) on chest computerized tomorgraphy angiogram (CTA). Panel B: Left atrial appendage (LAA) thrombus (yellow arrow) on chest CTA. Panel C: RAA thrombus (red arrow) on transesophageal echocardiography (TEE). Panel D: LAA thrombus (yellow arrow) on TEE.

A 63-year-old man with a past history significant for hypertension, low back pain and polysubstance abuse (tobacco and marijuana) presented with shortness of breath and hemoptysis for the last 8 days prior to admission. His initial exam showed elevated jugular venous pressure and bilateral basal crackles with reduced air entry on the right lower lung zone.

The patient was found to be in atrial fibrillation with a rapid ventricular response. His initial chest X-ray showed a moderate right-sided pleural effusion. Immediate bedside echo was concerning for bilateral ventricular dysfunction with concerns of right-sided heart pressure and volume overload. A chest CT angiogram was obtained and showed acute lower lobe pulmonary embolism, with possible distal infarct, moderate right sided pleural effusion, and filling defects in both atrial appendages concerning for thrombi (Figure 1, Panels A & B).

The patient was started on therapeutic anticoagulation and underwent therapeutic thoracentesis, gentle diuresis, and rate control for his atrial fibrillation. A few days later, a trans-esophageal echo confirmed the bilateral atrial thrombi (Figure 1, Panels C & D).

Huthayfa Ateeli MBBS¹, Andrew Kovoor MD¹, Hem Desai MBBS¹, Alana Stubbs MD², Tam Nguyen MD³

¹Department of Medicine, ²Radiology Department, and ³Cardiology Division

University of Arizona and Southern Arizona VA Health Care System

Tucson, AZ

References

1. Kim YY, Klein AL, Halliburton SS, Popovic ZB, Kuzmiak SA, Sola S, Garcia MJ, Schoenhagen P, Natale A, Desai MY. Left atrial appendage filling defects identified by multidetector computed tomography in patients undergoing radiofrequency pulmonary vein antral isolation: a comparison with transesophageal echocardiography. Am Heart J. 2007;154(6):1199-205. [CrossRef] [PubMed]
2. Shapiro MD, Neilan TG, Jassal DS, Samy B, Nasir K, Hoffmann U, Sarwar A, Butler J, Brady TJ, Cury RC. Multidetector computed tomography for the detection of left atrial appendage thrombus: a comparative study with transesophageal echocardiography. J Comput Assist Tomogr. 2007;31(6):905-9. [CrossRef] [PubMed] 

Reference as: Ateeli H, Kovoor A, Desai H, Stubbs A, Nguyen T. Medical image of the week: bilateral atrial appendange thrombi. Southwest J Pulm Crit Care. 2015;10(1):54-5. doi: http://dx.doi.org/10.13175/swjpcc006-15 PDF

November 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 38-year-old non-smoking woman presented with complaints of intermittent dry cough, occasional vomiting, and dyspnea, occasionally with fever and chills. She indicated that she has suffered recurrent bouts of bronchitis and pneumonia annually over the previous 10 years. The patient had a history of upper arm localized melanoma resection 10 years earlier. She had smoked for 10 years, but quit one year prior to presentation. Her past medical and surgical histories were otherwise unremarkable.

Frontal and lateral chest radiography (Figure 1) was 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 next panel)

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows mild, bilateral, streaky central opacities, possibly reflecting airway thickening
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows volume loss involving the right thorax with a mass-like opacity projected over the right hilum

Reference as: Gotway MB. November 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(5):264-77. doi: http://dx.doi.org/10.13175/swjpcc147-14 PDF

May 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ 

Clinical History: A 66-year-old woman presented with complaints of cough worsening over the previous several months. Her prior medical history was largely otherwise unremarkable. Frontal chest radiography (Figure 1) was performed for evaluation.  

Figure 1. Panel A: Frontal chest radiograph. Panel B: Right anterior oblique image. Panel C: Left anterior oblique image.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to move to the next panel)

1. The chest radiograph shows a solitary pulmonary nodule
2. The chest radiograph shows multifocal airway thickening and bronchiectasis
3. The chest radiograph shows multifocal, bilateral cavitary nodules and consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities within diminished lung volumes, suggesting fibrosis
5. The chest radiograph shows multiple small nodules, suggesting a miliary pattern

Reference as: Gotway MB. May 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(5):266-74. doi: http://dx.doi.org/10.13175/swjpcc059-14 PDF

Medical Image of the Week: Fat Embolism Syndrome

A 33-year-old man presented to the emergency department with shortness of breath and hemoptysis. He was discharged two days prior after hospitalization for a motor vehicle accident, in which he suffered a fracture of the shaft of the right femur. He had undergone open reduction and internal fixation of the fracture four days prior to this admission. He had diffuse parenchymal disease on his admission chest x-ray. A CT scan of the chest demonstrated multilobar ground glass opacities (Figure 1).

Figure 1. Thoracic CT scan showing ground glass opacities.

Bronchoscopy demonstrated progressively bloody BAL aliquots in two different lobes, consistent with diffuse alveolar hemorrhage (DAH). His workup for other etiologies was negative, and he was given a diagnosis of DAH secondary to fat embolism syndrome.

Joshua Malo, MD and Kenneth S. Knox, MD

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

University of Arizona, Tucson, AZ

Reference as: Malo J, Knox KS. Medical image of the week: fat embolism syndrome. Southwest J Pulm Crit Care. 2014;8(4):246. doi: http://dx.doi.org/10.13175/swjpcc041-14 PDF

Medical Image of the Week: Pneumomediastinum

Figure 1.  Chest x-ray (CXR) shows subtle evidence of pneumomediastinum with air outlining left cardiac border and trachea (arrows).

 

Figure 2. Chest computerized tomography (CT) showing pneumomediastinum (Panel A) extending into lower neck (Panel B) without evidence of pneumothorax.

A 65 year old man presented with mild increase in shortness of breath. He had a past medical history of diabetes mellitus, hypertension, and severe malnutrition with percutaneous endoscopic gastrostomy (PEG) placement after a colectomy and end ileostomy for sigmoid volvulus. CXR (Figure 1) suggested a pneumomediastinum with subsequent chest CT (Figure 2) confirming moderate sized pneumomediastinum. He had a chronic cough from chronic obstructive pulmonary disease (COPD) as well as aspiration and chest CT also demonstrated emphysema with small blebs. He denied any significant chest pain. He was followed conservatively with imaging and discharged in stable condition.

Pneumomediastinum can be caused by trauma, esophageal rupture after vomiting (Boerhaave’s syndrome) and can be a spontaneous event if no obvious precipitating cause is identified (1). Valsalva maneuvers such as cough, sneeze, vomiting and childbirth, can all cause pneumomediastinum. Risk factors include asthma, COPD, interstitial lung disease and inhalational recreational drug use. Hamman's sign (a crunching sound in time with the heartbeat) can occasionally be heard.  More commonly, subcutaneous emphysema is felt on exam (crepitus). Complications can include single or bilateral pneumothorax, tension pneumothorax and pleural effusion. CXR often does not identify mediastinal air and CT imaging is highly sensitive and confirmatory. Conservative management is recommended with close clinical follow up for possible complications.

Rene Franco, Jr MD, Mohammad Dalabih MD, Janet Campion MD

University of Arizona Medical Center, Tucson AZ

Reference

1. Newcomb AE, Clarke CP. Spontaneous Pneumomediastinum. Chest. 2005;128:3298-3302. [CrossRef] [PubMed] 

Reference as: Franco R Jr, Dalabih M, Campion J. Medical image of the week: pneumomediastinum. Southwest J Pulm Crit Care. 2014:8(1):46-7. doi: http://dx.doi.org/10.13175/swjpcc160-13 PDF

October 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ 

Clinical History

A 67-year-old man with a history of hypertension and chronic lymphocytic leukemia (CLL), the latter diagnosed 10 years earlier, in remission until recently, presented with complaints of weight loss, not eating much, lethargy, and shortness of breath. His CLL had recurred and he was treated with rituximab, and bendamustine (a nitrogen mustard alkylating agent) and intravenous immunoglobulin. Frontal chest radiography (Figure 1) was performed.

Figure 1. Initial chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows basal predominant linear opacities suggesting fibrosis
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multifocal ground-glass opacity and cavitary consolidation
4. The chest radiograph shows multifocal ground-glass opacity and consolidation associated with linear and reticular abnormalities
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. October 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(4):223-31. doi: http://dx.doi.org/10.13175/swjpcc133-13 PDF