Medical Image of the Month: Chronic Ogilvie’s Syndrome

Figure 1. Coronal view of abdominal CT scan showing a massively dilated colon.

Figure 2. Sagittal view of abdominal CT scan.

Figure 3. Axial view of abdominal CT scan.

A 42-year-old man with chronic encephalopathy secondary to traumatic brain injury (TBI), craniotomy, seizure disorder, chronic alcohol abuse, and chronic Ogilvie syndrome presented to the Banner University Medical Center-South Campus emergency department (ED) after being found in his driveway with altered mental status. He complained of multiple episodes of non-bloody diarrhea for the last day but otherwise altered & unhelpful. He was noted to have to be hypotensive with a blood pressure of 70-90/35-56 mm Hg, afebrile with a temperature of 36  C, an elevated white cell count of 13.3 X 10⁹ cells/L, a hemoglobin of 4.4 g/dL, a creatinine of 2.6 mg/dL, a BUN of 30 mg/dL, and an elevated lactic acid to 5.4 mmol/L. Physical exam showed a massively dilated tympanic abdomen. Resuscitation and broad-spectrum antibiotics were initiated, a CT scan ordered (Figures 1-3) and he was admitted to the medical intensive care unit (MICU) for further work up and management.

On chart review, it was shown that he had presented to the same ED twice in the past with episodes of chronic constipation. Gastroenterology and general surgery consults concluded that he had developed a chronic pseudo-obstruction pattern due to likely decreased gastrointestinal motility presumed secondary to TBI and immobility. He was evaluated and deemed to not qualify for neostigmine treatment due to finding of stool acting as a mechanical obstruction. During this MICU visit, he was treated for septic shock but unfortunately did not survive the hospital stay.

Learning Points/Take Home Message:

1. Ogilvie syndrome is an acquired dilation of the colon in the absence of any mechanical obstruction in severely ill patients characterized by abnormalities affecting the involuntary, rhythmic muscular contractions within the colon. The symptoms of Ogilvie syndrome mimic those of mechanical obstruction of the colon, but no physical obstruction is present.
2. Studies have shown that intravenous administration of neostigmine has led to rapid decompression of the colon in individuals with Ogilvie syndrome who did not respond to conservative management. 
3. Colonoscopic decompression, in which a thin, flexible tube is inserted into the anal passage and threaded up to the colon, may be used in refractory cases. Although colonoscopic decompression has not undergone clinical study, numerous reports in the medical literature cite it as an effective method for removing air from the colon and, potentially, reducing the risk of perforation. 
4. Surgery is used when affected individuals have signs of perforation or ischemia or have failed to respond to other treatment options. Surgery can be associated with significant morbidity and mortality.

Michael Bernaba MD, Emilio Power MD, Sidra Raoof MD, Babitha Bijin MD, Yuet-Ming Chan MD

Department of Internal Medicine

University of Arizona College of Medicine at South Campus

Tucson, AZ USA

References

1. McNamara R, Mihalakis MJ. Acute colonic pseudo-obstruction: rapid correction with neostigmine in the emergency department. J Emerg Med. 2008;35:167-70. [CrossRef] [PubMed]
2. Saunders MD, Kimmey MB. Systemic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther. 2005;22:917-25. [CrossRef] [PubMed]
3. Maloney N, Vargas HD. Acute intestinal pseudo-obstruction (Ogilvie's syndrome). Clin Colon Rectal Surg. 2005;18:96-101. [CrossRef] [PubMed]
4. De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg. 2009;96:229-39. [CrossRef] [PubMed]

Cite as: Bernaba M, Power E, Raoof S, Bijin B, Chan Y-M. Medical image of the month: chronic Ogilivie's syndrome. Southwest J Pulm Crit Care. 2018;17(6):146-8. doi: https://doi.org/10.13175/swjpcc117-18 PDF

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: Cutaneous Coccidioidomycosis

Figure 1. Right distal anterior thigh. Fungal culture grew Coccidioides immitis from biopsy.

A 46-year-old Hispanic man with no known past medical history presents to his primary care physician for a progressively worsening “rash” located over his right thigh. Patient described the lesion as raised, scaly, and itchy. It has been “growing” for the past one year and started out as a small “pimple”. Patient denied any trauma to the effected region over this time period. Surgical history was significant for a splenectomy 15 years prior that was needed after a traumatic accident. He works in construction and lives in southern Arizona. He denied alcohol, tobacco and or illicit drug use. Patient has attempted to treat this skin lesion with over the counter hydrocortisone ointment with no relief. He denied any other associated symptoms including fever/chills, headache, vision changes, night sweats, weight loss, cough, shortness of breath, and or joint pains. Vital signs were stable upon presentation. Physical exam was entirely benign other than the isolated skin lesion shown above (Figure 1). It measured roughly 5cm at its greatest dimension and was located just superior the right knee on the anterior portion of the distal thigh. Nodularity was appreciated upon palpation but no tenderness was noted. Areas of erythema were non-blanching. Small satellite lesions were seen on the perimeter.

He was sent to a dermatologist and biopsies were performed. Light microscopy and culture confirmed the diagnosis of cutaneous coccidioidomycosis. Initial laboratory work revealed a normal complete blood count and complete metabolic panel. Serum coccidioides IgM antibody was negative but IgG was confirmed to be positive with a reflex complement fixation titer of 1:16. Chest X-ray was normal. Patient was started on oral fluconazole 400mg daily. Repeat coccidioides IgG titers decreased to 1:8 at a four- week follow-up. Patient has been tolerating the medication well and skin lesion has begun to regress.

Norman Beatty MD¹ and Mayar Al Mohajer MD²

¹Departments of Internal Medicine and ²Infectious Diseases

University of Arizona College of Medicine

Tucson, AZ

Cite as: Beatty N, Al Mohajer M. Medical image of the week: cutaenous coccidioidomycosis. Southwest J Pulm Crit Care. 2015;11(5):226-7. doi: http://dx.doi.org/10.13175/swjpcc110-15 PDF

Medical Image of the Week: Maggots

Figure 1. Chronic ulcerated wound with clean base due to the debridement caused by the maggots.

An 80-year old man presented with pruritic exacerbation of his chronic wound. He had venous stasis ulcers chronically to the lower extremities bilaterally, requiring bandages. He presented with pruritis, but no fevers or pain. The bandage was removed which revealed the maggots (Figure 1).

Jarrod M. Mosier, MD

Department of Medicine and Emergency Medicine

Emergency Medicine-Critical Care Program

University of Arizona

Tucson, Arizona

Reference as: Mosier JM. Medical image of the week: maggots. Southwest J Pulm Crit Care. 2013;7(6):338. doi: http://dx.doi.org/10.13175/swjpcc154-13 PDF

August 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 60-year-old man presented with gradually worsening shortness of breath and dry cough over the previous six months, unresponsive to presumptive antibiotic therapy with levofloxacin first, followed by azithromycin. Frontal chest radiography (Figure 1) was performed. 

Figure 1. Frontal chest radiography.

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

1. The chest radiograph shows basal predominant fibrotic lung disease
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multifocal bronchiectasis
4. The chest radiograph shows multiple nodules
5. The chest radiograph shows upper lobe peripheral consolidation and reticulation

Reference as: Gotway MB. August 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(2):75-83. doi: http://dx.doi.org/10.13175/swjpcc102-13  PDF