June 2024 Medical Image of the Month: A 76-year-old Man Presenting with Acute Hoarseness

Figure 1. Anterior-posterior chest x-ray (A) showing moderate elevation of left hemidiaphragm (arrow) and an ill-defined nodular opacity in the left perihilar region (*) suspicious for a hilar mass. Axial image from a contrast enhanced chest CT (B) showing central left upper lobe mass extending into the hilum resulting in narrowing of the vascular and bronchial structures of the left upper lobe.

Figure 2. 400x magnification hematoxylin and eosin-stained endobronchial biopsy (A) demonstrating malignant cells with large hyperchromatic nuclei (circle) infiltrating through stromal tissue. Compare with the nuclear size of the nearby normal submucosal glands (arrows), 200x magnification image (B) demonstrating poorly differentiated carcinoma cells filling the subepithelial stroma. Normal ciliated mucosal cells are in the upper left of the image (arrowheads).

A 76-year-old man with a past medical history significant for coronary artery disease, diabetes mellitus, and 40-pack-year smoking history presented to the emergency department with 1 week of progressive hoarseness. Associated symptoms included a cough initially productive of green sputum that progressed to scant hemoptysis, as well as intermittent hiccups. Four days prior to presentation he sought treatment at a clinic in Mexico, where he was diagnosed with influenza and treated with Tamiflu and Moxifloxacin. His symptoms did not improve, prompting him to seek care at our hospital.

On interview, he denied fevers, chills, dysphagia, otalgia, odynophagia, dyspepsia, chest pain, dyspnea, or weight changes. His temperature was 36.3°C, heart rate 75 beats per minute, blood pressure 150/77 mmHg, respiratory rate 22 breaths per minute, and oxygen saturation 93% on room air. On physical examination, the patient was found to have a hoarse voice, with an otherwise normal oropharyngeal exam. Cardiopulmonary exam was notable for bowel sounds auscultated in the left lower lung fields. The remainder of the exam was unremarkable. Laboratory testing including CBC, CMP, and a respiratory pathogen PCR panel did not detect any viruses.

A chest X-ray was obtained (Figure 1A); imaging was significant for moderate elevation of left hemidiaphragm (A), an ill-defined nodular opacity in the left perihilar region, and suspicion for a hilar mass (B). Chest CT confirmed a large central left upper lobe hilar mass compressing regional vascular and bronchial structures (Figure 1B). The patient underwent Endobronchial ultrasound-guided fine needle aspiration (EBUS FNA) and endobronchial biopsy, which confirmed the diagnosis, recurrent laryngeal nerve injury secondary to left upper lobe non-small cell lung carcinoma (Figure 2).

Hoarseness can be caused by a diverse array of conditions, ranging from local inflammatory processes (e.g., laryngitis or benign vocal cord lesions), to more systemic, neurologic, or oncologic conditions. A systematic evaluation is therefore essential to create an appropriate differential and guide the diagnostic evaluation. This evaluation begins with a detailed history probing for any red flag symptoms: symptoms persisting greater than two weeks, dysphagia, odynophagia, weight loss, or hemoptysis, as was seen in the case above.

Recurrent laryngeal nerve injuries are a less common cause of hoarseness. An understanding of the anatomic course of the recurrent laryngeal nerve (RLN) aids in localizing pathology. The RLN branches off cranial nerve X, also known as the Vagus nerve, and supplies most of the laryngeal muscles. The left RLN extends inferiorly into the chest, and loops posteriorly under the aortic arch before returning superiorly through the neck. Similarly, the right RLN loops posteriorly around the right subclavian artery before traversing superiorly back through the neck. The majority of recurrent laryngeal nerve injuries are iatrogenic, secondary to thyroid or cardiothoracic surgery. However, in the absence of surgery, understanding the anatomy paired with further imaging can help localize the pathology.

The patient’s radiographic findings suggested an intrathoracic mass concerning for a primary lung malignancy. This mass was further characterized on chest CT, which confirmed a large central left upper lobe hilar mass compressing regional vascular and bronchial structures. In the setting of hoarseness, the malignancy was likely causing injury to the recurrent laryngeal nerve. Additionally, given the symptom of hiccups paired with image findings of an elevated hemidiaphragm, the phrenic nerve was also likely being compressed. A biopsy would then further identify the lung mass.

Bronchoscopy showed patent airways and extensive nodular mucosa and endobronchial tumor at the left upper lobe / lingula. Endobronchial biopsy of the left upper lobe revealed infiltrating malignant cells in the submucosal connective tissue. No keratin production or gland formation was seen. Further work-up with immunohistochemical preparations showed the tumor cells to be negative for TTF-1 and p40, markers indicative of pulmonary adenocarcinoma and squamous cell carcinoma, respectively. In light of these features, the most accurate diagnosis is non-small cell carcinoma, not otherwise specified (NOS).

The differential for dysphonia in an adult extends beyond the anatomic boundaries of the laryngopharynx, including an intrathoracic malignancy causing recurrent laryngeal nerve injury. Additionally, phrenic nerve palsy secondary to a mediastinal mass should be included in the differential for an elevated hemidiaphragm.

Alexandra Fuher MD¹, Carrie B. Marshall MD², William Aaron Manning MD³

¹Department of Internal Medicine, University of Colorado Anschutz Medical Campus

²Department of Pathology, University of Colorado Anschutz Medical Campus

³Department of Pediatrics, University of Colorado Anschutz Medical Campus

References

1. Culp JM, Patel G. Recurrent Laryngeal Nerve Injury. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560832.
2. Reiter R, Hoffmann TK, Pickhard A, Brosch S. Hoarseness-causes and treatments. Dtsch Arztebl Int. 2015 May 8;112(19):329-37. [CrossRef] [PubMed]
3. Feierabend RH, Shahram MN. Hoarseness in adults. Am Fam Physician. 2009 Aug 15;80(4):363-70. [PubMed]
4. Travis WD, Brambilla E, Noguchi M, et al. Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification. Arch Pathol Lab Med. 2013 May;137(5):668-84. [CrossRef] [PubMed]

Cite as: Fuher A, Marshall CB, Manning WA. June 2024 Medical Image of the Month: A 76-year-old Man Presenting with Acute Hoarseness. Southwest J Pulm Crit Care Sleep. 2024;28(6):78-80. doi: https://doi.org/10.13175/swjpccs002-24 PDF

Medical Image of the Month: An Unexpected Cause of Chronic Cough

Figure 1. Axial image from a contrast-enhanced CT demonstrates a hollow, calcified structure in the bronchus intermedius with thickening suggesting inflammation in the surrounding bronchial wall (arrow).

 

Figure 2. Photograph of chicken bone fragment retrieved from bronchus intermedius during flexible bronchoscopy (A).  In retrospect, this fragment of bone is visible on the topogram from the chest CT (B) and is circled. Note the prominent notch that is visible on CT and on the actual bone fragment (arrowheads).

Sometimes it is as simple as it looks!  A previously healthy nonsmoking 40 years old man presented with a 7-month history of dry cough which was misdiagnosed as asthma. He had persistent cough despite appropriate asthma treatment including empiric PPIs. This patient had undergone extensive lab work up and evaluation; from negative viral and fungal panel, repeated pulmonary function tests which were within normal limits, chest x-rays, and CT scans which had shown small local calcification in the bronchus intermedius with significant thickening of the surrounding bronchial wall (Figure 1). The decision was made to proceed with flexible bronchoscopy, which yielded a chicken bone fragment with surrounding granulation tissue as shown in Figure 2A. In retrospect the bone is visible within the  bronchus intermedius on the topogram from the CT scan, see Figure 2B.

Foreign body aspiration in adults reported in low rates (0.66 per 100 000) (1). Despite being uncommon, neurological disorders, alcohol abuse, advanced age and altered level of consciousness all found to be the main underlying cause of foreign body aspiration in adults (2). Still, 10% of adult patients with foreign body aspiration have no known risk factors (3). Usually, diagnosis of foreign body aspiration in adults is straightforward only if the patient’s history involves aspiration or choking event. But, if the initial event goes unnoticed, the clinical picture maybe similar to obstructive lung diseases such as COPD or asthma.

Yazan Khair ¹, Hussam Al-Jawaldeh², Ayah AL Mufleh³ , Maxim Abu Joudeh⁴, Emad Hammode⁵  

¹Pulmonary department, Royal Medical Services (RMS), Amman, Jordan

²Internal Medicine Resident, Canyon Vista Medical Center, Sierra Vista, AZ USA                

³Internal Medicine transitional program, King Hussein Cancer Center, Amman, Jordan

⁴Internal Medicine Resident, Canyon Vista Medical Center, Sierra Vista, AZ USA

⁵Program Director of Canyon Vista Medical Center Internal Medicine program, Sierra Vista, AZ USA

References

1. Lund, ME. Foreign body removal in: Ernst A, Herth, FJF eds. Principles and Practice of Interventional Pulmonolgy. New York, NY: Springer; 2013:477-488.
2. Singh A, Kaur M. Recurrent pneumonitis due to tracheobronchial foreign body in an adult. JIACM, 2007:8:242-44.
3. Mise K, Jurcev Savicevic A, Pavlov N, Jankovic S. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc. 2009 Jun;23(6):1360-4. [CrossRef] [PubMed]

Cite as: Khair Y, Al-Jawaldeh H, Mufleh A, Joudeh M, Hammode E. Medical Image of the Month: An Unexpected Cause of Chronic Cough. Southwest J Pulm, Crit Care & Sleep. 2022;25(2):23-24. doi: https://doi.org/10.13175/swjpccs032-22 PDF 

February 2019 Imaging Case of the Month: Recurrent Bronchitis and Pneumonia in a 66-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 66–year old woman presented with complaints of a non-productive cough worsening over the previous several weeks. She complained that her cough had also occurred several months earlier, but resolved, and then subsequently returned.

The patient indicated that she has had bouts of bronchitis off and on for many years. Her smoking history included only 3 cigarettes / day for two years, quitting 20 years earlier. She did not note any allergies and her list of medications included only vitamin supplements, baby aspirin, omeprazole, and lisinopril. Her surgical history was remarkable only for remote tonsillectomy and hysterectomy.

Her physical examination was largely unremarkable, although some course breath sounds were detected over the medial right base. Her vital signs showed normal pulse rate and blood pressure, breathing at 12 breaths / minute. Her room air oxygen saturation was 97%.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Initial frontal chest x-ray.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to be directed to the second of sixteen pages)

1. Chest radiography shows a vague solitary pulmonary opacity
2. Chest radiography shows basilar fibrotic opacities
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows marked cardiomegaly
5. Chest radiography shows numerous small nodular opacities

Cite as: Gotway MB. February 2016 imaging case of the month: Recurrent bronchitis and pneumonia in a 66-year-old woman. Southwest J Pulm Crit Care. 2019;18(2):31-49. doi: https://doi.org/10.13175/swjpcc006-19 PDF

Medical Image of the Month: Superior Vena Cava Syndrome

Figure 1. Coronal CT thorax with contrast showing a large apical mass with near complete atelectasis of the right upper lobe, mediastinal extension and effacement of the superior vena cava (arrow).

Figure 2. Caval-superficial-umbilical-portal pathway.  EMV = external mammary vein, EV = epigastric vein, IEV = inferior epigastric vein, IMV = internal mammary vein, SEV= superior epigastric vein (2).

Figure 3. Axial CT thorax with contrast showing avid arterial enhancement of hepatic segment IV (arrow, hot quadrate sign), consistent with superior vena cava syndrome.

Although superior vena cava syndrome (SVCS) may result from internal or external occlusion of the superior vena cava, 60-90% of cases are caused by external compression from malignant tumors, predominately lung cancer and lymphoma (1). Additional causes of SVCS via external occlusion include fibrosing mediastinitis, while internal occlusion may result from pacemaker lead or indwelling central venous catheter thrombosis (1). Symptoms of SVCS, such as facial and neck swelling, dyspnea and cough, typically develop over 2-4 weeks prior to diagnosis, during which collateral vessels develop (2). More severe symptoms of disease include laryngeal edema, cerebral edema, orthostatic syncope secondary to decreased venous return and altered mental status (3). In the presence of SVCS, cavoportal collaterals that may develop include caval-superficial-umbilical-portal pathways and caval-mammary-phrenic-hepatic capsule-portal pathways (3). Figure 2 demonstrates the anastomosis of inferior and superficial epigastric veins with internal and external mammary veins, allowing for recanalization of the paraumbilical vein and drainage into left portal vein. The presence of a caval-superficial-umbilical-portal pathway may be detected as a wedge-shaped area of increased enhancement in segment IV of the liver on CT or MRI, a radiographic finding known as the hot quadrate sign (Figure 3). Following diagnosis of SVCS in the setting of malignancy, goals of management may be palliative or curative and should take into account life expectancy. Endovascular stenting can provide near immediate symptomatic relief of SVCS, but requires the addition of chemotherapy, radiotherapy or combined-therapy if the goals of treatment are curative (1). Although the median life expectancy of a patient with SVCS due to underlying malignancy is often reported as 6 months, the prognosis is dependent on tumor type and the presence or absence of poor prognostic factors, including age >50 years old, history of tobacco use and treatment with corticosteroids (3).

Elliot Breshears MS IV, Lev Korovin MD, and Veronica Arteaga MD.

Department of Medical Imaging

The University of Arizona

Tucson, AZ, USA

References

1. Wan JF, Bezjak A. Superior vena cava syndrome. Hematol Oncol Clin North Am. 2010;24(3):501-13. [CrossRef] [PubMed]
2. Kapur S, Paik E, Rezaei A, Vu DN. Where there is blood, there is a way: unusual collateral vessels in superior and inferior vena cava obstruction. RadioGraphics. 2010;30(1):67-78. [CrossRef] [PubMed]
3. Manthey DE, Ellis LR. Superior vena cava syndrome (SVCS). In: Todd KH, Thomas CR Jr. Oncologic Emergency Medicine: Principles and Practice. Switzerland: Springer; 2016:211-222. Available at: https://books.google.com/books?id=_qQqDAAAQBAJ&pg=PA211&lpg=PA211&dq=Manthey+DE,+Ellis+LR.&source=bl&ots=MWH6bcbHSf&sig=L7Ul5sfS1sSGBTF5cnK7MvKF9eA&hl=en&sa=X&ved=2ahUKEwjGkoTC9LrdAhUEEHwKHbV2CF4Q6AEwAHoECAEQAQ#v=onepage&q=Manthey%20DE%2C%20Ellis%20LR.&f=false (accessed 9/14/18).

Cite as: Breshears E, Korovin L, Arteaga V. Medical image of the month: superior vena cava syndrome. Southwest J Pulm Crit Care. 2018;17(4):114-5. doi: https://doi.org/10.13175/swjpcc103-18 PDF 

Medical Image of the Week: Post Pneumonectomy Syndrome

Figure 1.Computed tomography of the chest. Panel A: lung windows reveal hyperexpansion of right lung with extreme shift of mediastinum to the left hemithorax. Panel B: mediastinal windows reveals rotation of the heart toward midline.

A 73 year-old woman with a history of left pneumonectomy in 2012 for Stage IB adenocarcinoma of the lung presented to the outpatient pulmonary clinic with dyspnea on exertion and fatigue. Computed tomography of the chest reveals hyperexpansion of the right lung with complete shift of the heart and mediastinal structures into the left hemithorax, (Figure  1). There is tethering of the right mainstem bronchus and right-sided vessels with a stretched configuration of the trachea, esophagus and right-sided vasculature.  The heart is rotated toward the midline. The central airways are patent, however, the tethering and rotation of the mediastinal structures are concerning for post-pneumonectomy syndrome (PPS).

PPS is a rare and late complication after pneumonectomy and results from extreme shift and rotation of the mediastinum. Symptoms can include progressive dyspnea, cough, inspiratory stridor and recurrent pneumonia (1). Dyspnea can be caused by bronchial compression or by compression of the pulmonary vein (2). Dysphagia and acid reflux can result from esophageal compression (3). PPS is more common after right pneumonectomy, however cases following left pneumonectomy are well described. Treatment options include surgical correction using saline‐filled tissue expanders to restore normal mediastinal position (4).

Billie Bixby MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona

University Medical Center Tucson

Tucson, AZ USA

References

1. Valii, AM, Maziak DE, Shamii FM, Matzinger RF. Postpneumonectomy syndrome: recognition and management. Chest. 1998; 114:1766. [CrossRef] [PubMed]
2. Partington SL, Graham A, Weeks SG. Pulmonary vein stenosis following left pneumonectomy: a variant contributor to postpneumonectomy syndrome. Chest. 2010;137(1):205-6. [CrossRef] [PubMed]
3. Soll C, Hahnloser D, Frauenfelder T, Russi EW, Weder W, Kestenholz PB. The postpneumonectomy syndrome: Clinical presentation and treatment. Eur J Cardiothorac Surg. 2009; 35: 319-24. [CrossRef] [PubMed]
4. Jung JJ, Cho JH, Kim HK, et al. Management of post‐pneumonectomy syndrome using tissue expanders. Thoracic Cancer. 2016;7(1):88-93. [CrossRef] [PubMed]

Cite as: Bixby B, Knepler J. Medical image of the week: post pneumonectomy syndrome. Southwest J Pulm Crit Care. 2018;16(6):332-3. doi: https://doi.org/10.13175/swjpcc071-18 PDF 

Medical Image of the Week: Mediastinal Lipomatosis

Figure 1. Chest X-ray showing right sided mediastinal mass.

Figure 2. Coronal (A) and axial (B) CT Images showing a right paratracheal homogenously fat-enhancing mass.

A 61-year-old man presented to the pulmonary clinic for evaluation of a chronic cough of 6 months’ duration.  Other medical problems included class three obesity, obstructive sleep apnea on CPAP therapy, and hypertension.  Chest X-Ray (Figure 1) revealed a right mediastinal mass which then prompted a chest CT to be performed. The chest CT (Figure 2) demonstrated a homogenously enhancing, well circumscribed and fat-attenuating 8 x 5 cm mass in the right paratracheal region without invasion or compression into surrounding structures.

Mediastinal lipomatosis was diagnosed.  This is a benign soft tissue tumor made of mature adipocytes that can be seen with obesity, chronic corticosteroid use, and Cushing’s syndrome.  They are thought to represent up to 2.3% of all primary mediastinal tumors (1).  They are occasionally associated with compression of surrounding structures which can cause superior vena cava syndrome, dry cough, dysphagia, and occasionally arrhythmias (2).  Management is typically conservative with weight loss encouraged unless mass effect is present that significantly affects quality of life, in which case surgical options may be explored. 

Although this patient’s cough could be due to this lipoma, he also had symptoms of cough possibly exacerbated by severe gastroesophageal reflux disease which was not yet managed.  A trial of a proton pump inhibitor was pursued with follow-up arranged to determine if further intervention is necessary.

Bryan Borg MD and James Knepler MD

Department of Medicine

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

University of Arizona

Tucson, AZ USA

References

1. Gaerte SC, Meyer CA, Winer-Muram HT. Fat-containing lesions of the chest. Radiographics. 2002;22:61-78. [CrossRef] [PubMed]
2. Cutilli T, Schietroma M, Marcelli VA, Ascani G, Corbacelli A. Giant cervico-mediastinal lipoma. A clinical case. Minerva Stomatol. 1999 Jan-Feb;48(1-2):23-8. [PubMed]

Cite as: Borg B, Knepler J. Medical image of the week: mediastinal lipomasosis. Southwest J Pulm Crit Care. 2018;16:228-9. doi: https://doi.org/10.13175/swjpcc046-18 PDF 

Medical Image of the Week: Barium Aspiration

Figure 1: Upright X-Ray of the chest showing dense opacifications in the bilateral lower lobes consistent with Barium Aspiration.

An 88-year old man was referred for video fluoroscopic swallow study (VFSS) for concerns of aspiration as the cause of his chronic cough. As part of the study, he was given barium sulfate nectar which he aspirated and developed respiratory distress and hypoxia requiring hospital admission. Chest X-ray obtained at that time is shown (Figure 1).

Although inert, acute inflammation and even death attributed to barium aspiration has been described (1,2). Severe respiratory complications tend to occur in patients with extensive comorbidities (2,3). Treatment is mostly supportive and severe cases may require invasive ventilatory support. Bronchoscopy and suction clearance may be attempted although the success is variable. Recovery is usually complete although fibrosis is a known complication (4).

Bhupinder Natt, MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center

Tucson, AZ USA

References

1. Kaira K, Takise A, Goto T, Horie T, Mori M. Barium sulphate aspiration. Lancet 2004;364(9452):2220. [CrossRef] [PubMed]
2. Gray C, Sivaloganathan S, Simpkins KC. Aspiration of high density barium contrast medium causing acute pulmonary inflammation- report of two fatal cases in elderly women with disordered swallowing. Clinic Radiol. 1989;40(4):397-400. [CrossRef] [PubMed]
3. Fruchter O, Dragu R. Images in Clinical Medicine. A deadly examination. N Engl J Med. 2003;348(11):1016. [CrossRef] [PubMed]
4. Voloudaki A, Ergazakis N, Gourtsoyiannis N. Late changes in barium sulfate aspiration. HRCT Features. Eur Radiol. 2003;13(9):2226-9. [CrossRef] [PubMed]

Cite as: Natt B. Medical image of the week: barium aspiration. Southwest J Pulm Crit Care. 2017;15(6): . doi: https://doi.org/10.13175/swjpcc146-17 PDF 

Medical Image of the Week: Pulmonary Vein Thrombosis

Figure 1. Axial CT view shows the thrombus in the pulmonary vein (arrows) and collateral formation.

Figure 2. Coronal view of thoracic CT angiography  showing thrombus in the pulmonary vein (arrow).

A 71-year-old woman with chronic lymphocytic leukemia and remote left lower lobe pneumonectomy presented to the emergency department from an outpatient clinic with symptoms of cough, progressive shortness of breath, and fatigue for 2 weeks.  Pertinent physical examination findings included adequate oxygen saturation at room air, known II/VI systolic mitral murmur with radiation through the precordium, and a well-healed left lower lobe pneumonectomy scar.  Imaging was remarkable for acute pulmonary venous thrombosis (PVT) of the left inferior pulmonary vein with involvement of several tributary veins (Figures 1 and 2). Given the rarity of PVT, treatment guidelines have yet to be established (1); however, consensus appears to be systemic anticoagulation, thrombectomy, or resection (1-3).  Therefore, the patient was initially placed on a heparin drip upon admission and was discharged on an oral anticoagulant.

Pulmonary vein thrombosis (PVT) is a rare condition only described through case reports, that is potentially life threatening and presents with nonspecific symptoms. Common inciting events are lung transplantation, pneumonectomy (typically early after surgery and mainly left upper lobe pneumonectomy), radiofrequency ablation complication, malignancy (either lung or metastatic), idiopathic and atrial fibrillation (1-3). 

Close clinical follow up is necessary as life-threatening complications can occur, such as gangrene of the lung (which can occur if there is no collateral circulation from the intercostal veins) or embolic stroke (3). Current literature review suggests CT or MRI as imaging modality of choice for tracking regression or resolution of disease. TEE may also be used to assess for extension of thrombi into the left atrium (1,3).

Jessica Vondrak, MD and Bonnie Barbee, MD

Department of Internal Medicine

Banner University Medical Center

Tucson, AZ USA

References

1. Chaaya G, Vishnubhotia P. Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus. 2017 Jan 23;9(1):e993. [CrossRef] [PubMed]
2. Selvidge SD, Gavant ML. Idiopathic pulmonary vein thrombosis: detection by CT and MR imaging. AJR AM J Roentgenol. 1999 Jun;172(6):1639-41. [CrossRef] [PubMed]
3. Porres DV, Morenza OP, Pallisa E, Rogue A, Andreu J, Martinez M. Learning from the pulmonary veins. Radiograhpics. 2013 Jul-Aug;33(4):999-1022. [CrossRef] [PubMed]

Cite as: Vondrak J, Barbee B. Medical image of the week: pulmonary vein thrombosis. Southwest J Pulm Crit Care. 2017;14(5):228-9. doi: https://doi.org/10.13175/swjpcc048-17 PDF 

February 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 49-year-old man presented with complaint of slow worsening of shortness of breath over a period of several months. He was otherwise healthy with no significant past medical history.

Laboratory data, include white blood cell count, coagulation profile, and serum chemistries were within normal limits. Oxygen saturation on room air was 94%.

Frontal and lateral chest radiographs (Figure 1) were 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 second of nine pages)

1. Frontal and lateral chest radiography shows a right paratracheal mass
2. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
3. Frontal and lateral chest radiography shows left-sided lung nodules
4. Frontal and lateral chest radiography shows lobulated left-sided pleural disease
5. Frontal and lateral chest radiography shows numerous small nodules

Cite as: Gotway MB. February 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(2):73-84. doi: https://doi.org/10.13175/swjpcc020-17 PDF

Medical Image of the Week: Tracheobronchial Foreign Body Aspiration

Figure 1. Panel A: The chest x-ray failed to show the aspirated foreign body. Panels B and C: Flexible bronchoscopy was performed and the insulin syringe cap was visualized in the right mainstem bronchus and retrieved with forceps.

Figure 2. Panel A: CT chest shows interval development of ground glass opacities and air fluid level in the right middle lobe (arrow). Panel B: The foreign body is visualized in the right lower lobe bronchus as an endobronchial-filling defect (arrow). Panel C: Flexible bronchoscopy was performed and cashew piece was retrieved with suction.

Case 1 (Figure 1) is a 58-year-old man who accidentally inhaled his insulin syringe cap while swinging on his recliner with the cap perched in his mouth. He developed a dry irritating cough. On exam he had mild stridor in the upper airways and bilateral wheezing. The insulin cap was visualized by bronchoscopy in the right mainstem bronchus and retrieved with forceps.

Case 2 (Figure 2) is a 65-year-old man with chronic dysphagia and poor dentition who choked on a cashew. It took repeated coughing attempts to produce the cashew, but it was unclear whether the entire content was cleared. He then developed non-massive hemoptysis that persisted for 2 weeks. Thoracic CT showed ground glass opacities and an air fluid level in the right middle lobe. The foreign body was visualized in the right lower lobe bronchus as an endobronchial-filling defect. Bronchoscopy revealed a cashew piece in the right lower lobe bronchus. Forceps trials failed due to fragility of the foreign body, which was ultimately retrieved with scope suction.

Rigid bronchoscopy is the gold standard for diagnosis and management of tracheobronchial foreign body aspiration, but flexible bronchoscopy is another accepted method that is also more comfortable for the patient (1). Virtual bronchoscopy is a noninvasive procedure that can assist with localizing the foreign body and may have a role to play in follow-up assessment of airway patency (2). Pneumonia and atelectasis are common complications. Less common complications include bronchiectasis, bronchostenosis, hemoptysis, tracheal perforation, pneumomediastinum, and even cardiopulmonary arrest (3). Tracheal foreign bodies pose more danger than bronchial foreign bodies; in such cases the foreign body should be pushed to distal airways, crumbled if it is organic, and then extracted (1).

Khushboo Goel, MD¹, Huthayfa Ateeli, MBBS², Joshua Dill, DO2, Dena L’Heureux MD³

¹Department of Internal Medicine, University of Arizona, Tucson, AZ, USA

²Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA

³Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Southern Arizona VA Health Care System, Tucson, AZ, USA

References

1. Altunas B, Aydin Y, Eroglu A. Foreign bodies in trachea: a 25 year experience. Eurasian J Med. 2016;48(2):119-123. [CrossRef] [PubMed]
2. Kshatriya RM, Khara NV, Paliwal RP, Patel SN. Role of virtual and flexible bronchoscopy in the management of a case of unnoticed foreign body aspiration presented as a nonresolving pneumonia in an adult female. Lung India. 2016; 33(4):420-423. [CrossRef] [PubMed]
3. Altunas B, Aydin Y, Eroğlu A. Complications of tracheobronchial foreign bodies. Turk J Med Sci. 2016;46(3):785-800. [CrossRef] [PubMed]

Cite as: Goel K, Ateeli H, Dill J, L’Heureux D. Medical image of the week: tracheobronchial foreign body aspiration. Southwest J Pulm Crit Care. 2016;13(4):184-5. doi: http://dx.doi.org/10.13175/swjpcc092-16 PDF

Medical Image of the Week: Bronchopleural Fistula

Figure 1. The blue arrow indicates a fistulous communication between bronchus and the pleura.

Figure 2. Red arrow indicates radiotracer trapping in the pleural space and adjacent right anterior lower lung field.

A 58-year-old man with past medical history significant for chronic smoking and seizures was referred to the emergency room after a chest x-ray done by his primary care physician for evaluation of cough showed a hydropneumothorax. His symptoms included dry cough for past 2 months without fever, chills or other associated symptoms. He did not have any thoracic procedures performed and had no past history of recurrent infections. He was hemodynamically stable. Physical examination was only significant with decreased breath sounds on the right side of the chest.

Thoracic CT with contrast was performed which showed complete collapse of the right lower lobe, near complete collapse of right middle lobe as well as an air-fluid level. There was a suspicion of a direct communication between bronchi and pleural space at the posterior lateral margin of the collapsed right lower lobe (Figure 1). The presence of bronchopleural fistula (BPF) was confirmed with the help of lung scintigraphy, which showed trapping of radiotracer in the right lung at a location consistent with the chest CT findings of BPF (Figure 2). The patient was admitted and extensive infectious work up was negative. Biopsy of the right pleura was negative for malignancy. He underwent video-assisted thoracoscopic surgery (VATS) decortication of his right lung and was stable on subsequent follow up with complete resolution of his cough.

BPF has mortality rate between 18 to 67% (1). CT of the chest can occasionally demonstrate a direct fistulous communication, as seen in our case.  However, Westcott and Volpe (2) have shown sensitivity of CT chest to be 50%. Other useful noninvasive imaging techniques include lung scintigraphy. In this modality, the fistula is identified by seeing a trapping of radioisotope labeled gas as there is no mechanism for a clearance of gas after its diffusion into the pleural space.  Raja et al. (3) demonstrated that lung scintigraphy had 83% sensitivity and 100% specificity in diagnosing BPF.  

As seen in this case lung nuclear scintigraphy offers a cheaper, more sensitive, and less invasive approach to diagnosis of BPF.

Hem Desai MD, MPH and Anthony Witten DO

Department of Internal Medicine

University of Arizona

Tucson, AZ USA

References

1. Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg. 1997 May;63(5):1391-6; discussion 1396-7. [CrossRef] [PubMed]
2. Westcott JL, Volpe JP. Peripheral bronchopleural fistula: CT evaluation in 20 patients with pneumonia, empyema, or postoperative air leak. Radiology. 1995 Jul;196(1):175-81. [CrossRef] [PubMed]
3. Raja S, Rice TW, Neumann DR, Saha GB, Khandekar S, MacIntyre WJ, Go RT. Scintigraphic detection of post-pneumonectomy bronchopleural fistulae. Eur J Nucl Med. 1999 Mar;26(3):215-9. [CrossRef] [PubMed] 

Cite as: Desai H, Witten A. Medical image of the week: bronchopleural fistula. Southwest J Pulm Crit Care. 2016;13(3)150-1. doi: http://dx.doi.org/10.13175/swjpcc069-16 PDF