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.

Rick Robbins, M.D. 5/3/18 Rick Robbins, M.D. 5/3/18

May 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 79-year-old man with a past medical history significant for mild, intermittent asthma since childhood and mild aortic stenosis presents to the Emergency Room with fevers and chills for 5 days, associated with dry cough and dyspnea on exertion. His past medical history was otherwise relatively unremarkable, with coronary artery disease as evidenced by coronary artery calcium at a calcium scoring CT, hypothyroidism, and dyslipidemia. The patient has allergies to dust and penicillin, and his only medications included thyroid replacement, aspirin, and an albuterol inhaler as needed. He was a 15-pack-year smoker, quitting 30 years ago. His past surgical history was remarkable only for tonsillectomy, inguinal hernia repair, meniscal repair, and sigmoid colon resection for diverticular abscess 14 years earlier. The patient was afebrile, his heart rate was 96 beats / minute and regular, decreased breath sounds at the lung bases was noted, and the white blood cell count was normal. Electrocardiography showed no abnormalities. Oxygen saturation was 92% on room air. Frontal chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the frontal chest imaging findings? (Click on the correct answer to proceed to the second of nineteen pages)

Cite as: Gotway MB. May 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(5):254-78. doi: https://doi.org/10.13175/swjpcc062-18 PDF

Rick Robbins, M.D. 7/23/14 Rick Robbins, M.D. 7/23/14

Medical Image Of The Week: Septic Pulmonary Emboli Misdiagnosed As Metastatic Disease

Figure 1. Representative thoracic CT axial images showing multiple pulmonary nodules (red arrows).

A 54-year-old previously healthy man presented with acute onset of left-sided, sharp pleuritic chest pain and dry cough. He denied having fever, hemoptysis, shortness of breath, or unintentional weight loss. Review of system was positive for bright blood per rectum for the last year. He had a root canal procedure done 3 weeks prior to presentation. His is a 30 pack-year smoker, drinks alcohol occasionally, but denied any IV drug use.

On admission, he was afebrile and hemodynamically stable. Clinical examination was positive for fecal occult blood test. CBC revealed WBC of 12,800/mm³ and his hemoglobin was11.9 g/dL. Thoracic CT scan with contrast was negative for pulmonary embolism, but showed multiple bilateral pulmonary nodules suspicious for malignancy (Figure 1). The left upper lobe showed a subpleural 2.4 x 1.5 cm rounded opacity and emphysematous changes. CT of the abdomen and pelvis showed folds in the stomach but was otherwise unremarkable.

Esophagogastroduodenoscopy was negative. Colonoscopy showed non-bleeding internal hemorrhoids. He underwent percutaneous CT guided lung biopsy. Pathology report showed distended alveoli filled with polymorphonuclear leukocytes mixed with fibrin consistent with septic emboli and no evidence of malignancy. Special stains for organisms were negative. Blood cultures were negative, Trans-esophageal echocardiograph was normal. Mandibular film done was negative for dental abscess. HIV serology, Quantiferon gold, ß-d glucan, Aspergillus, and mycobacterial culture of sputum were negative. During his hospital stay he developed a fever and his WBC count increased. He was empirically started on broad spectrum antibiotics and he clinically improved significantly.

Septic pulmonary embolus (SPE) is a serious and uncommon condition that poses a diagnostic challenge and carries a high mortality (1,2). Presenting symptoms are often non-specific. Blood cultures may be negative initially. Similarly, chest radiography is not helpful to establish a diagnosis. CT is more useful, usually showing multiple peripheral nodular opacities. SPE can be suspected by the presence of potential source of underlying infection, febrile illness and multiple pulmonary nodules.

Dima Dandachi MD and Sathish Krishnan MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med 2014;108(1):1-8. [CrossRef] [PubMed]
Shiota Y, Taniguchi A, Yuzurio S, Horita N, Hosokawa S, Watanabe Y, Tohmori H, Ono T; Okayama Respiratory Disease Study Group. Septic pulmonary embolism induced by dental infection. Acta Med Okayama. 2013;67(4):253-8. [PubMed]

Reference as: Dandachi D, Krishnan S. Medical image of the week: septic pulmonary emboli misdiagnosed as metastatic disease. Southwest J Pulm Crit Care. 2014;9(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc083-14 PDF