May 2023 Medical Image of the Month: Methamphetamine Inhalation Leading to Cavitary Pneumonia and Pleural Complications

Figure 1. Two axial images from a thoracic CT angiogram with intravenous contrast upon admission demonstrates ground-glass opacities in the left upper and bilateral lower lobes.

Figure 2.  Axial images from noncontrast CT 19 days later show progression with necrosis and cavitation with areas of pleural dehiscence and loculated hydropneumothorax formation.

A 31-year-old man with a self-reported history significant for active methamphetamine and OxyContin use (last use of methamphetamine the same day with confirmation on urine drug screen) presented to the hospital with several hours of dyspnea. Having gone into cardiac arrest shortly after, he received several rounds of epinephrine and CPR and was intubated before spontaneous circulation returned. Bedside ultrasound revealed global hypokinesis with left ventricular ejection fraction of 10 to 15%, trivial pericardial effusion, and a moderate left pleural effusion. Chest CT (Figure 1) revealed segmental to subsegmental pulmonary emboli in the left lower lobe and ground-glass opacities in the left upper and bilateral lower lobes. He was treated as septic shock with Vancomycin and Cefepime, eventually speciating methicillin-sensitive Staphylococcus aureus in respiratory culture. Due to difficulty liberating the patient from the ventilator, he underwent tracheostomy tube placement. Chest x-ray on hospital day 18 showed a large left partially loculated hydropneumothorax, for which a left thoracostomy tube was placed. The next day repeat CT chest without contrast (Figure 2) showed persistent moderate left lung volume loss with tethering of the lateral and separate anterior margin of the left upper lobe to the costal pleural margin. A dense consolidation of the left lung base had progressed to developing irregular cavitary spaces with air-fluid level. There was a dehiscence of the cavitary space with the posterior left pleura.  The right upper lobe showed extensive tree-in-bud ground-glass opacities and consolidation. The right lower lobe showed necrosis with intrapulmonary cavitary spaces/air-fluid levels. There was associated focal dehiscence of the parenchyma along the posterior cavity with the pleura. Patient had developed bilateral cavitary lung lesions with persistent bilateral hydropneumothoraces.

Typical findings of amphetamine induced lung injury can include ground-glass opacities as seen here. Worldwide prevalence of amphetamine use ranged between 0.3-1.3% for those aged 15-64 in 2009 (1). Crystal meth refers to the pure form of d-methamphetamine hydrochloride that can be smoked and inhaled as heated vapor as well. It can also be administered intravenously. Other amphetamines include MDMA, methyl methcathinone (commonly referred to as bath salts), and methylenedioxyamphetamine. Neural catecholamine reuptake is blocked, and neurotransmitter is expunged into the synaptic cleft. Additionally, serotonin and dopamine reuptake blockade and increased release take place.

With inhalation, there is higher percentage uptake, faster peak time, and slower clearance in the lungs compared to other organs as evidence by data from positron emission tomography. Time to peak concentration is the same between inhalation and intravenous use. Laboratories that produce amphetamines in the United States of America reduce L-ephedrine or D-pseudoephedrine either over red phosphorous with hydrochloric acid or with liquid ammonia and lithium. Therefore, they pose risks of contamination. Red phosphorous is flammable and causes smoke inhalation injury. Other solvents used also contribute to respiratory illness including pulmonary edema and mucous membranes irritation (1).

Typical respiratory symptoms from illicit drug use, including amphetamine use, include dyspnea, cough, dark sputum, and chest pain. Mechanisms include toxic effects on the respiratory system, coronary artery constriction, and impaired coronary artery oxygen delivery leading to chest pain. Dyspnea is a primarily a result of ventilation-perfusion mismatch from vasospasm. Bronchospasm is precipitated by airway mucosal irritation. Mucosal ulceration and burns as well as subsequent diffuse alveolar capillary injury lead to hemoptysis.  Cardiogenic pulmonary edema stems from the same causes of chest pain as well as acute hypertension and myocardial ischemia. Noncardiogenic pulmonary edema is a result of alveolar epithelial and endothelial damage.

As compared to cocaine, amphetamines have lower rates of barotrauma including pneumothorax, pneumopericardium, and pneumomediastinum, however these are still significant. There have been reports of MDMA-related epidural pneumatosis and retropharyngeal emphysema (1). Air dissects along fascial planes when alveoli are injured and travels up the pulmonary vascular sheath into the mediastinum, pericardium, and between the parietal and visceral layers.  When inhaled, coughing, and performing a Valsalva maneuver predispose the patient to this complication (2). Additionally, pneumothorax is more common with exertion shortly after consumption. Attempts at intravenous administration along the chest, supraclavicular regions, and internal jugular veins increase risk of pneumothorax (3). Hemothorax and pseudoaneurysm have been documented as well (2).

Kia Ghiassi DO¹, Colin Jenkins MD¹, Prateek Juneja DO²

^1,2University of California Riverside, Riverside, CA USA

²Inspira Health, Vineland, NJ USA

References

1. Tseng W, Sutter ME, Albertson TE. Stimulants and the lung : review of literature. Clin Rev Allergy Immunol. 2014 Feb;46(1):82-100. [CrossRef] [PubMed]
2. Nguyen ET, Silva CI, Souza CA, Müller NL. Pulmonary complications of illicit drug use: differential diagnosis based on CT findings. J Thorac Imaging. 2007 May;22(2):199-206. [CrossRef] [PubMed]
3. Gotway MB, Marder SR, Hanks DK, et al. Thoracic complications of illicit drug use: an organ system approach. Radiographics. 2002 Oct;22 Spec No:S119-35. [CrossRef] [PubMed]

Cite as: Ghiassi K, Jenkins C, Juneja P. May 2023 Medical Image of the Month: Methamphetamine Inhalation Leading to Cavitary Pneumonia and Pleural Complications. Southwest J Pulm Crit Care Sleep. 2023;26(5):80-82. doi: https://doi.org/10.13175/swjpccs010-23 PDF

Medical Image of the Month: Severe Acute Respiratory Distress Syndrome and Embolic Strokes from Polymethylmethacrylate (PMMA) Embolization

Figure 1. The contrast-enhanced CT of the chest on the left (Panel A) was acquired at the time of admission. The contrast-enhanced CT of the chest on the right (Panel B) was obtained 3 days into the hospitalization. The initial study demonstrated ground glass opacities most pronounced in the upper lobes, left greater than right. The follow up CT demonstrated marked progression of her airspace disease bilaterally, consistent with the clinical picture of the adult respiratory distress syndrome (ARDS).

Figure 2. An axial susceptibility weighted image (SWI) of the brain demonstrates extensive foci of susceptibility artifact (black dots) most pronounced in the genu and splenium of the corpus callosum (blue arrows) and the bilateral internal capsules (red arrows) – most consistent with embolic phenomenon.

A 35-year-old lady with a history of depression and anxiety presented to the emergency room with worsening shortness of breath after receiving polymethylmethacrylate (PMMA) injections in her buttock for cosmetic purposes in Mexico. Immediately after the injection in the outpatient office, she became acutely short of breath, tachypneic, and tachycardic. She was brought to the emergency room where she was hypoxic with oxygen saturations in the low 80s on a non-rebreather, tachypneic with a respiratory rate in the 40s, and tachycardic with heart rates in 140s. She was emergently intubated. A CTA of the chest demonstrated bilateral ground glass opacities throughout, most pronounced in the upper lobes which progressed to significant bilateral airspace disease consistent with acute respiratory distress syndrome (Figure 1). Her neurological examination declined over the course of her hospitalization. An MRI of the brain with contrast demonstrated bilateral foci of susceptibility artifact throughout the entirety of the brain most consistent with an embolic phenomenon in the setting of a suspected right-to-left shunt (Figure 2). Her mental status did not improve during her hospital course, and her family was deciding on whether to pursue comfort measures.

Discussion: Embolic complications of PMMA have been documented in the literature in relation to interventional procedures of the spine where it is used as a cement (i.e. vertebroplasty/kyphoplasty) (1). In those instances, the emboli are radiopaque and can be identified on conventional imaging modalities such as chest radiography or CT imaging (2). In the case of our patient, we were not able to confirm the exact formulation of the PMMA, but we suspect that it was delivered in the form of a dermal filler which was likely in the form of particles/microspheres. Migration of the particles/microspheres in the form of vascular emboli can occur if injected into blood vessels during procedures (3).

Sooraj Kumar MBBS¹, Sharanyah Srinivasan MBBS¹, and Tammer El-Aini MD²

¹Banner University Medical Center – South Campus, Department of Internal Medicine

²Banner University Medical Center – Main Campus, Department of Pulmonary and Critical Care

References

1. Abdul-Jalil Y, Bartels J, Alberti O, Becker R. Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty. Spine (Phila Pa 1976). 2007 Sep 15;32(20):E589-93. [CrossRef] [PubMed]
2. Yeom JS, Kim WJ, Choy WS, Lee CK, Chang BS, Kang JW. Leakage of cement in percutaneous transpedicular vertebroplasty for painful osteoporotic compression fractures. J Bone Joint Surg Br. 2003 Jan;85(1):83-9. [CrossRef] [PubMed]
3. Lemperle G, Morhenn VB, Pestonjamasp V, Gallo RL. Migration studies and histology of injectable microspheres of different sizes in mice. Plast Reconstr Surg. 2004 Apr 15;113(5):1380-90. [CrossRef] [PubMed]

Cite as: Kumar S, Srinivasan S, El-Aini T. Medical image of the month: severe acute respiratory distress syndrome and embolic strokes from polymethylmethacrylate (PMMA) embolization. Southwest J Pulm Crit Care. 2021;22(4):86-7. doi: https://doi.org/10.13175/swjpcc008-21 PDF

Medical Image of the Month: Mucinous Adenocarcinoma of the Lung Mimicking Pneumonia

Figure 1. A contrasted, coronal-reformatted CT image of the chest demonstrates unilateral ground glass opacification of the right lung with superimposed interlobular septal thickening (blue arrows). There is also volume loss of the left lung with elevation of the left hemidiaphragm (red arrow).

Clinical Scenario: A 60-year-old man with a history of chronic obstructive pulmonary disease presented to the hospital with worsening shortness of breath over a period of 3 days. He had a 50-pack-year history of smoking, coronary artery disease, and a previous history of a left lung mass of unknown pathology status post left upper lobectomy. He was bought to the emergency room via ambulance after being found at home with oxygen saturations in the 60s. Upon arrival to the emergency room, he required continuous oxygen at 15 L/min to maintain his oxygen saturations above 88%. He had a progressive, markedly productive cough over the last few weeks prior to presentation. He had been treated for pneumonia with multiple courses of antibiotics over the last two months without any significant improvement. His blood work was significant for a leukocytosis with neutrophilia and an elevated D-dimer. He underwent a CTA of the chest in the emergency room to evaluate for a pulmonary embolism. The CTA of the chest had no evidence of pulmonary thromboembolic disease. However, there was unilateral ground glass opacification of the right lung with interlobular septal thickening along with volume loss of the left lung and associated elevation of the left hemidiaphragm (Figure 1). He was admitted to the medical ICU and started on broad-spectrum antibiotics. He underwent a bronchoscopy which demonstrated mucinous adenocarcinoma of the lung. His oxygen requirement was eventually weaned after multiple days in the ICU. He was discharged with follow up in the oncology clinic.

Discussion: Mucinous adenocarcinoma of the lung is the rarest type of adenocarcinoma of the lung. It is characterized as mucinous adenocarcinoma in situ, minimally invasive adenocarcinoma, and invasive mucinous adenocarcinoma. Mucinous adenocarcinoma of the lung is morphologically characterized by tall columnar cells with abundant cytoplasm that contain varying amounts of mucin. Mucus secreted by these cells can commonly be discharged as sputum. However, if airway obstruction occurs secondary to excessive mucus production, a post-obstructive pneumonia may develop. The prognosis of mucinous adenocarcinoma of the lung is poor.

Nicholas Blackstone MD¹, Tammer El-Aini MD²

¹Department of Internal Medicine and ²Department of Pulmonary and Critical Care, South Campus, Banner University Medical Center – Tucson, Tucson, AZ USA

References

1. Liu Y, Zhang HL, Mei JZ, Guo YW, Li RJ, Wei SD, Tian F, Yang L, Wang H. Primary mucinous adenocarcinoma of the lung: A case report and review of the literature. Oncol Lett. 2017 Sep;14(3):3701-3704. [CrossRef] [PubMed]
2. Marchetti A, Buttitta F, Pellegrini S, Chella A, Bertacca G, Filardo A, Tognoni V, Ferreli F, Signorini E, Angeletti CA, Bevilacqua G. Bronchioloalveolar lung carcinomas: K-ras mutations are constant events in the mucinous subtype. J Pathol. 1996 Jul;179(3):254-9. [CrossRef] [PubMed]
3. Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, Beer DG, Powell CA, Riely GJ, Van Schil PE, Garg K, Austin JH, Asamura H, Rusch VW, Hirsch FR, Scagliotti G, Mitsudomi T, Huber RM, Ishikawa Y, Jett J, Sanchez-Cespedes M, Sculier JP, Takahashi T, Tsuboi M, Vansteenkiste J, Wistuba I, Yang PC, Aberle D, Brambilla C, Flieder D, Franklin W, Gazdar A, Gould M, Hasleton P, Henderson D, Johnson B, Johnson D, Kerr K, Kuriyama K, Lee JS, Miller VA, Petersen I, Roggli V, Rosell R, Saijo N, Thunnissen E, Tsao M, Yankelewitz D. International association for the study of lung cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011 Feb;6(2):244-85. [CrossRef] [PubMed]
4. Cai D, Li H, Wang R, Li Y, Pan Y, Hu H, Zhang Y, Gong R, Pan B, Sun Y, Chen H. Comparison of clinical features, molecular alterations, and prognosis in morphological subgroups of lung invasive mucinous adenocarcinoma. Onco Targets Ther. 2014 Nov 18;7:2127-32. [CrossRef] [PubMed].
5. Xie GD, Liu YR, Jiang YZ, Shao ZM. Epidemiology and survival outcomes of mucinous adenocarcinomas: A SEER population-based study. Sci Rep. 2018 Apr 17;8(1):6117. [CrossRef] [PubMed]

Cite as: Blackstone N, El-Aini T. Medical image of the month: mucinous adenocarcinoma of the lung mimicking pneumonia. Southwest J Pulm Crit Care. 2021;22(1):8-10. doi: https://doi.org/10.13175/swjpcc072-20 PDF

Medical Image of the Month: Idiopathic Pulmonary Hemosiderosis

Figure 1. A-C: T1W 3D GRE post contrast multilevel axial images. D-F: CT axial images in a lung window (obtained three years before) both demonstrate innumerable centrilobular nodules consistent with the diagnosis of IPH.

The patient is a 36-year-old woman with a complex medical history including multiple venous thromboembolic events, miscarriages, heterozygous state for factor V Leiden deficiency, and Systemic Lupus Erythematosus. These images have been obtained during multiple admissions for shortness of breath during which she has been diagnosed with pulmonary embolism, anti-coagulation failure, pulmonary hypertension, and intracardiac right to left shunting. Images A-C are T1 weighted MRI axial sections showing centrilobular micronodules which are unchanged when compared to images D-F obtained during a CT scan of the chest three years prior. These findings are consistent with pulmonary hemosiderosis.

Idiopathic pulmonary hemosiderosis (IPH) is a rare condition that occurs with recurrent diffuse alveolar hemorrhage (1). Hemosiderin, a heme byproduct, gradually accumulates within the lung tissue, and can lead to fibrosis (2). IPH has a characteristic triad of hemoptysis, iron deficiency anemia, and pulmonary infiltrates on imaging (2) - although clinical presentation may be highly variable. The gold standard for diagnosis is lung biopsy, although bronchoalveolar lavage has 92% sensitivity of finding hemosiderin-laden macrophages in IPH (2). Classically, the disorder is found in children, but there have been more cases recorded in adults in recent years (3).

Radiographic findings: On chest x ray, areas of air-space consolidation or ground-glass opacities may be seen, usually with a perihilar or lower lung predominance. Consolidations typically clear within 3 days and are replaced by a reticular pattern (4). This may initially resolve but may progress to fibrosis after multiple occurrences - appearing as permanent reticulation or miliary stippling (1). On CT, the subacute phase demonstrates diffuse nodules and patchy areas of ground glass opacification. During an exacerbation, CT shows diffuse, homogenous areas of ground glass attenuation (4). On MRI, T1 images may show diffusely increased parenchymal signal intensity, whereas T2 images may show markedly reduced signal intensity due to the hemosiderin (4). The 3D gradient echo higher resolution MRI sequences in our patient, allowed for the recognition of the chronic micronodular pattern displayed.

Long term, low-dose, glucocorticoids are the main treatment for IPH, with immunosuppressants added on for severe cases. Tapering or reduction of glucocorticoids usually led to recurrence of pulmonary hemorrhage in patients (2). A large number of IPH cases coexist with Celiac disease (known as Lane-Hamilton Syndrome) and a gluten free diet may lead to remission (3).

On imaging, the differential diagnosis is broad, particularly if no remote imaging is available. In our patient’s case, the micronodular pattern may be seen with miliary infections, hypersensitivity pneumonitis, some forms of bronchiolitis (particularly smoking related or inhalational diseases). Microangiopathies are also to be considered, such as capillary hemangiomatosis.  IPH is a diagnosis of exclusion, and all other causes of diffuse alveolar hemorrhage must first be investigated, such as bronchiectasis, interstitial pneumonia, infections, connective tissue disease, coagulation disorders, systemic vasculitis, and/or anti-GBM disease (3).

Cynthia Ha, MS IV¹ and Diana Palacio, MD²

¹Lake Erie College of Osteopathic Medicine, Erie, PA

²Department of Medical Imaging, University of Arizona College of Medicine – Tucson, AZ

References

1. Repetto G, Lisboa C, Emparanza E, et al. Idiopathic pulmonary hemosiderosis. Clinical, radiological, and respiratory function studies. Pediatrics. 1967;40(1):24‐32. [PubMed]
2. Zhang Y, Luo F, Wang N, Song Y, Tao Y. Clinical characteristics and prognosis of idiopathic pulmonary hemosiderosis in pediatric patients. J Int Med Res. 2019;47(1):293‐302. [CrossRef] [PubMed]
3. Chen XY, Sun JM, Huang XJ. Idiopathic pulmonary hemosiderosis in adults: review of cases reported in the latest 15 years. Clin Respir J. 2017;11(6):677‐681. [CrossRef] [PubMed]
4. Primack SL, Miller RR, Müller NL. Diffuse pulmonary hemorrhage: clinical, pathologic, and imaging features. AJR Am J Roentgenol. 1995;164(2):295‐300. [CrossRef] [PubMed] 

Cite as: Ha C, Palacio D. Medical image of the month: idiopathic pulmonary hemosiderosis. Southwest J Pulm Crit Care. 2020;20(6):190-1. doi: https://doi.org/10.13175/swjpcc033-20 PDF 

Medical Image of the Month: Viral Pneumonias

Figure 1. Pulmonary viral infection spectrum on thoracic CT scan in lung windows: A= Coronavirus NL63; B= Adenovirus; C= Influenza AH1 2009; D= COVID-19; E= Coronavirus HKU1; F= Influenza AH1 2009.

Numerous viruses, including the corona, influenza and adenoviruses can cause lower respiratory tract infection in adults (1). Viral pneumonia in adults can be classified into two clinical groups: so-called atypical pneumonia in otherwise healthy hosts and viral pneumonia in immunocompromised hosts. Until the COVID-19 pandemic, influenza virus types A and B caused most cases of viral pneumonia in immunocompetent adults. Immunocompromised hosts are susceptible to pneumonias caused by a wide variety of viruses including cytomegalovirus, herpesviruses, measles virus, and adenovirus. The CT imaging findings consist mainly of patchy or diffuse ground-glass opacity, with or without consolidation, and reticular areas of increased opacity, are variable and overlapping. The imaging findings in COVID-19 pneumonia are generally not distinctive compared to other viral pneumonias, including other coronaviruses such as SARS and MERS (2). A recent study systematically reviewed the longitudinal changes of CT findings in COVID-19 pneumonia. The results suggested that the lung abnormalities increase quickly after the onset of symptoms, peak around 6-11 days, and are followed by persistence of the findings.

Bacterial pneumonias may also take multiple forms and are sometimes difficult to radiographically separate from viral pneumonia (3). However, the presence of ground-glass opacities alone is unusual for a bacterial pulmonary infection. Rather, bacterial infections commonly present as areas of consolidation with air bronchogram formation, centrilobular nodules (often with branching configurations) and airway thickening.

Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

References

1. Kim EA, Lee KS, Primack SL, et al. Viral pneumonias in adults: radiologic and pathologic findings. Radiographics. 2002 Oct;22 Spec No:S137-49. [CrossRef] [PubMed]
2. Wang Y, Dong C, Hu Y, Li C, Ren Q, Zhang X, Shi H, Zhou M. Temporal Changes of CT Findings in 90 Patients with COVID-19 Pneumonia: A Longitudinal Study. Radiology. 2020 Mar 19:200843. [CrossRef] [PubMed]
3. Panse PM, Jokerst CE, Gotway MB. May 2020 Imaging Case of the Month: Still Another Emerging Cause for Infiltrative Lung Abnormalities. Southwest J Pulm Crit Care. 2020. May 1. (in press). [CrossRef]

Cite as: Gotway MB. Medical image of the month: viral pnuemonias. Southwest J Pulm Crit Care. 2022;20(5):163-4. doi:  https://doi.org/10.13175/swjpcc028-20 PDF 

Medical Image of the Month: Metastatic Pulmonary Calcifications in a Kidney Transplant Recipient

Figure 1. Axial and coronal views of thoracic CT scan showing upper lobe predominant centrilobular ground glass nodules.

Figure 2. Transbronchial biopsy yielded nine tissue fragments, each of which demonstrated moderate to marked interstitial calcification (amorphous purple material) along the alveolar septae, perivascular spaces and within the bronchioles consistent metastatic calcification.  There were secondary changes of mild alveolar fibrosis and interstitial hemosiderin laden macrophages (golden brown pigment).  There was no evidence of an inflammatory response or malignancy to otherwise explain the CT findings in this patient.

A 40-year-old man presented with shortness of breath, cough and abnormal imaging. He had a past medical history of end stage renal disease (ESRD) secondary to Alport syndrome and underwent three kidney transplants in 2004, 2010 and 2016. He was intermittently on dialysis between the transplants. He also had a history of coronary artery disease, congestive heart failure and parathyroidectomy. His CT scan (Figure 1) from 2019 showed diffuse centrilobular ground glass opacities sparing the peripheral lung and lung bases. Pulmonary function testing showed obstruction, with reduced diffusion capacity. Bronchoscopy with bronchoalveloar lavage and transbronchial biopsy of the right upper and middle lobes was consistent with metastatic pulmonary calcification (MPC) (Figure 2).

MPC is a rare metabolic pulmonary disease which is usually found incidentally or on autopsy. It occurs with chronically elevated calcium and phosphorus levels (1). It is very commonly associated with ESRD and rarely in primary hyperparathyroidism, osteoporosis, sarcoidosis, renal and liver transplant and hematological malignancies (2-5). CT shows diffuse, nodular areas of ground-glass opacity or consolidation seen in the upper lung zones with pleural sparing. Diagnosis is made on histopathology. There is no definitive treatment for MPC. MPC should be considered with radiological nodular ground glass opacities, particularly in the context of chronic kidney disease or kidney transplant.

Nikhil Madan¹ MD FCCP, Vipul Patel¹ MD, Christine Minerowicz² MD, Harpreet Greewal¹ MD, and Thomas Kaleekal MD FCCP

¹Division of Pulmonary and Critical Care and Transplant

Newark Beth Israel Medical Center

Newark, NJ USA

²Department of Pathology and Laboratory Medicine

Rutgers Robert Wood Johnson Medical School

New Brunswick, NJ USA 

References

1. Chan ED, Morales DV, Welsh CH, McDermott MT, Schwarz MI. Calcium deposition with or without bone formation in the lung. Am J Respir Crit Care Med. 2002 Jun 15;165(12):1654-69. [CrossRef] [PubMed]
2. Kuhlman JE, Ren H, Hutchins GM, Fishman EK. Fulminant pulmonary calcification complicating renal transplantation: CT demonstration. Radiology. 1989; 173:459e60. [CrossRef] [PubMed]
3. Bendayan D, Barziv Y, Kramer MR. Pulmonary calcifications: a review. Respir Med. 2000; 94:190e3. [CrossRef] [PubMed]
4. Izadyar M, Mahjoub F, Ardakani SN, Ahmadi J. Pulmonary metastatic calcification in a leukemic patient: a case report. J Pediatr Hematol Oncol. 2010;32:e108e10. [CrossRef] [PubMed]
5. Surani SR, Surani S, Khimani A, Varon J. Metastatic pulmonary calcification in multiple myeloma in a 45-year-old man. Case Reports Pulmonol. 2013; 2013:341872. [CrossRef] [PubMed]

Cite as: Madan N, Patel V, Minerowicz C, Greewal H, Kaleekal T. Medical image of the month: metastatic pulmonary calcifications in a kidney transplant recipient. Southwest J Pulm Crit Care. 2020;20(2):71-2. doi: https://doi.org/10.13175/swjpcc001-20 PDF

February 2020 Imaging Case of the Month: An Emerging Cause for Infiltrative Lung Abnormalities

Prasad M. Panse MD*, Fiona F. Feller MD^†, Yasmeen M. Butt MD^‡, Michael B. Gotway MD*

Departments of *Radiology, ^†Medicine, and ^‡Laboratory Medicine

Mayo Clinic, Arizona

Phoenix, Arizona

Clinical History: A 25-year-old man with no previous medical history presented to the Emergency Room with complaints of worsening non-productive cough and fever to 102°F over the previous 7 days. The patient also complained of some nausea, vomiting, and generalized muscle aches. The patient denies rhinorrhea, sore throat, congestion, and diarrhea. The patient also illicit drug use, and drinks alcohol only occasionally. He said he previously smoked 1-2 packs-per day, having quit 6 months earlier.

The patient’s physical examination showed normal vital signs, although his respiration rate was approximately 18/minute. The physical examination showed some mild basilar crackles bilaterally, but was otherwise entirely within normal limits.

Basic laboratory data showed a white blood cell count near the upper of normal= 10.3 x 10⁹ / L (normal, 4–10.8 x 10⁹/L) with a normal platelet count and no evidence of anemia, normal serum chemistries and renal function parameters, and normal liver function tests. The patient was referred for chest radiography (Figure 1).

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

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to be directed to the second of fourteen pages)

1. The chest radiograph shows bilateral consolidation
2. The chest radiograph shows findings suggesting increased pressure pulmonary edema
3. The chest radiograph shows mediastinal and peribronchial lymph node enlargement
4. The chest radiograph shows mild perihilar infiltration
5. The chest radiograph shows normal findings

Cite as: Panse PM, Feller FF, Butt YM, Gotway MB. February 2020 imaging case of the month: an emerging cause for infiltrative lung abnormalities. Southwest J Pulm Crit Care. 2020;20(2):43-58. doi: https://doi.org/10.13175/swjpcc004-20 PDF 

Medical Image of the Month: Radiation-induced Organizing Pneumonia

Figure 1. Axial contrast enhanced CT depicting marked skin thickening of the right breast with fibrotic changes in the adjacent costal lung parenchyma.

Figure 2. Axial/Coronal CT images in lung window showing central ground glass attenuation with surrounding consolidation areas in both lung fields involving regions beyond the radiation field.

Radiotherapy post breast conserving surgery has been in vogue for the treatment of early breast cancer. Organizing pneumonia is one of the responses the lung has to acute lung injury. However, an unusual organizing pneumonia is being recognized with peculiarity of involving the lung zones beyond the actual irradiated parenchyma. Clinically patients may be asymptomatic or present with fever, nonproductive cough, dyspnea, malaise, fatigue and weight loss. The “reverse halo” sign describes the central ground glass haze surrounded by consolidation. Subsequent imaging may reveal migratory infiltrates.

The recognition of this entity is important as a differential with a good prognosis. Though the response to steroids is marked, radiation-induced organizing pneumonia can quickly relapse once the steroid is withdrawn (1,2).

Saika Amreen MD, Nidha Nazir MBBS, Naseer A. Choh MD, and Tariq Gojwari MD.

Department of Radiodiagnosis

Sher-i-Kashmir Institute of Medical Sciences (SKIMS)

Soura, Srinagar, India

References

1. Takigawa N, Segawa Y, Saeki T, et al. Bronchiolitis obliterans organizing pneumonia syndrome in breast-conserving therapy for early breast cancer: radiation-induced lung toxicity. Int J Radiat Oncol Biol Phys. 2000 Oct 1;48(3):751-5. [CrossRef] [PubMed]
2. Otani K, Seo Y, Ogawa K. Radiation-induced organizing pneumonia: a characteristic disease that requires symptom-oriented management. Int J Mol Sci. 2017 Jan 27;18(2). pii: E281. [CrossRef] [PubMed]

Cite as: Amreen S, Nazir N, Choh NA, Gojwari T. Medical image of the month: radiation-induced organizing pneumonia. Southwest J Pulm Crit Care. 2019;19(6):167-8. doi: https://doi.org/10.13175/swjpcc014-19 PDF

Medical Image of the Week: The Atoll Sign in Cryptogenic Organizing Pneumonia

Figure 1. Portable chest X-ray shows bilateral airspace opacities (yellow arrows) and possible trace pleural effusion (blue arrow).

Figure 2. Computed tomography of the chest showing (A) patchy ground glass opacity in the upper lungs with additional scattered circular areas of opacity in a reverse halo configuration (blue arrows, atoll sign) and (B) extensive bibasilar consolidation with air bronchograms.

A 54-year-old woman presented to the emergency department with cough and worsening shortness of breath. Her cough began approximately 1 month prior to presentation, at which time she was diagnosed with pneumonia by her primary care physician based on a chest X-ray at an outside institution. She tried and failed courses of azithromycin, doxycycline, and levofloxacin.

The patient had an oxygen saturation of 55% and hyperpyrexia to 101.7 F in the emergency department. An initial chest X-ray was suggestive of moderate multifocal pneumonia with pleural effusion (Figure 1). Subsequent chest computed tomography (CT; Figure 2) revealed findings consistent with cryptogenic organizing pneumonia (COP) including multiple upper lobe atoll signs. Infectious and autoimmune workups were negative and the patient experienced a rapid recovery with pulse steroids, providing further evidence for the diagnosis of COP.

CT is the best imaging modality for evaluation of potential COP. Features include consolidations and nodules, bronchial wall thickening or dilatation, and ground glass opacities (1). The atoll sign, consisting of a central ground glass opacity and surrounding consolidation which may also be called a reverse halo sign, is highly specific but not sensitive for organizing pneumonia (2). Definitive diagnosis requires lung biopsy, although the disease is often managed based on a presumptive diagnosis (3).

Joseph Frankl, BS¹ and Veronica A. Arteaga, MD²

¹University of Arizona College of Medicine and ²Department of Medical Imaging

Banner University Medical Center Tucson

Tucson, AZ USA

References

1. Lee JW, Lee KS, Lee HY, Chung MP, Yi CA, Kim TS, Chung MJ. Cryptogenic organizing pneumonia: serial high-resolution CT findings in 22 patients. AJR Am J Roentgenol. 2010 Oct;195(4):916-22. [CrossRef] [PubMed]
2. Davidsen JR, Madsen HD, Laursen CB. Reversed halo sign in cryptogenic organising pneumonia. BMJ Case Rep. 2016 Feb 8;2016. pii: bcr2015213779. [CrossRef] [PubMed]
3. Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax. 2008 Sep;63 Suppl 5:v1-58. [CrossRef] [PubMed]

Cite as: Frankl J, Artega VA. Medical image of the week: the atoll sign in cryptogenic organizing pneumonia. Southwest J Pulm Crit Care. 2017;15(2):92-3. doi: https://doi.org/10.13175/swjpcc100-17 PDF

Medical Image of the Week: Evolution of Low Grade Adenocarcinoma

Figure 1. Coned down chest CT images. Panels a-d: small ground glass focus in the right upper lobe demonstrating slow growth over a period of 10 years (yellow arrows) and gradual development of a soft tissue component (red arrows).

Ground glass lesions above 5 mm in greatest diameter found on chest computed tomography (CT) require initial followed up in 3 months according to the Fleischner Society Guidelines, to exclude a transient inflammatory focus (1). If persistent, surveillance for at least 24 months to confirm stability is recommended. Any change in size or density should warrant further action, ideally surgical consultation, given the suboptimal yield of percutaneous biopsy and risk of inappropriate staging if the whole lesion is not examined. This may result in the inability to recognize the transition from in-situ adenocarcinoma into minimally invasive or invasive lesions, which in turn results in inaccurate staging and prognosis.

Diana Palacio MD, Berndt Schmit MD, and Veronica Arteaga MD

Department of Medical Imaging

Banner-University Medical Center Tucson

Tucson, AZ USA

Reference

1. MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz EF Jr, Swensen SJ; Fleischner Society. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005 Nov;237(2):395-400. [CrossRef] [PubMed]

Cite as: Palacio D, Schmit B, Arteaga V. Medical image of the week: evolution of low grade adenocarcinoma. Southwest J Pulm Crit Care. 2017;14(3):103. doi: https://doi.org/10.13175/swjpcc026-17 PDF 

December 2015 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: An 80-year-old woman with a history of polycythemia vera (12 years), migraines, hypertension, and gastroesophageal reflux disease presented with complaints of declining functional status due to worsening shortness of breath over 3-4 weeks’ duration. She also complained of occasional palpitations. No history of fever, cough, chest pain, or hemoptysis was elicited. A frontal chest radiograph (Figure 1) was performed.

Figure 1.  Panel A: Frontal chest radiograph obtained at presentation, when the patient complained of worsening shortness of breath. Panel B: 3 years earlier.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of five panels)

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows fairly diffuse, bilateral, increased opacity
3. The frontal chest radiograph shows layering pleural effusions bilaterally
4. The frontal chest radiograph shows multifocal consolidation
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. December 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(6):254-9. doi: http://dx.doi.org/10.13175/swjpcc150-15 PDF 

Medical Image of the Week: Asbestosis

Figure 1. Thoracic CT scan in soft tissue windows showing pleural plaques (arrows).

Figure 2. Thoracic CT scan in soft tissue windows showing subpleural curvilinear opacities (arrows).

Figure 3. Panel A: ground glass opacity (arrow). Panel B: parenchymal band (arrow).

A 76-year-old man with a past medical history of diabetes mellitus, hypertension, and an unspecified industrial-related asbestos exposure presented to the hospital after a syncopal episode and a ground level fall. A computed tomography (CT) of the chest was performed on admission which revealed several abnormalities including multiple bilateral calcified pleural plaques, pleural thickening, peripheral groundglass opacities (GGO) in the nondependent portion of the lungs and subpleural reticular and band like opacities. The patient unfortunately developed alcohol withdrawal and aspiration pneumonia requiring prolonged mechanical ventilation and was unable to provide additional details regarding his lung disease.

Asbestos is a naturally occurring mineral that historically was praised for its versatility. Its properties including heat and electrical resistance, tensile strength, and insulating capabilities made it a common component in materials used in both commercial and domestic settings.  Exposure to asbestos is linked to numerous respiratory diseases, including pleural and parenchymal disease, both malignant and nonmalignant. Pleural plaques are the most common manifestation of asbestos exposure (1,2). These are distinct areas of fibrosis that usually arise from the parietal pleura. Figure 1 shows bilateral pleural plaques located over the lateral and posterior chest walls as well as along the diaphragms, which is essentially pathognomonic for this disease. Asbestosis refers to lung fibrosis caused by asbestos dusts. Regional involvement of the lung parenchyma may be more pronounced in the subpleural and basilar locations.  An early finding of asbestosis is subpleural curvilinear opacities which are felt to represent peribronchial fibrosis (Figure 2). Additional features of asbestosis include ground glass opacities in the nondependent regions (Figure 3A), bilateral parenchymal bands (Figure  3B) and small nodular opacities, particularly suggestive when present with coexistent pleural disease. Honeycombing is a finding seen in more advanced disease.

Christopher Strawter MD¹, Veronica Arteaga MD², Jarrod Mosier MD^1,3

¹Pulmonary, Allergy, Critical Care, & Sleep Medicine; ²Radiology; ³Emergency Medicine

University of Arizona

Tucson, Arizona

References

1. Roach HD, Davies GJ, Attanoos R, Crane M, Adams H, Phillips S. Asbestos: when the dust settles an imaging review of asbestos-related disease. Radiographics. 2002;22(Spec No):S167–84. [CrossRef] [PubMed]
2. Peacock C, Copley SJ, Hansell DM. Asbestos-related benign pleural disease. Clin Radiol. 2000;55:422-32. [CrossRef] [PubMed]

Reference as: Strawter C, Arteaga V, Mosier J. Medical image of the week: asbestosis. Southwest J Pulm Crit Care. 2014;9(6):309-10. doi: http://dx.doi.org/10.13175/swjpcc156-14 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

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