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.
Medical Image of the Week: Tumor-Induced Hypoglycemia
Figure 1. CT of the abdomen with IV contrast (axial image) demonstrating numerous large enhancing liver metastases (red oval) and tumor thrombus in the anterior segment branch of the right portal vein (arrow).
A 39 year-old man with a history of widely metastatic (brain, liver and lung) nonseminomatous germ cell tumor was admitted to the hospital with severe abdominal pain and altered mental status. A CT of the abdomen and pelvis with IV contrast revealed a marked increase in the size of the liver metastases, portal vein tumor thrombus and changes of pseudocirrhosis. There were numerous large heterogeneously enhancing masses within the liver parenchyma with central necrosis (Figure 1).
The patient had significant and sustained hypoglycemia, with the lowest glucose recorded of 30 mg/dl. He required multiple IV doses of 50% dextrose and an infusion of 10% dextrose to maintain a serum glucose level greater than 55 mg/dl. His mental status improved with treatment of the hypoglycemia. The patient decided to pursue a palliative approach to care and was discharged with home hospice services.
Tumor-induced hypoglycemia (TIH) is a paraneoplastic syndrome that is uncommon in clinical practice (1). The more common cause of TIH is insulin hypersecretion in the setting of pancreatic beta-cell tumors. Mechanisms that may lead to TIH without insulin hypersecretion include the hypersecretion by tumors of insulin-like growth factor 2 (IGF2) and it’s precursors, insulin-like growth factor 1 (IGF1), somatostatin, and glucagon-like peptide 1. Other pathogenic causes of hypoglycemia include tumor autoimmune hypoglycemia, massive tumor burden, massive tumor liver infiltration, and pituitary or adrenal gland destruction by the tumor. TIH unrelated to pancreatic tumors is called non-islet-cell tumor hypoglycemia (NICTH). The most common cause of NICTH is the hypersecretion of IGF2 and IGF2 precursors by the tumor. This results in increased glucose consumption peripherally and decreased production of glucose in the liver. We did not measure levels of IGF2 in our patient. It was felt the most likely cause of his hypoglycemia was extensive tumor invasion and destruction of the liver due to his advanced disease.
Pavan Parashar MD1, Meghan Bullock BSN, RN, OCN, Linda Snyder MD2
1Department of Medicine, Geriatrics, Palliative and General Medicine, Banner University Medical Center-Tucson
2Department of Medicine, Pulmonary, Critical Care and Palliative Medicine, Banner University Medical Center-Tucson
Reference
- Iglesias P, Díez JJ. Management of endocrine disease: a clinical update on tumor-induced hypoglycemia. Eur J Endocrinol. 2014;170(4):R147-57. [CrossRef] [PubMed]
Reference as: Parashar P, Bullock M, Snyder L. Medical image of the week: tumor-induced hypoglycemia. Southwest J Pulm Crit Care. 2015;10(5):300-1. doi: http://dx.doi.org/10.13175/swjpcc049-15 PDF
Medical Image Of The Week: Metastatic Testicular Cancer
Figure 1. Axial image of the abdomen demonstrating multiple hypodense hepatic lesions (orange oval) and a large left adrenal mass (green arrow).
Figure 2. Axial image of the abdomen with innumerable hepatic metastatic lesions and a mass arising from the left adrenal gland resulting in compression of the left kidney (red arrow) and lateral displacement of the spleen (blue arrow).
A 30 year-old man with metastatic embryonal testicular cancer was admitted to the hospital with severe abdominal pain. A contrast enhanced CT of the abdomen demonstrated large metastatic burden throughout the liver and the left adrenal gland (Figures 1 and 2). The mass arising from the left adrenal gland caused significant mass effect. The left kidney was compressed, though without hydronephrosis, and the spleen was displaced laterally. Renal and hepatic functions were preserved. His pain was controlled with opioids and oral steroids with significant improvement.
Michael Debo DO1, Linda Snyder MD2, S. Michelle Rhodes MD3.
1Department of Internal Medicine, Genesys Regional Medical Center; Grand Blanc, MI
2Departments of Medicine, Pulmonary and Critical Care and Palliative Medicine, University of Arizona Medical Center; Tucson, AZ
3Departments of Emergency Medicine, Geriatrics, Palliative and General Medicine, University of Arizona Medical Center; Tucson, AZ
Reference as: Debo M, Snyder L, Rhodes SM. Medical image of the week: metastatic testicular cancer. Southwest J Pulm Crit Care. 2014;8(6):354-5. doi: http://dx.doi.org/10.13175/swjpcc063-14 PDF