August 2023 Imaging Case of the Month: Chew Your Food Carefully

Michael B Gotway MD¹ and Yasmeen M Butt MD²

¹Departments of Radiology and ²Laboratory Medicine, Division of Anatomic Pathology

Mayo Clinic-Arizona

Scottsdale, Arizona USA

History of Present Illness

A 50-year-old woman presents with a history of chronic dyspnea and cough, becoming particularly problematic following COVID-19 infection 4 months prior to presentation. While she did experience significant periodic oxygen desaturations during her COVID-19 infection, she was not hospitalized for this illness. The patient also reported wheezing in the previous few weeks. 

Past Medical History, Family History and Social History

The patient’s past medical history was also notable for gastroesophageal reflux disease as well as both Coombs positive and iron deficiency anemia. She reports a history of asthma, well controlled with inhaler use.

The patient’s past surgical history included adenoidectomy, cholecystectomy, and gastric laparoscopic band placement.

Her medications included prednisone (20 mg daily), dextroamphetamine-amphetamine, furosemide, omeprazole, fluoxetine, zolpidem (Ambien), daily Bactrim, occasional Loratadine (Claritin). She also utilized an albuterol inhaler and Fluticasone-based (both Flonase and Breo Ellipta) inhalers.

The patient is a former smoker, ½ pack-per day for 26 years, having quit 11 years prior to presentation. She also reported a history of vaping (agent inhaled unclear) for 8 years, quitting 3 years earlier. She has no known allergies. She drinks alcohol socially and denied illicit drug use.

Physical Examination

The patient’s physical examination showed her temperature to be 99°F with normal pulse and respiratory rate but her blood pressure elevated at 160/90 mmHg. She was obese (263 lbs., BMI= 41). Bilateral basal rales were noted at her examination, but no other abnormal physical examination findings were detected.

Laboratory Evaluation

The patient’s room air pulse oximetry was 85%. A complete blood count showed an upper normal white blood cell count at 1.9 x10⁹/L (normal, 4.5 – 11 x10⁹/L). Her hemoglobin and hematocrit values were 10.7 gm/dL (normal, 12 – 16 gm/dL) and 37.1% (normal, 36 – 46%). The patient’s serum chemistries and liver function studies were entirely normal. The patient had an elevated anti-nuclear antibody titer at 1:320. An echocardiogram noted diastolic dysfunction but normal left ventricular contractility.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography.

Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the second of 11 pages)

1. Frontal chest radiography shows normal findings
2. Frontal chest radiography shows marked cardiomegaly
3. Frontal chest radiography shows mediastinal lymphadenopathy
4. Frontal chest radiography shows pleural effusion
5. Frontal chest radiography shows multifocal peribronchial consolidation

Cite as: Gotway MB, Butt YM. August 2023 Imaging Case of the Month: Chew Your Food Carefully. Southwest J Pulm Crit Care Sleep. 2023;27(2):15-22. doi: https://doi.org/10.13175/swjpccs034-23 PDF

May 2021 Imaging Case of the Month: A Growing Indeterminate Solitary Nodule

Joseph Jeehoon Kim, MD^°

Kenneth K. Sakata, MD^‡

Natalya Azadeh, MD, MPH^‡

Maxwell Smith, MD^↑

Michael B. Gotway, MD^†

^°Department of Medicine, Mayo Clinic Arizona

^↑Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona

^‡Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona

^†Department of Radiology, Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

A 58-year-old woman with a history of orthotopic heart transplant, performed for Adriamycin-induced cardiomyopathy, treated with mycophenolate and tacrolimus, presented for routine interval follow up. The patient’s past medical history was significant for follicular thyroid carcinoma treated with total thyroidectomy and bilateral breast carcinoma in remission as well as hypothyroidism and type II diabetes mellitus. In addition to tacrolimus and mycophenolate, the patient’s medications included aspirin, insulin, itraconazole (for anti-fungal prophylaxis), levothyroxine, prednisone (tapering since transplant), and valganciclovir. The patient recently complained of rhinorrhea and cough productive of brown-tinged sputum, improving over the previous 2 weeks; she denied fever, chills, shortness of breath, night sweats chest pain, or gastrointestinal symptoms.

Physical examination showed the patient to be afebrile with normal heart and respiratory rates and blood pressure. Her room air oxygen saturation was 99%.

The patient’s complete blood count and serum chemistries showed largely normal values, with the white blood cell count at the upper normal at 9.7 x 10⁹ /L (normal, 4-10 x 10⁹ /L). Her liver function testing and renal function testing parameters were also within normal limits. Echocardiography showed normal left ventricular systolic function. The patient underwent frontal chest radiography (Figure 1).

Figure 1. Frontal chest radiography.

Which of the following represents an appropriate interpretation of her frontal chest radiograph? (Click on the correct answer to be directed to the second of nine pages). 

1. Frontal chest radiography shows a right pleural effusion
2. Frontal chest radiograph shows a left apical nodule
3. Frontal chest radiography shows multifocal consolidation
4. Frontal chest radiography shows peribronchial and mediastinal lymphadenopathy
5. Frontal chest radiography shows cardiomegaly

Cite as: Kim JHJ, Sakata KK, Azadeh N, Smith M, Gotway MB. May 2021 Imaging Case of the Month: A Growing Indeterminate Solitary Nodule. Southwest J Pulm Crit Care Med. 2021;229(5):88-99. doi: https://doi.org/10.13175/swjpcc013-21 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: Hot Tub Lung

Figure 1. Chest radiograph showing diffuse micronodular disease.

Figure 2. Representative images from the thoracic CT scan confirming diffuse micronodular disease with a centrilobular distribution.

Figure 3. Lung biopsy from VATS showing granulomas. Panel A: Low power view. Panels B & C: High power views.

The patient is a 65-year-old man with progressively worsening shortness of breath for 2 months. He had a past medical history of type 2 diabetes mellitus, hypertension, hypothyroidism and a 40 pack-year history of smoking. He suffered from chronic neck pain and sought relief by spending up to 6 hours daily in a hot tub. Chest x-ray (Figure 1) showed numerous small nodules which were confirmed on thoracic CT (Figure 2). The nodules spared the pleural space consistent with a centrilobular distribution. Bronchoscopy with bronchoalveolar lavage grew Mycobacterium avium intracellulare (MAC) and a lung biopsy obtained by video-assisted thorascopic surgery (VATS) showed non-caseating granulomas (Figure 3). Culture of the hot tub water also grew MAC.  He was advised to stop using the hot tub and was treated with prednisone, clarithromycin, rifampin and ethambutol. He rapidly improved though he stopped his therapy after about 3 weeks due to intolerance.  He continued to do well and was asymptomatic when last seen.

Hot tub lung may represent either an infectious process or a hypersensitivity pneumonitis to MAC inhaled from the hot tub. Improvement is usually seen with prednisone, anti-MAC therapy or both (1). The thoracic CT findings are consistent with subacute hypersensitivity pneumonitis including areas of ground-glass attenuation, centrilobular nodules, and air trapping on expiratory images (2). Granulomas, a compact collection of macrophages, are a nonspecific finding seen in both infectious (mycobacteria and fungi) and noninfectious lung diseases (sarcoidosis, hypersensitivity pneumonitis, hot tub lung, and several others) (3). In our patient’s case the clinical history, radiologic findings, lung histology and rapid improvement with removal of MAC exposure are all consistent with hot tub lung.

Allen R. Thomas, MD

Phoenix VA

Phoenix, AZ USA

References

1. Khoor A, Leslie KO, Tazelaar HD, Helmers RA, Colby TV. Diffuse pulmonary disease caused by nontuberculous mycobacteria in immunocompetent people (hot tub lung). Am J Clin Pathol. 2001 May;115(5):755-62. [CrossRef] [PubMed]
2. Hartman TE, Jensen E, Tazelaar HD, Hanak V, Ryu JH.CT findings of granulomatous pneumonitis secondary to Mycobacterium avium-intracellulare inhalation: "hot tub lung". AJR Am J Roentgenol. 2007 Apr;188(4):1050-3. [CrossRef] [PubMed]
3. Hutton Klein JR, Tazelaar HD, Leslie KO, Colby TV. One hundred consecutive granulomas in a pulmonary pathology consultation practice. Am J Surg Pathol. 2010 Oct;34(10):1456-64. [CrossRef] [PubMed]

Cite as: Thomas AR. Medical image of the month: hot tub lung. Southwest J Pulm Crit Care. 2018;17(3):93-4. doi: https://doi.org/10.13175/swjpcc077-18 PDF 

Medical Image of the Week: Leukemic Infiltrates

Figure 1. AP portable chest x-ray demonstrating diffuse bilateral infiltrates.

Figure 2. Histology showing extensive interstitial and perivascular lymphocytic infiltrates.

Figure 3. Immunohistochemical staining for CD8 positive T-cell immunophenotype.

A 50 year-old white man with newly diagnosed, acute T-cell prolymphocytic leukemia presented with progressive exertional dyspnea and non-productive cough. The patient was due to meet with his hematologist that day to discuss initiation of treatment. The patient had not noted fever, chills, night sweats, chest pain, or lower extremity swelling. Blood pressure was 112/60 mm Hg, respiratory rate was 36/minute and labored, pulse was 110/minute and temperature was 37 degrees Celsius. Oxygen saturation measured by pulse oximetry was 62% on room air at rest, and rose to 90% after the application of a 100% non-rebreather mask. Diffuse rales were present on chest auscultation. Marked splenomegaly was present on abdominal examination. Peripheral white blood count was 112.2 K/ul with 99% lymphocytes. Smudge cells were noted. Hemoglobin was 12.9 g/dl and platelet count was 93K/ul. Procalcitonin level was 0.3 pg/ml. The chest radiograph demonstrated diffuse bilateral infiltrates (Figure 1). The patient developed rapidly progressive hypoxemia, was intubated orally, and mechanical ventilation was initiated. Lung biopsies were performed via a video-assisted thoracic surgical approach of the right middle and right lower lobes. Microscopic examination demonstrated extensive leukemic infiltration of the pulmonary interstitium and perivascular space (Figure 2). Immunohistochemical staining showed that the infiltrating cells expressed a CD8 positive T-cell immunophenotype (Figure 3) pattern similar to the patient’s peripheral blood flow cytometry study. Therapy began with an escalating dose of alemtuzumab and intermittent pentostatin, but the patient developed progressive multi-organ failure and expired.

Acute T-cell prolymphocytic leukemia is an aggressive mature T-cell leukemia usually characterized by peripheral blood lymphocytosis and splenomegaly (1). Extramedullary involvement most commonly affects the skin (2). Diffuse interstitial and perivascular pulmonary involvement with respiratory failure has not been previously reported. Pathological involvement of the pulmonary interstitial space should be considered in patients with acute T-cell prolymphocytic leukemia and respiratory insufficiency.

Charles J. VanHook1, Carlyne Cool2, Todd DeBoom3, Robert Fisher4, and

Douglas J. Tangel1

1Department of Intensive Care Medicine

Longmont United Hospital

Longmont, CO

2Department of Pathology and Department of Medicine

University of Colorado and National Jewish Health

Denver, CO

3Department of Pathology

Longmont United Hospital

Longmont, CO

4Department of Oncology

Longmont United Hospital

Longmont, CO

References

1. Dearden CE. T-cell prolymphocytic leukemia. Med Oncol. 2006;23(1):17-22. [CrossRef] [PubMed]
2. Valbuena JR, Herling M, Admirand JH, Padula A, Jones D, Medeiros LJ. T-cell prolymphocytic leukemia involving extramedullary sites. Am J Clin Pathol. 2005;123(3):456-64. [CrossRef] [PubMed]

Reference as: VanHook CJ, Cool C, DeBoom T, Fisher R, Tangel DJ. Medical image of the week: leukemic infiltrates. Southwest J Pulm Crit Care. 2015;10(5):235-7. doi: http://dx.doi.org/10.13175/swjpcc043-15 PDF

Medical Image of the Week: Pulmonary Herniation

Figure 1. Thoracic CT scan.

  Figure 2. Saggital view of thoracic CT scan.

A 49-year-old obese gentleman with a known history of chronic obstructive pulmonary disease, diabetes mellitus and GERD presented with complaints of a popping sensation in his left chest with coughing and deep breathing, associated with pain at the same site. Physical examination showed small bulge at the level of the herniation that was most obvious with coughing. CT scan of chest done 2 months ago showed 2. 5 cm pulmonary hernia identified at the left 7-8 costal interspace (Figures 1 and 2). This was thought to have resulted from an open lung biopsy of his left lung done 4 years before presentation to evaluate for acute respiratory failure or chest tube insertion at same site 3 years prior to presentation for treatment of a pneumothorax. Surgical repair was done with round Bard Kugel hernia patch. His symptoms resolved after the procedure.

Ramasubramanian Baalachandran MD, Naser Mahmou  MD, and Laura Meinke MD

Department of Medicine

University of Arizona – School of Medicine

Tucson, Arizona.

Reference

1. Fackeldey V, Junge K, Hinck D, Franke A, Willis S, Becker HP, Schumpelick V. Repair of intercostal pulmonary herniation. Hernia. 2003;7(4):215-7. [CrossRef] [PubMed]

Reference as: Baalachandran R, Mahmou N, Meinke L. Medical image of the week: pulmonary herniation. Southwest J Pulm Crit Care. 2014;9(4):197-8. doi: http://dx.doi.org/10.13175/swjpcc122-14 PDF