Medical Image of the Week: Intracavitary View of Mycetoma

Figure 1. Thoracic CT scan shows Monod’s sign, a mycetoma within an existing cavity, in the left upper lobe.

Figure 2. A: Current thoracic CT scan. B: thoracic CT scan 8 months earlier.

Figure 3. Bronchoscopic views of the cavity with intracavitary mycetoma in the left upper lobe.

A 46-year-old Hispanic man with no medical history presents to the pulmonary service for a second opinion regarding his unresolved pneumonia that initially presented as fever and cough; he did not have hemoptysis. He was found to have left upper lobe cavitary lesion and had been diagnosed with Aspergillus multiple times, with the initial diagnosis one year prior to presentation. He was seen by an outside pulmonologist and was placed on voriconazole 200 mg/day. Since being on the voriconazole he has not been feeling better. He continued to note symptoms of productive cough, fatigue, and weakness. Monod’s sign (Figure 1) is appreciated on CT imaging during initial encounter at an outside facility. Comparison of parenchymal damage is seen in Figure 2 comparing CT scans 8 months apart. Patient’s fungal cavity was appreciated on bronchoscopic exam (Figure 3). Ultimately, he was evaluated by cardiothoracic surgery and underwent a left upper lobectomy which he tolerated well.

Aspergillomas present as a mycetoma within an existing cavity. Monod’s sign is the radiographic finding of a mycetoma within the existing cavity as evidenced in the CT scan. This is not to be confused with the air-crescent sign which is seen more often with invasive aspergillosis, a separate clinical entity. This case is unique given its unique radiographic sign along with the visualization of fungal cavity from within through the bronchoscope.

Steve Tseng, DO and Raed Alalawi, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

References

1. Pesle GD, Monod O. Bronchiectasis due to aspergilloma. Dis Chest. 1954;25(2):172-183. [PubMed]
2. Thompson BH, Stanford W, Galvin JR, Kurihara Y. Varied radiologic appearances of pulmonary aspergillosis. Radiographics. 1995 Nov;15(6):1273-84. [CrossRef] [PubMed]

Cite as: Tseng S, Alalawi R. Medical image of the week: Intracavitary view of mycetoma. Southwest J Pulm Crit Care. 2018;16(6):360-1. doi: https://doi.org/10.13175/swjpcc082-18 PDF 

March 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 66 year-old man with orthotopic heart transplantation 1 year previously presented with complaints of recent-onset small volume (<1 teaspoon) hemoptysis, post-nasal drip, and night sweats. The patient indicated he had recent contact with several young grandchildren who had upper respiratory tract symptoms. The patient’s past medical history was remarkable for recurrent constrictive pericarditis (surgically treated), hypertension, type II diabetes mellitus (treated with insulin), psoriasis, sleep-disordered breathing, and grade 2 cardiac transplant rejection diagnosed 6 months earlier. The patient’s medication list included insulin, Cellcept (mycophenolate mofetil), Prograf (tacrolimus), prednisone, among others. On physical examination, the patient was mildly tachycardic (heart rate = 104 beats/minute) with an oxygen saturation on room air of 92%. The white blood cell count was within the normal range, but C-reactive protein and B-type natriuretic peptide levels were reportedly elevated.

Frontal chest radiography (Figure 1) was performed, with a radiograph from one month other also shown for comparison.

Figure 1. Frontal (A) chest radiography shows interval development of a thick-walled left lower lobe cavity since a chest radiograph performed one month previously.

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

1. The frontal chest radiograph shows a new lung cavity
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows large lung volumes with a cystic appearance
4. The frontal chest radiograph shows new peribronchial lymph node enlargement
5. The frontal chest radiograph shows new poorly defined nodular opacities bilaterally

Cite as: Gotway MB. March 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016(Mar);12(3):90-101. doi: http://dx.doi.org/10.13175/swjpcc023-16 PDF 

Medical Image of the Week: Septic Emboli

Figure 1. Panels A-F: Selected static images from the thoracic CT showing numerous septic pulmonary emboli with cavitation. Lower panel: movie of selected images from thoracic CT scan.

A 46-year-old man was admitted with altered mental status. His past medical history included HIV/AIDS on HAART therapy, hepatitis B and C, non-Hodgkin's lymphoma (NHL), deep venous thrombosis with insertion of an inferior vena caval filter, and poly-substance abuse. Vitals revealed fever and tachycardia. On exam, he was lethargic and confused, and had bilateral crackles on lung auscultation. Computerized axial tomography (CT) of the head was unremarkable and chest X-ray revealed patchy nodular infiltrates in the right upper lobe and bilateral lower lobes. Work up for an infectious cause was initiated including opportunistic infections and he was started on empiric antibiotics for pneumonia. On Day 2, his roommate who came to visit him, revealed that he was recently admitted in another hospital for headache and flu-like symptoms, and discharged with a peripherally inserted central catheter (PICC) in place as he was scheduled for a positron emission tomography (PET) the next morning for evaluation of recurrence of NHL. However, he presented for the PET scan 10 days after discharge, during which period he was abusing heroin through the PICC line. A thoracic CT was also obtained which showed innumerable scattered cavitary pulmonary opacities with peripheral ground glass opacities consistent with septic pulmonary emboli in the right and left upper lobe and right middle lobe (Figure 1). Blood and urine cultures grew methicillin-resistant Staphylococcus aureus, CD4 count was 180, cryptococcus and histoplasma antigens were negative, as were urine antigens for pneumococcus and legionella. He was also found to have deep venous thrombosis of the right upper extremity. Trans-esophageal echocardiogram was negative for valvular vegetations. He was successfully treated with vancomycin and rifampin and discharged home.

Septic pulmonary emboli are embolization of infectious particles into the lungs via the pulmonary arterial system. Septic pulmonary emboli can occur from varying sources. Patients may be asymptomatic or present with sepsis. CXR shows multiple nodules in the periphery of the lower lobes. CT chest may show feeding vessel sign (a vessel coursing directly to a nodule or mass) in 50% of patients. Early diagnosis and prompt treatment can lead to a successful outcome.

Nanditha Malakkla MD and Chandramohan Meenakshisundaram MD

St. Francis Hospital

Evanston, IL

References

1. Fidan F, Acar M, Unlu M, Cetinkaya Z, Haktanir A, Sezer M. Septic pulmonary emboli following infection of peripheral intravenous cannula. Eur J Gen Med. 2006;3:132–5.
2. Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology. 1990;174:211–3. [CrossRef] [PubMed]
3. Hind CR. Pulmonary complications of intravenous drug misuse. 1. Epidemiology and non-infective complications. Thorax 1990; 45:891-8. [CrossRef] [PubMed]

Reference as: Malakkla N, Meenakshisundaram C. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2014;9(3):183-4. doi: http://dx.doi.org/10.13175/swjpcc120-14 PDF 

Medical Image of the Week: Aspergilloma

Figure 1.  Axial thoracic computed tomography (CT) image showing emphysematous disease throughout with prominent bullous disease in the upper lobes.  Areas of consolidation were concerning for infection.  Large cavitation with particulate matter (arrow) was seen in the left upper lobe. 

A 69-year-old woman, a current smoker, with very severe chronic obstructive pulmonary disease and prior atypical mycobacterium, was found unresponsive by her family and intubated in the field by emergency medical services for respiratory distress.  Her CT thorax showed severe emphysematous disease, apical bullous disease, and a large left upper lobe cavitation with debris (Figure 1).  She was treated with broad-spectrum antibiotics and anti-fungal medications.  Hemoptysis was never seen.  Sputum cultures over a span of two weeks repeatedly showed Aspergillus fumigatus and outside medical records confirmed the patient had a known history of stable aspergilloma not requiring therapy. 

Aspergillomas usually arises in cavitary areas of the lung damaged by previous infections.  The fungus ball is a combination of colonization by Aspergillus hyphae and cellular debris.  Individuals with aspergillomas are usually asymptomatic or have mild symptoms (chronic cough) and do not require treatment unless it begins to invade into the cavity wall.  When bleeding complications arise, surgical resection is curative but in high-risk patients, embolization may be considered as a stabilizing measure. 

Wendy Hsu, MD, Carmen Luraschi-Monjagatta, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

University of Arizona 

Tucson, AZ 

Reference 

Kousha M1, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011;20(121):156-74. [CrossRef] [PubMed]

Reference as: Hsu W, Luraschi-Monjagatta C, Carr G. Medical image of the week: aspergilloma. Southwest J Pulm Crit Care. 2014;8(5):282-3. doi: http://dx.doi.org/10.13175/swjpcc044-14 PDF 

Medical Image of the Week: Coccidioidomycosis Pneumothorax

Figure 1. Right-sided pneumothorax (A) with subsequent placement of pigtail catheter and re-expansion of right lung (B).  CT shows bilateral multifocal airspace consolidation with nodules and cavitary interstitial disease (C).

Figure 2. PAP stain (A) and GMS stain (B) demonstrating Coccidioidomycosis from BAL (magnification, 400x).

A 36-year-old man with AIDS and disseminated coccidioidomycosis presented with severe right chest pain, shortness of breath, and a right-sided pneumothorax on CXR. A pigtail catheter was placed with near resolution of the pneumothorax. A bronchoscopy with bronchoalveolar lavage revealed spherules on cytology as well as coccidioidomycosis on culture. No other pathogens were identified. The pigtail catheter was removed three days later with resolution of the pneumothorax.

Rupture of subpleural coccidioidomycosis cavity into the pleural space resulting in pyopneumothorax and/or bronchopleural fistula is rare with reported rates of 1.4 – 2.6% for cavitary lesions (1).  Despite antiretroviral therapy and an undetectable viral load, disease was unresponsive to fluconazole.  Therapy was subsequently initiated with amphotericin B lipid complex, which resulted in significant improvement of his disease.

Ishna Poojary MD,  Christopher Geffre MD PhD,  Tirdad Zangeneh DO MA and Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

1. Tiu CT, Cook J, Pineros DF, Rankin LF, Lin YS, Ghitan M, Brichkov I, Shaw JP, Chapnick EK. Pneumothorax in a young man in Brooklyn, New York. Clin Inf Dis. 2011;53(12);1296-7. [CrossRef] [PubMed] 

Reference as: Poojary I, Geffre C, Zangeneh T, Campion J. Medical image of the week: coccidioidomycosis pneumothorax. Southwest J Pulm Crit Care. 2013;7(4):251-2. doi: http://dx.doi.org/10.13175/swjpcc140-13 PDF

May 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 21-year-old woman presented with complaints of cough. Frontal and lateral chest radiography (Figures 1A & B) was performed. A detail comparison chest radiograph from several years prior (Figure 1C) is presented as well.

 

Figure 1. Frontal (A) and lateral (B) chest radiography at presentation and a radiograph from several years earlier (C).

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph predominantly shows bilateral linear and reticular abnormalities
2. The chest radiograph shows a combination of nodules, masses and thin-walled cysts
3. The chest radiograph shows multifocal consolidation with air bronchograms
4. The chest radiograph shows multifocal pleural abnormalities
5. The chest radiograph shows mediastinal widening & hilar lymphadenopathy

Reference as: Gotway MB. May 2013 imaging case of the month. Southwest J Pulm Crit Care.2013;6(5):218-30. PDF