April 2018 Imaging Case of the Month

Robert W. Viggiano, MD*

Michael B. Gotway, MD**

*Pulmonary Department and **Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 65-year-old non-smoking man with a past medical history significant for hyperlipidemia, hypertension, coronary artery disease, and pacemaker placement, presented for a routine medical evaluation.

The patient was allergic to penicillin, and his list of medications included aspirin, a diuretic, an ACE inhibitor, and a statin, in addition to over-the-counter vitamin supplements. Laboratory evaluation showed a normal complete blood count, electrolyte panel, and liver function tests. Frontal and chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography performed at presentation (A) and three years earlier (B).

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 ten pages)

1. Chest frontal imaging shows a mediastinal mass
2. Chest frontal imaging shows bilateral peribronchial and mediastinal lymph node enlargement
3. Chest frontal imaging shows bilateral pleural fluid collections
4. Chest frontal imaging shows focal masses
5. Chest frontal imaging shows reduced lung volumes with basilar fibrotic changes

Cite as: Viggiano RW, Gotway MB. April 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(4):194-205. doi: https://doi.org/10.13175/swjpcc056-18 PDF

Medical Image of the Week: Tortuosity of Thoracic Aorta Mimicking a Lung Mass

Figure 1. PA (A) and lateral (B) chest X-ray showing a 5x4 cm round mass with sharp margins in retrocardiac area.

Figure 2. A-C: Initial CT image showing thoracic aorta acutely angulated above the diaphragm and crossing to the right side of the chest. Then the aorta acutely angulates again and descends into the abdomen on the right. D: Follow-up CT image after 2 years showing saccular dilatation of transverse area of thoracic aorta.

An 83-year-old female presented with epigastric discomfort and nausea for 1 month. Her past medical history included hypertension and osteoarthritis. Her vital signs at were unremarkable. Her electrocardiogram revealed only atrial premature beats. Laboratory examination, including complete blood count, liver function test, blood urea nitrogen, creatinine, and electrolytes were normal.

Esophagogastroduodenoscopy revealed minimal changes of reflux esophagitis, erosive gastritis, and extrinsic compression of lower esophagus. Her chest x-ray (Figure 1) showed a 5x4 cm sized round retrocardiac mass with sharp margin. Chest CT was ordered to evaluate the lung mass and it revealed that acutely angulated lower thoracic aorta which crossed from left to right above the left diaphragm (Figure 2). After treatment with a proton pump inhibitor and a gastrointestinal pro-motility agent, her symptoms gradually decreased. Follow-up CT after 2 years shows saccular dilatation of the transverse area of thoracic aorta (Figure 2D), however, she has no specific symptoms.

Abnormal vascular structures like a severe tortuous thoracic aorta occasionally can be confused with a lung mass or neoplasm. The most common cause of aortic disease mimicking lung mass on CXR is an aortic aneurysm (1). Some cases have reported an intervention or even an operation being performed. The symptoms of tortuosity of thoracic aorta are varied from asymptomatic to dysphagia, gastroesophageal reflux, nausea and vomiting (2). Therefore, clinical symptom is not helpful to diagnose the underlying cause. As in this case, chest computed tomography (CT) can be beneficial for the differential diagnosis between vascular lesion and lung mass. Chest CT also gives additional information for communication of the aneurysm with the aorta, relationship of vascular structure to mediastinal organs. In children, Loeys-Dietz syndrome or arterial tortuosity syndrome should be considered (3). If aortic aneurysm or tortuosity of aorta is diagnosed as a cause in older age, close observation should be performed because of the possibility of progression to aortic aneurysm, dissection or compression of adjacent organs.

Jong Seol Park, MD and Yong Sung Kim, MD, PhD

Department of Internal Medicine

Wonkwang University Sanbon Hospital

Gunpo, Korea

References

1. Wixson D, Baltaxe HA, Sos TA. Pitfalls in the plain film evaluation of the thoracic aorta: the mimicry of aneurysms and adjacent masses and the value of aortography. Part I. Transverse aortic arch. Cardiovasc Radiol. 1979 Apr 27;2(2):69-76. [CrossRef] [PubMed]
2. Badila E, Bartos D, Balahura C, Daraban AM. A rare cause of Dysphagia - Dysphagia aortica - complicated with intravascular disseminated coagulopathy. Maedica (Buchar). 2014 Mar;9(1):83-7. [PubMed]
3. Na KJ, Park KH. Multiple aortic operations in loeys-dietz syndrome: report of 2 cases. Korean J Thorac Cardiovasc Surg. 2014 Dec;47(6):536-40. [CrossRef] [PubMed] 

Cite as: Park JS, Kim YS. Medical image of the week: tortuosity of thoracic aorta mimicking a lung mass. Southwest J Pulm Crit Care. 2017;15(2):80-1. doi: https://doi.org/10.13175/swjpcc086-17 PDF 

January 2016 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

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 44 year-old man presented with refractory heart failure following the relatively asymptomatic detection of severe aortic regurgitation at auscultation 11 years earlier. When the valvular disease was discovered, the patient’s left ventricular ejection fraction was 25%. He underwent open aortic valvular replacement and his systolic function stabilized on medication in the years that followed, but eventually his cardiac function deteriorated further and he was listed for cardiac transplant.

As part of the pre – transplant evaluation frontal and lateral chest radiography (Figure 1) was performed.

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

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

1. The frontal chest radiograph shows a relatively circumscribed opacity at the left base
2. The frontal chest radiograph shows abnormal mediastinal contours
3. The frontal chest radiograph shows basal predominant fibrotic abnormalities
4. The frontal chest radiograph shows large lung volumes with a cystic appearance
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. January 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;12(1):13-9. doi: http://dx.doi.org/10.13175/swjpcc001-16 PDF

Medical Image of the Week: Virtual Anatomical Dissociation During Electromagnetic Navigation Bronchoscopy

Figure 1. During the first navigation virtual bronchoscope image and 3D map (top left and bottom left) show the tip of the locatable guide in the posterior segment of the right upper lobe matching live video bronchoscope image.

Figure 2. Second navigation: the virtual bronchoscope image and 3D map (top left and bottom left) show the tip of the bronchoscope in the right main bronchus whereas the video bronchoscope shows the tip in the posterior segment of the right upper lobe.

A 59 year-old woman with a 40 pack-year smoking history was referred to our practice with a 2.5 cm spiculated right upper lobe lung nodule for a diagnostic bronchoscopy.

We performed electromagnetic navigation bronchoscopy under general anesthesia in the operating room. After successfully navigating to the lesion and obtaining 3 needle biopsy samples and two cytology brush samples we lost target alignment. After attempting to rotate and reposition the catheter several times it was decided to re-navigate from the trachea. Two images comparing virtual navigation to real anatomy during the first and second navigation attempts are provided bellow (Figures 1 and 2).

Why are the virtual images different? (Click on the correct answer for a discussion)

1. It is an artifact from respiratory movements
2. The locatable guide is outside the sensing volume
3. You should suspect a pneumothorax
4. Your registration procedure was suboptimal, you should repeat it.

Cite as: Vazquez-Guillamet R, Horn E, Sarver R, Melendres L. Medical image of the week: virtual anatomical dissociation during electromagnetic navigation bronchoscopy. Southwest J Pulm Crit Care. 2015;11(5):238-9. doi: http://dx.doi.org/10.13175/swjpcc111-15 PDF

Medical Image of the Week: Superior Vena Cava Syndrome

Figure 1. Contrast-enhanced CT of the chest in the arterial phase in the coronal plane demonstrates a large paratracheal mass (blue circle) that is invading the SVC resulting in the tumor thrombus noted in right heart chambers.

Figure 2. Contrast-enhanced CT of the chest in the arterial phase at the level of the right atrium (blue arrow), tricuspid annulus (yellow arrow), and right ventricle (green arrow) demonstrates a thrombus extending from the right atrium across the tricuspid valve in to the right ventricle.

A 65 year old Native American man with past medical history significant for hypertension presented with a two week history of generalized edema, most prominent in the face and upper extremities. The patient had gained 30 lbs in the previous 6 months. He denied any fever, night sweats, dyspnea, hemoptysis, change in voice, chest pain, abdominal pain, nausea, vomiting, or hematemesis but did acknowledge a 40+ pack-year smoking history. Family history was significant for two brothers deceased from lung cancer. On presentation, he was hemodynamically stable, had visibly distended neck veins and collateral veins on the chest and abdomen. Routine laboratory tests included a comprehensive metabolic panel remarkable for mild transaminitis, complete blood count with thrombocytopenia (69,000) and mild anemia (hemoglobin 13.5).  Urinalysis and infectious workup were unremarkable. A CT chest/abdomen/pelvis confirmed superior vena cava (SVC) syndrome from a thrombus in the right atrium extending cephalad into the SVC and left brachiocephalic vein. Patient was started on dexamethasone 4mg every 6 hours and a heparin drip. A fine needle biopsy of the large mediastinal paratracheal mass showed non-small cell lung carcinoma.  He received cycle 1 of carboplatin and docetaxel. Five days after chemotherapy, patient had large volume hemoptysis. Repeat CTA chest demonstrated enlargement of the right suprahilar mass invading the mediastinum/SVC with extension into the right atrium and crossing into the right ventricle (Image 1 and 2). Considering severity of the disease and poor prognosis patient and patient’s family accepted comfort care.

SVC syndrome results from mechanical obstruction of the SVC. Dyspnea, facial swelling and distended neck veins are the characteristic clinical manifestations (1). In the era of antibiotics, 70-90% of cases are due to mediastinal malignancies (2). Symptomatic relief with steroids, radiation/chemotherapy and intravascular stents are mainstays of emergent treatment (1). However, similar to our case, due to aggressive nature of the disease the mortality is inevitable.

Manjinder Kaur DO, Charity Adusei MS III, Tammer Elaini MD, and Laura Meinke MD

Department of Medicine

The University of Arizona and Sourthern Arizona VA Health Care System

Tucson, AZ, USA

References

1. Khan UA, Shanholtz CB, McCurdy MT. Oncologic mechanical emergencies. Emerg Med Clin North Am. 2014;32(3):495-508. [CrossRef] [PubMed]
2. Rossow CF, Luks AM. A 68-year-old woman with hoarseness and upper airway edema. Ann Am Thorac Soc. 2014;11(4):668-70. [CrossRef] [PubMed]

Cite as: Kaur M, Adusei C, Elaini T, Meinke L. Medical image of the week: superior vena cava syndrome. Southwest J Pulm Crit Care. 2015;11(3):114-5. doi: http://dx.doi.org/10.13175/swjpcc084-15 PDF

November 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 38-year-old non-smoking woman presented with complaints of intermittent dry cough, occasional vomiting, and dyspnea, occasionally with fever and chills. She indicated that she has suffered recurrent bouts of bronchitis and pneumonia annually over the previous 10 years. The patient had a history of upper arm localized melanoma resection 10 years earlier. She had smoked for 10 years, but quit one year prior to presentation. Her past medical and surgical histories were otherwise unremarkable.

Frontal and lateral chest radiography (Figure 1) was performed.

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

Which of the following statements regarding the chest radiograph is most accurate? (click on the correct answer to proceed to the next panel)

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows mild, bilateral, streaky central opacities, possibly reflecting airway thickening
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows volume loss involving the right thorax with a mass-like opacity projected over the right hilum

Reference as: Gotway MB. November 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(5):264-77. doi: http://dx.doi.org/10.13175/swjpcc147-14 PDF

Medical Image of the Week: Metastatic Melanoma with Hemorrhage

Figure 1. Axial image of CT Chest with contrast showing pulmonary metastatic masses and alveolar opacities consistent with pulmonary hemorrhage.

Figure 2. Coronal image of CT Chest with contrast showing innumerable pulmonary nodules and masses along with ground-glass alveolar opacities representing alveolar hemorrhage.

A 62 year-old gentleman presented with right leg swelling due to an extensive DVT in the right femoral vein.  He was found to have a right groin mass attributed to metastatic malignant melanoma.  Chest X-ray and CT revealed multiple bilateral pulmonary nodules.  He was started on warfarin 3mg daily for acute DVT and referred to Oncology.  2 weeks later he developed hemoptysis and was found to be hypoxemic.  He was admitted to our MICU.  His INR upon admission was 8.2 and hemoglobin 6.4.  CT Chest showed innumerable bilateral pulmonary nodules and ground-glass alveolar opacities with thickening and nodularity of intra-lobular septa adjacent to the nodules.  Warfarin was held and packed RBC and FFP transfusions were given with progressive improvement in hemoptysis and pulmonary status.

Tauseef Afaq Siddiqi, MD; Abdulmajid Eddib, MD; Phillip Factor, DO; and Steven Knoper, MD

Department of Medicine

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ 85724, USA

Reference as: Siddiqi TA, Eddib A, Factor P, Knoper S. Medical image of the week: metastatic melanoma with hemorrhage. Southwest J Pulm Crit Care. 2013;6(6):287-8. http://dx.doi.org/10.13175/swjpcc079-13 PDF

Medical Image of the Week: Right Neck Mass with Thoracic Extension

Figure 1. Coronal MRI image showing cavitary lesion (1.9 cm, yellow arrow) in the right lower lobe and multiple enlarged mediastinal and hilar lymph nodes with the largest lymph node measuri 2 x 2.5 cm.

Figure 2. Coronal MRI image of neck showing ill-defined infiltrative mass (2.8 x 4.1 x 6.4 cm, yellow star) in the right lateral neck posterior to the sternocleidomastoid muscle and jugular vein.

Figure 3. Right upper lobe endobronchial lesion (yellow arrow).  Biopsy showed Coccidioides spherules.

Figure 4. Hematoxylin and eosin (upper panel) and Gomori's methenamine silver stain stains of 4R lymph node showing Coccidioides spherule.

A 28-year-old female with a history of chronic pancreatitis s/p total pancreatectomy and auto-islet cell transplantation developed a progressively enlarging right neck mass of 4 weeks duration. Coccidioides IgM antibodies were negative and IgG antibodies were positive by immunoassay (EIA), with titers 1:4 by complement fixation (CF).  Fine needle aspiration with subsequent excisional biopsy of the right neck mass was performed and showed reactive lymphoid hyperplasia without fungal elements.  Bronchoscopy with right upper lobe endobronchial biopsy and 4R lymph node endobronchial ultrasound-fine needle aspiration revealed granulomatous inflammation and Coccidioides spherules on Gomori's methenamine silver stain.  Fungal cultures from the right neck mass fine needle aspiration, endobronchial biopsy, and 4R lymph node grew Coccidioides after three weeks of culture.

Tauseef Afaq Siddiqi, MD¹

Candy Wong, MD¹

Robert Ricciotti, MD²

Afshin Sam, MD¹

¹ Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine 

² Department of Pathology

University of Arizona

Tucson, AZ 85724

Reference as: Siddiqi TA, Wong C, Ricciotti R, Sam A. Medical image of the week: right neck mass with thoracic extension. Southwest J Pulm Crit Care. 2013;6(5):196-8. PDF

December 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 40-year-old man presented with persistent left chest and flank pain one year following emergent spine surgery for a traumatic burst fracture of L2 associated with left diaphragmatic injury. Frontal chest radiography (Figure 1) was performed.

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

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

1. The chest radiograph shows left lower lobe mass-like consolidation
2. The chest radiograph shows diffuse interstitial thickening
3. The chest radiograph shows a large left pleural effusion
4. The chest radiograph shows a left-sided mediastinal mass
5. The chest radiograph shows a left hydropneumothorax

Reference as: Gotway MB. December 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:286-91. PDF

June 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 46 -year-old man presents to the emergency room with hemoptysis. Frontal and lateral chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal and lateral chest radiography shows a lobulated, circumscribed lesion within the left hilum. The right hilum appears normal, no lung consolidation is present, and no pleural abnormalities are seen. There is no evidence of mediastinal lymph node enlargement. There is relative lucency involving the left lung, particularly the left upper lobe, compared with the right side.

Which of the differential diagnostic considerations listed below is the least likely consideration for the appearance of the lesion on the chest radiograph?

1. Bronchogenic carcinoma
2. Adenoid cystic carcinoma
3. Carcinoid tumor
4. Sarcoidosis
5. Allergic bronchopulmonary aspergillosis

 Reference as: Gotway MB. June 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:214-21. (click here for a PDF version of the manuscript)