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.

Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Necrotizing Soft Tissue Infection

Figure 1. Axial view showing extensive gluteal and perineal soft tissue inflammation with gas formation (arrow).

 

Figure 2. Saggital view showing gas formation (arrow).

 

A 70-year-old man with a history of coronary artery disease, chronic back pain, and general debilitation presented to the emergency department with complaints of fever, weakness and right buttock discomfort. Physical exam was remarkable for a temperature of 101.7º F, and for moderate erythema of the skin of the right inguinal area and right buttock, with associated tenderness. Laboratory exam was significant for a WBC of 22.7 K/ɥL, erythrocyte sedimentation rate of 82 mm, and serum creatinine phosphokinase of 2856 U/L. CAT of the abdomen and pelvis demonstrated extensive gluteal and perineal soft tissue inflammation with gas formation, consistent with a necrotizing soft tissue infection (Figures 1 and 2).

Three basic subsets of necrotizing soft tissue infections (NSTIs) have been described. Type I infections are the most common form and are characterized by a polymicrobial process typically involving gram positive cocci, gram negative rods, and anaerobes. Type I infections occur most commonly in diabetics, in patients with severe peripheral vascular disease, or in the presence of other immune compromising conditions.  Type II infections involve Group A Streptococcus, either alone or in combination with Staphylococcus aureus. Type II NSTI’s occur most commonly in immunocompetent hosts. Type III NSTI’s, caused by Vibrio vulnoficus, are found in patients with exposure to warm sea water, with liver disease being the most common predisposing condition (1-3). Fournier’s gangrene is a NSTI that involves the perineum (2).

Physical examination often reveals fever and local erythema or tenderness. Gas formation may be present on imaging studies, with CAT scans more sensitive than plain films (1). Treatment relies on early antibiotic therapy with anaerobic coverage, fluid resuscitation, and aggressive debridement. Hyperbaric oxygen therapy may have a role as well (1). Mortality is high, in the range of 40%, and recovery is often prolonged (1,3).

Angela Taylor MD, Milena Beer PA, and Charles J. VanHook MD

Longmont United Hospital

Longmont, Colorado USA

References

  1. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. [CrossRef] [PubMed]
  2. Pucket Y, Fisher B, Dissanaike S. Clinical comparison of Fournier's gangrene to other necrotizing soft tissue infections. Research Journal of Infectious Diseases. 2015;3:1. [CrossRef]
  3. Khamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Yodluangfun S, Tantraworasin A. Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthc Policy. 2015 Feb 16;8:1-7. [CrossRef] [PubMed] 

Cite as: Taylor A, Beer M, VanHook CJ. Medical image of the week: necrotizing soft tissue infection. Southwest J Pulm Crit Care. 2016 Mar;12(3):102-3. doi: http://dx.doi.org/10.13175/swjpcc005-16 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Cheyne-Stokes Respiration

Figure 1. Cheyne-Stokes Breathing pattern seen. The red arrow indicates the cycle time which is defined as the duration of the central apnea (or hypopnea) + the duration of a respiratory phase.

A 62 year-old male with a past medical history congestive heart failure, chronic obstructive pulmonary disease, and obesity with a body mass index of 38.02 kg/m2 underwent an overnight polysomnogram for clinical suspicion for obstructive sleep apnea. He was found to have a periodic breathing as seen in the image above.

Cheyne-stokes respiration (CSR) is a type of periodic breathing characterized by crescendo-decrescendo pattern of respiration separated by central sleep apneas (CSA) or hypopneas (1). CSR-CSA may be seen in up to 15-37% of systolic heart failure patients (2,3). A longer cycle length, usually between 45-90 seconds, as well as the waxing and waning breathing pattern differentiate CSR from other forms of cyclic central apnea. CSA leads to chronically increased sympathetic activity and exerts multiple deleterious effects on the failing heart (2). The presence of CSR has been associated with higher mortality and rapid deterioration in cardiac function (4).

Jared Bartell and Safal Shetty, MD

University of Arizona Medical Center

Tucson, AZ

References

  1. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM; American Academy of Sleep Medicine. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012;8(5):597-619. [CrossRef]  [PubMed]
  2. Yumino D, Bradley TD. Central sleep apnea and Cheyne-Stokes respiration. Proc Am Thorac Soc. 2008;5(2):226-36. [CrossRef] [PubMed]
  3. Garcia-Touchard A, Somers VK, Olson LJ, Caples SM. Central sleep apnea: implications for congestive heart failure. Chest. 2008;133(6):1495-504. [CrossRef] [PubMed]
  4. Hanly PJ, Zuberi-Khokhar NS. Increased mortality associated with Cheyne-Stokes respiration in patients with congestive heart failure. Am J Respir Crit Care Med. 1996;153(1):272-6. [CrossRef] [PubMed] 

Reference as: Bartell J, Shetty S. Medical image of the week: Cheyne-Stokes respiration. Southwest J Pulm Crit Care. 2015;10(3):145-6. doi: http://dx.doi.org/10.13175/swjpcc017-15 PDF

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