November 2021 Imaging Case of the Month: Let’s Not Dance the Twist

Prasad M. Panse MD and Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

Editor’s Note: Parts of this presentation were used in the June 2020 Pulmonary Case of the Month.

History of Present Illness: An 82-year-old man presented to his physician for general health maintenance as well as a complaint of persistently poor quality sleep and poor appetite with weight loss. The patient had undergone robotic-assisted radical left nephroureterectomy and cystectomy with pelvic lymph node dissection and urinary diversion for left clear cell renal cell carcinoma (staged T2a, grade 2) and transitional cell carcinoma of the bladder (carcinoma in situ at surgery), approximately 9 months earlier. The patient’s bladder malignancy was initially treated with transurethral resection, with histopathology at that procedure showing high-grade papillary urothelial malignancy with lamina propria invasion, but no muscular invasion; this procedure was followed by formal complete resection approximately 3 months later. The patient’s post-operative course was complicated by significant bleeding which required transfusion of 3 units of blood. He had undergone inferior vena caval filter placement prior to surgery when preoperative testing revealed lower extremity deep venous thrombus and pulmonary embolism.

Past Medical History: The patient’s past medical history was remarkable for atrial fibrillation treated with anticoagulation and hypertension. He also had a history of coronary artery disease and myocardial infarction with moderate systolic dysfunction His medical list included warfarin (for his atrial fibrillation), acetaminophen, vitamin supplementation, hydrochlorothiazide, atorvastatin, ramipril, metoprolol, and zolpidem. He denied allergies. The patient was a former smoker, previously smoking 2 packs-per day for 35 years, quitting over 30 years prior to presentation.

His past surgical history was remarkable for laminectomy in addition to the recent urinary surgery. He also had a history of rectal laceration complicating previous prostatectomy for prostate carcinoma (Gleason 3 + 4, T2).

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 physical examination did not disclose any salient abnormalities.

Initial Laboratory: The patient’s complete blood count and serum chemistries showed largely normal values, with the white blood cell count was normal at 6.7 x 10⁹ /L (normal, 4-10 x 10⁹ /L). His liver function testing and renal function testing parameters were also within normal limits. Echocardiography showed mildly decreased left ventricular systolic function, but this finding was stable. The patient underwent frontal chest radiography (Figure 1A).

Figure 1. A: Frontal chest radiography. B: Frontal chest radiography performed just over 1 year prior to A shows no specific abnormalities.

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

1. Frontal chest radiography shows no specific abnormalities
2. Frontal chest radiograph shows a nodule
3. Frontal chest radiography shows bilateral interstitial thickening
4. Frontal chest radiography shows bilateral pleural effusions
5. Frontal chest radiography shows mediastinal and peribronchial lymph node enlargement

Cite as: Panse PM, Gotway MB. November 2021 Imaging Case of the Month: Let’s Not Dance the Twist. Southwest J Pulm Crit Care. 2021;23(5):115-25. doi: https://doi.org/10.13175/swjpcc053-21 PDF

May 2019 Imaging Case of the Month: Asymptomatic Pulmonary Nodules and Cysts in a 47-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 47-year-old previously healthy woman presented to her new physician for a routine physical examination. The patient had no complaints. The patient’s physical examination showed normal vital signs and clear lungs; the physical examination was essentially unremarkable. The patient’s past medical history included a brief smoking history, having quit over 20 years earlier, as well as seasonal allergies. Her past surgical history included an appendectomy nearly 20 years earlier and a hysterectomy for bleeding related to uterine leiomyomas approximately 12 years prior to presentation. The patient was not taking any prescription medications.

Basic laboratory data, including a complete blood count, electrolyte panel, and liver function studies were all within the normal range. An electrocardiogram revealed normal findings. 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 be directed to the second of eleven pages)

1. The chest radiograph shows mediastinal and hilar lymph node enlargement
2. The chest radiograph shows multifocal nodular pulmonary consolidation
3. The chest radiograph shows multiple, bilateral cavitary nodules
4. The chest radiograph shows multiple, bilateral circumscribed nodules
5. The chest radiograph shows nodular interstitial thickening

Cite as: Gotway MB. May 2019 imaging case of the month: Asymptomatic pulmonary nodules and cysts in a 47-year-old woman. Southwest J Pulm Crit Care. 2019;18(5):106-19. doi: https://doi.org/10.13175/swjpcc022-19 PDF 

Medical Image of the Week: Recurrent Sarcoidosis Resembling Malignancy

Figure 1. CT scan showing multiple splenic masses.

The patient is a 64-year-old, non-smoking, woman who presented with a dry cough for a year and had a history of sarcoidosis. Five years ago, she presented with cough, bilateral pulmonary nodules and mediastinal adenopathy. At that time by a fine needle aspiration (FNA) under endobronchial ultrasound biopsy (EBUS), revealing non caseating granulomatous inflammation. She had complete remission after she was treated with a course of steroids. Follow up chest CT showed remission of her disease. On this presentation, she was found to have incidental multiple splenic masses on a CT scan of the chest (Figure 1). Physical examination was normal, CBC and chemistry were normal, and she had negative tests for tuberculosis, rheumatologic disease, systemic sclerosis, and mixed connective tissue disease. 

Pulmonary function tests were consistent with restrictive impairment and mild decrease in diffusion capacity for carbon monoxide. Positron Emission Tomography (PET scan) showed increased uptake corresponding to these lesions with no other areas of abnormal uptake in the body. CT-guided biopsy of splenic lesion showed non-caseating granulomas consistent with sarcoidosis. She was retreated with a course of steroids and a follow up CT scan of the abdomen showed resolution of the splenic masses.

Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by non-caseating granulomas. It is thought to result from an exaggerated host cellular immune response to an unknown antigen. Although the lungs are involved in 90 % of patients, other organs can be affected with the lungs or in isolation. Visceral involvement is usually asymptomatic and presents as hepatosplenomegaly on physical exam, or less often as isolated nodular splenic lesions suspicious of lymphoma. Rarely patients can have elevated liver enzymes from liver involvement or cytopenias from splenic enlargement (1).

Other differential diagnoses include infectious, neoplastic or benign conditions that may have similar morphology, such as tuberculosis, histoplasmosis, and lymphomas, hemangiomas and hamartomas. Diagnosis is usually confirmed by a biopsy and the disease responds to steroid treatment in over 70% of patients (2). Splenectomy is a therapeutic option in cases of steroids failure, severe hypersplenism, inability to exclude malignancy, or if risk of splenic rupture is high (3).

Isolated splenic sarcoidosis is a rare condition that can be the first presentation of sarcoidosis or a site of disease recurrence. It can mimic a variety of infectious, benign or malignant conditions especially when it presents with cytopenias due to hypersplenism, making biopsy necessary. Fortunately, splenic sarcoidosis responds to steroid treatment in most patients. Splenectomy can be considered in refractory cases.

Fuad Zeid MD¹, Hasan S. Yamin MD¹, Ahmed Amro MD², Fadi Alkhankan MD³, and Hani Alkhankan MD⁴

¹Pulmonary and Critical Care and ²Internal Medicine

Marshall University

Huntington, WV USA

³Pulmonary and Critical Care

Mercy hospital/ St. Louis University

St. Louis, MO USA

⁴McLaren Oakland Pulmonary/Critical Care,

Pontiac, MI USA

References

1. Vakil A, MD, Upadhyay H, Sherani K, Cervellione K, Fein A. A case of splenic sarcoidosis: initial diagnosis and one-year symptom follow-up. Chest. 2014;145(3):210A [Abstract].
2. Calik M, Aygun M, Yesildag M, et al. Nodular splenic sarcoidosis: a rare case report and review of the literature. Chest. 2014;146(4):399A [Abstract].
3. Sharma OP, Vucinic V, James DG. Splenectomy in sarcoidosis: indications, complications, and long-term follow-up. Sarcoidosis Vasc Diffuse Lung Dis. 2002 Mar;19(1):66-70. [PubMed]

Cite as: Zeid F, Yamin HS, Amro A, Alkhankan F, Alkhankan H. Medical image of the week: recurrent sarcoidosis resembling malignancy. Southwest J Pulm Crit Care. 2018;18(5):279-80. doi: https://doi.org/10.13175/swjpcc057-18 PDF 

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

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

May 2015 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 66 year-old woman presented with a history of hypothyroidism on replacement therapy, and a past medical history of pancreatitis, presented to her gastroenterologist with complaints of abdominal pain and loose stools. The episodes of pancreatitis began over a decade earlier with epigastric pain that was ultimately attributed to cholecystitis, for which endoscopic retrograde cholangiopancreatography (ERCP) was performed; this procedure precipitated her first episode of pancreatitis. During the ERCP procedure, her common bile duct was noted to be narrowed and several stones were removed, with placement of a stent, after which her epigastric pain resolved. A second stent placement procedure was required for recurrent epigastric pain approximately three weeks later, with good result.

Nearly a decade later, the patient presented with loose stools and fecal urgency associated with abdominal pain. Upper endoscopy showed mild gastric erosions (the patient was taking non-steroidal anti-inflammatory agents for intermittent back pain) and colonoscopy showed mild, non-specific colitis. The paint was diagnosed with pancreatic insufficiency and enzyme replacement therapy was begun, with symptomatic improvement.

During the course of her gastrointestinal consult, a frontal chest radiograph (Figure 1) was performed.

 

Figure 1. Frontal chest radiograph.

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

1. The frontal chest radiograph shows a poorly defined opacity in the extreme right 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

Reference as: Gotway MB. May 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;10(5):223-34. doi: http://dx.doi.org/10.13175/swjpcc070-15 PDF

September 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 57-year-old non-smoking woman presented to her physician as an outpatient with complaints of worsening cough, fever, chills, and shortness of breath. The patient’s past medical history includes systemic lupus erythematosus diagnosed 18 years earlier, for which the patient has been variably treated with corticosteroids, hydroxychloroquine, and azathioprine. Additional past medical and surgical history includes migraines, mood disorder, diabetes mellitus treated with metformin, hysterectomy for endometriosis, and iron-deficient anemia. The patient was also diagnosed with small lymphocytic lymphoma 3 years earlier following a right breast biopsy when an abnormal opacity was discovered incidentally at routine screening breast imaging. She has not been treated for this neoplasm as no B symptoms have been reported.

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

Figure 1. Panel A: Initial frontal chest x-ray. Panel B: Initial lateral chest x-ray.

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 linear and curvilinear opacities suggesting cystic lung disease
4. The chest radiograph shows mild streaky central opacities, possibly reflecting airway thickening
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. September 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(3):161-76. doi: http://dx.doi.org/10.13175/swjpcc117-14 PDF