August 2024 Imaging Case of the Month: An Unexplained Pleural Effusion

Matthew T. Stib MD

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

Scottsdale, AZ USA

Clinical History: A 65-year-old woman with presents with intermittent right-sided chest pain and shortness of breath / dyspnea on exertion for several months’ duration.

The patient’s past medical history includes a history of myocardial infarction with stent placement and atrial fibrillation. She has no prior surgical history aside from carpal tunnel release and tonsillectomy.

The patient is a lifelong non-smoker, she reports no allergies and she drinks alcohol only socially and denies illicit drug use. Her medications include Xarelto (rivaroxaban) for her atrial fibrillation, alendronate, atorvastatin, metoprolol, and pantoprazole in addition to a multivitamin.

On physical examination the patient was obese but not in acute distress, with normal blood pressure, pulse rate, and respiratory rate. Her pulmonary and cardiovascular examination was unremarkable aside for dullness to percussion over the right posterior and lateral thorax, and her musculoskeletal examination did not disclose any abnormalities. She was neurologically intact. Oxygen saturation at rest on room air  95%, 93% with exercise.

A complete blood count showed a normal white blood cell count at 6.5 x 10⁹/L (normal, 3.4 – 9.6 x 10⁹/L), with a normal absolute neutrophil count of 3.65 x 10⁹/L (normal, 1.4 – 6.6 x 10⁹/L); the percent distribution of lymphocytes, monocytes, and eosinophils was normal. Her hemoglobin and hematocrit values were 13 gm/dL (normal, 13.2 – 16.6 gm/dL) and 39.7% (normal, 34.9 – 44.5%). The platelet count was normal at 274 x 10⁹/L (normal, 149 – 375 x 10⁹/L). The patient’s serum chemistries and liver function studies were largely normal, including an albumin level at 4.3 gm/dL (normal, 3.5 – 5 gm/dL), with mildly elevated alanine aminotransferase at 59 U/L (normal, 7-45 U/L) and aspartate aminotransferase of 68 U/L (normal, 8-43 U/L); alkaline phosphatase levels, bilirubin, and coagulation studies were normal. SARS-CoV-2 PCR testing was negative. The erythrocyte sedimentation rate was normal at 8 mm/hr (normal, 0-29 mm/hr), as was her C-reactive protein at <2 mg/L (normal, <2 mg/L).  

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal and lateral chest radiography. To view Figure 1 in a separate, enlarged window click here.

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

1. Frontal chest radiography shows normal findings
2. Frontal chest radiography shows a moderate-to-large right pleural effusion
3. Frontal chest radiography shows mediastinal lymphadenopathy
4. Frontal chest radiography shows pneumothorax
5. Frontal chest radiography shows numerous small nodules

Cite as: Stib MT, Gotway MB. August 2024 Imaging Case of the Month: An Unexplained Pleural Effusion. Southwest J Pulm Crit Care Sleep. 2024;29(2):9-18. doi: https://doi.org/10.13175/swjpccs038-24 PDF

March 2024 Medical Image of the Month: Sputum Cytology in Patients with Suspected Lung Malignancy Presenting with Acute Hypoxic Respiratory Failure

Figure 1. Axial image from a CT scan (A) showing masslike consolidation in the right lower lobe (*). Axial image from FDG-PET CT (B) showing the hypermetabolic center of the mass-like consolidation (arrow).

Figure 2. Sputum cytology low power (A) and high power (B) H&E stains showing clusters of malignant cells.

A 71-year-old woman presented with right-sided mass-like consolidation and pleural effusion on CT (Figure 1A), discovered incidentally after placement of a drug-eluting stent for coronary artery disease. The patient had a medical history significant for COPD, hypertension, hyperlipidemia, and coronary artery disease, status post a recent drug-eluting stent (less than 1 month ago). The patient received a presumptive diagnosis of pneumonia with parapneumonic effusion. Findings persisted despite multiple courses of empiric antibiotic therapy. She then underwent thoracentesis; pleural fluid was exudative; however, cytology was inconclusive. An FDG PET-CT (Figure 1B) revealed hypermetabolic activity in the right lower lobe with radiotracer activity up to 7.7 SUV concerning for malignancy. Diagnostic bronchoscopy was planned; however, her condition deteriorated suddenly the day before her planned procedure. EMS found the patient to be severely hypoxic, SpO2 in the 70s. Patient was taken by ambulance to the local emergency room.

Upon arrival, the patient was in mild respiratory distress which improved upon applying non-invasive positive-pressure ventilation. She had mild tachycardia and reduced air movement in the right lower third of the chest on physical exam. Repeat CT confirmed the persistence of the right lower lobe mass-like consolidation and moderate-sized pleural effusion. Empirical treatment for post-obstructive pneumonia was initiated. Right-sided thoracentesis again demonstrated exudative pleural fluid with negative cytology for malignancy and negative culture results. Due to concerns about her respiratory status, diagnostic bronchoscopy was abandoned. However, the patient was coughing up blood-tinged sputum which was sent for cytology (Figure 2) confirming a diagnosis of non-small cell lung cancer favoring adenocarcinoma. Immunostains performed on sections of the cell block showed malignant cells positive for CK7 and TTF1 and negative for P40 supporting the diagnosis of adenocarcinoma of lung.

This case emphasizes the importance of utilizing noninvasive testing like sputum cytology in patients with severe morbidity to help uncover underlying diagnoses. Studies and medical case reports highlighted the significance of sputum analysis in diagnosing lung cancer (1,2). Challenges posed by this case underscore the importance of considering alternative noninvasive measures to aid in making accurate diagnosis and help patient's and family understanding the underlying etiology of her persistent pneumonia )overall prognosis.

Abdulmonam Ali MD
Pulmonary & Critical Care
SSM Health
Danville, IL USA

References

1. Thunnissen FB. Sputum examination for early detection of lung cancer. J Clin Pathol. 2003 Nov;56(11):805-10. [CrossRef] [PubMed]
2. Ammanagi AS, Dombale VD, Miskin AT, Dandagi GL, Sangolli SS. Sputum cytology in suspected cases of carcinoma of lung (Sputum cytology a poor man's bronchoscopy!). Lung India. 2012 Jan;29(1):19-23. [CrossRef] [PubMed]

Cite as: Abdulmonam A. March 2024 Medical Image of the Month: Sputum Cytology in Patients with Suspected Lung Malignancy Presenting with Acute Hypoxic Respiratory Failure. Southwest J Pulm Crit Care Sleep. 2024;28:30-31. doi: https://doi.org/10.13175/swjpccs008-24 PDF

August 2022 Imaging Case of the Month: It’s All About Location

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

A 78–year–old man with a history of hyperlipidemia, hypertension, paroxysmal atrial fibrillation, and transcatheter aortic valve replacement on anticoagulation presented to the Emergency Room with a 2-month history of cough and exertional shortness of breath. He denied fever, chills, nausea, and chest pain. The patient had undergone three COVID-19 vaccines, the most recent 3 months earlier. He had noted some recent bruising, but denied any recent trauma.

The patient’s past medical history also included a history of prostate carcinoma 10 years earlier treated with radiation therapy. The patient’s past surgical history was remarkable for remote vasectomy, endoscopic sinus surgery and percutaneous aortic valve replacement. He was a former smoker and reported no allergies or illicit drug use; alcohol use was at most moderate, consisting of an occasional beer. The patient’s medications included a statin, warfarin, and metoprolol.

The patient’s physical examination showed normal vital signs and was remarkable only for some decreased breath sounds over the left lower thorax. The patient was afebrile. Bruising was noted involving the right hand and right abdominal wall, but without limitations in range of motion or associated pain.

A complete blood count showed a hemoglobin and hematocrit value of 7.7 gm/dL (normal, 13.2-16.6 gm/dL) and 23.9% (normal, 38.3–48.6%) and a platelet count of <2 x x10⁹/L (normal, 135-317 x10⁹/L). The white blood cell count was minimally abnormal at 9.7 x10⁹/L (normal, 3.4-9.6 x10⁹/L), with a mild left shift with a neutrophil level of 7.11 x10⁹/L (normal, 1.56-6.45 x10⁹/L). The eosinophil count was normal, but reticulocytes were elevated at 4.06% (normal, 0.60-2.71%). The INR was elevated at 2.3, with a prolonged prothrombin time of 25.8 sec (normal, 9.4-12.5 sec). Fibrinogen was also mildly abnormally elevated. Serum chemistries were largely within normal limits, with a mild elevation in lactate dehydrogenase at 273 U/L (normal, 122–222 U/L). Serum iron values were low at 30 mg/dL (normal, 50-150 mg/dL), with the total iron binding capacity abnormally decreased also. An ECG was unremarkable. A serum NT-Pro BNP value was elevated at 1174 pg/mL (normal, ≤122 pg/mL). Liver and renal function were within normal limits.

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

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

Which of the following represents an appropriate interpretation of the frontal chest and lateral radiograph? (Click on the correct answer to be directed to the second of twelve pages)

1. Frontal chest radiography shows a large left pleural effusion
2. Frontal chest radiograph shows focal right lung opacity
3. Frontal chest radiography shows pleural calcification
4. Frontal chest radiography shows right peribronchial lymph node enlargement
5. More than one of the above

Cite as: Gotway MB. August 2022 Imaging Case of the Month: It’s All About Location. Southwest J Pulm Crit Care Sleep. 2022;25(2):15-22. doi: https://doi.org/10.13175/swjpccs034-22 PDF

February 2021 Imaging Case of the Month: An Indeterminate Solitary Nodule

Prasad M. Panse MD

Clinton E. Jokerst MD

Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Phoenix, Arizona 85054

Clinical History: A 43 -year-old woman with no past medical history presented to the Emergency Room with complaints of right chest wall pain extending into the right upper quadrant. The patient was a non-smoker, denied any allergies, and was not taking any prescription medications.

Physical examination showed the patient to be afebrile with normal heart and respiratory rates and blood pressure = 110/75 mmHg. Her room air oxygen saturation was 99%.

The patient’s complete blood count and serum chemistries showed normal values. Her liver function testing and renal function testing parameters were also within normal limits.

Which of the following represents an appropriate next step for the patient’s management?

1. Perform abdominal ultrasound
2. Perform chest radiography
3. Perform unenhanced chest CT
4. More than one of the above
5. None of the above

Cite as: Panse PM, Jokerst CE, Gotway MB. February 2021 Imaging Case of the Month: An Indeterminate Solitary Nodule. Southwest J Pulm Crit Care. 2020;21(5):41-55. doi: https://doi.org/10.13175/swjpcc006-21 PDF

Medical Image of the Week: Chylothorax

Figure 1. A: CT of the chest (coronal image) demonstrating large right hilar and mediastinal adenopathy, leading to moderate to severe narrowing of the superior vena cava (SVC). B: CT of the chest (axial image) demonstrating moderate to severe narrowing of the pulmonary artery trunk due to compression from mediastinal adenopathy. A left pleural effusion is noted.

Figure 2. Pleural fluid sample demonstrating milky, pink fluid. The triglyceride level was 532 mg/dl and cholesterol level 63 mg/dl.

A 73-year-old man with untreated stage IV adenocarcinoma of the lung was admitted to the hospital with several days of progressively worsening dyspnea on exertion. The chest CT showed a large left pleural effusion with enlarging bilateral hilar and mediastinal lymphadenopathy, compression of the superior vena cava and right main pulmonary artery consistent with progressive lung cancer (Figure 1). Therapeutic and diagnostic left sided thoracentesis was performed, removing approximately 450 ml of milky, pink fluid suggestive of hemochylothorax (Figure 2). Analysis of the fluid was significant for 27,720 red blood cells, 476 total nucleated cells with lymphocyte predominance (87%), glucose 158 mg/dl, cholesterol 63 mg/dl, and amylase 28 U/L. The pleural fluid was exudative (protein 4.4 g/dl) with a significantly elevated triglyceride level of 532 mg/dl. No malignant cells were identified in the fluid.

This case illustrates a nontraumatic chylothorax secondary to metastatic adenocarcinoma of the lung. The leading cause of non-traumatic chylothorax is malignancy by compression and/or lymphangitic invasion (1). Thoracic duct invasion or leak can only be seen with nuclear medicine scintigraphy; however, this test was not performed on this patient. The appearance of the pleural fluid in chylothorax can be deceiving as less than half of pleural fluid samples will be milky in appearance (2). In addition, milky appearing pleural fluid is not specific for a chylothorax, as milky fluid can be seen in a cholesterol pleural effusion (pseudochylothorax) or an empyema. The detection of chylomicrons on pleural fluid lipoprotein electrophoresis is the definitive diagnostic criterion for chylothorax, however it is not widely available and is costly (3). The classic diagnostic criterion is a pleural fluid triglyceride level of >110 mg/dl in an appropriate clinical setting of mediastinal malignancy, lymphoma, recent thoracic surgery or penetrating trauma to the neck or thorax (4). A pleural fluid triglyceride level between 50 and 110 mg/dl does not exclude the diagnosis of chylothorax and clinicians should perform lipoprotein electrophoresis of the pleural fluid to detect chylomicrons. To distinguish a chylothorax from a pseudochylothorax (both have milky appearance), clinicians should obtain a cholesterol level on the fluid. The cholesterol level in a chylothorax is usually less than 200 mg/dl while a pseudochylothorax will have high levels, typically greater than 200 mg/dl.

The patient chose to undergo palliative radiation of the chest and symptomatic treatment of his dyspnea.  

John Dicken MD¹, Madhav Chopra MD², Faraz Jaffer MD² and Linda Snyder MD²

¹Department of Internal Medicine and ²Division of Pulmonary, Allergy, Critical Care and Sleep

Banner University Medical Center-Tucson

Tucson, AZ USA

References

1. McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010 Jan;104(1):1-8. [CrossRef] [PubMed]
2. Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural fluid characteristics of chylothorax. Mayo Clin Proc. 2009 Feb;84(2):129-33. [CrossRef] [PubMed]
3. Hooper C, Lee YC, Maskell N; BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii4-17. [CrossRef] [PubMed]
4. Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc. 1980 Nov;55(11):700-4. [PubMed]

Cite as: Dicken J, Chopra M, Jaffer F, Snyder L. Medical image of the week: Chylothorax. Southwest J Pulm Crit Care. 2018;17(2):70-1. doi: https://doi.org/10.13175/swjpcc100-18 PDF 

June 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 30-year-old woman with no significant past medical history presented with complaints of chronic back pain, partially controlled with Ibuprofen. Recently she began to notice shortness of breath. 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 eight pages)

1. The chest radiograph shows a diffuse linear, interstitial pattern
2. The chest radiograph shows a large pleural effusion
3. The chest radiograph shows a mediastinal mass
4. The chest radiograph shows multifocal, bilateral consolidation
5. The chest radiograph shows numerous small nodules

Cite as: Gotway MB. June 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(6):269-78. doi: https://doi.org/10.13175/swjpcc068-17 PDF 

April 2017 Imaging Case of the Month

Michael B. Gotway, MD and John K. Sweeney, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: An 86-year-old man with a previous history of transcatheter aortic valve implantation 1 year earlier, coronary artery disease status-post coronary artery bypass grafting surgery 12 years earlier, atrial fibrillation on warfarin, and pacemaker placement 8 years earlier presented with altered mental status.

The patient’s white blood cell count was borderline elevated at 10.3 x 10³/mcl (normal, 4.8 – 10.8 x 10³/mcl)  and hyponatremia was noted (serum sodium = 129 mEq/L, normal =  136 – 145 mEq/L). The patient’s anticoagulation profile was within the therapeutic range (INR = 1.4), and the platelet count was normal. Oxygen saturation on room air was normal. The patient’s medication list included warfarin, digoxin, aspirin, metoprolol, montelukast, and atorvastatin.

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? (Click on the correct answer to proceed to the second of eight pages)

1. Frontal chest radiography shows a cavitary lung mass
2. Frontal chest radiography shows focal consolidation suggesting aspiration pneumonia
3. Frontal chest radiography shows increased pressure edema
4. Frontal chest radiography shows malposition of the patient’s left subclavian pacemaker
5. Frontal chest radiography shows rib fractures

Cite as: Gotway MB, Sweeney JK. April 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(4):141-52. doi: https://doi.org/10.13175/swjpcc042-17 PDF

Medical Image of the Week: Lung Entrapment

Figure 1. Pleural Fluid (a) and the collapsed left lung within the hemi-thorax (b).

Figure 2. Malignant involvement of the visceral pleura (arrows).

Figure 3.  Persistent pneumothorax (white arrows) after several days of pleural catheter (black arrow) drainage.

A 74-year-old woman with a history of breast cancer 10 years ago treated with lumpectomy and radiation presented for evaluation of shortness of breath. She was diagnosed with left sided pleural effusion which was recurrent requiring multiple thoracenteses. There was increased pleural fludeoxyglucose (FDG) uptake on PET-CT indicative of recurrent metastatic disease. She underwent a medical pleuroscopy since the pleural effusion analysis did not reveal malignant cells although the suspicion was high and tunneled pleural catheter placement as adjuvant chemotherapy was initiated.

Figure 1 shows a pleurscopic view of the collapsed left lung and the effusion in the left hemi thorax. Figure 2 shows extensive involvement of the visceral pleura with metastatic disease preventing complete lung inflation. Figure 3 shows persistent pneumothorax-ex-vacuo despite pleural catheter placement confirming the diagnosis of entrapment.

Incomplete lung inflation can be due to pleural disease, endobronchial lesions or chronic telecasts.

Lung entrapment and trapped lung are related but distinct clinical entities (1). A trapped lung is a proper diagnosis when there is no active pleural disease however a fibrous peel has been formed due to a remote process and the mechanical effects of the pleura are the primary problem. Lung entrapment is used when incomplete lung inflation is secondary to visceral pleural peel secondary to active infection, inflammation or malignancy and the underlying process then becomes the primary problem.

The parietal pleural biopsies obtained during the pleuroscopy confirmed recurrent metastatic disease and the patient is currently undergoing chemotherapy.

Bhupinder Natt MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona Health Sciences,

Tucson, AZ USA

Reference

1. Huggins JT, Doelken P, Sahn SA. The unexpandable lung. F1000 Med Rep. 2010 Oct 21;2:77. [CrossRef] [PubMed]

Cite as: Natt B, Knepler J. Medical image of the week: lung entrapment. Southwest J Pulm Crit Care. 2016;13(1):36-7. doi: http://dx.doi.org/10.13175/swjpcc059-16 PDF

Medical Image of the Week: Hydropneumothorax

Figure 1. Gastrograffin Esophagram revealing the presence of contrast in the right pleural space (arrow).

Figure 2. Chest CT revealing right hydropneumothorax containing Gastrograffin. Note the presence of Gastrograffin in the esophagus as well as pleural space (arrow).

Figure 3. Chest CT showing a communicating channel between the esophagus and right pleural space (arrow).

A 67-year-old woman who underwent a robotic laparoscopic surgical repair secondary to a large paraesophageal hernia with gastric volvulus. Post-operatively, she developed respiratory distress and a chest CT revealed a large right hydropneumothorax. A Gastrograffin esophagram was done showing Gastrograffin in the esophagus, stomach as well as in the right pleural space suggesting an esophageal-pleural fistula (Figure 1). A chest tube was placed and contrast was present revealing a esophageal-pleural fistula (Figures 2 and 3).

Esophageal perforation should be considered in all patients with unexplained chest pain. Rapid recognition and diagnosis is key as delay in treatment is associated with increased mortality and morbidity (1). Causes of esophageal perforations include upper endoscopy, Boerhaave’s syndrome, foreign body ingestion, trauma, malignancy and intra-operative injury (2). Treatment depends on the location and the extent of the perforation as surgical intervention is the gold standard.

Bassel Saksouk MD¹, Choua Thao MD¹ and Carmen Luraschi MD²

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Division of Pulmonary and Critical Care

Las Vegas, NV

References

1. Iannettoni MD, Vlessis AA, Whyte RI, Orringer MB. Functional outcome after surgical treatment of esophageal perforation. Ann Thorac Surg. 1997;64(6):1606-9. discussion 1609-10. [PubMed]
2. Bayram AS, Erol MM, Melek H, Colak MA, Kermenli T, Gebitekin C. The success of surgery in the first 24 hours in patients with esophageal perforation. Eurasian J Med. 2015;47(1):41-7. [CrossRef] [PubMed] 

Cite as: Saksouk B, Thao C, Luraschi C. Medical image of the week: hydropneumothorax. Southwest J Pulm Crit Care. 2015;11(3):124-5. doi: http://dx.doi.org/10.13175/swjpcc095-15 PDF

Medical Image of the Week: Septated Pleural Effusion

Figure 1. Thoracic ultrasound showing pleural effusion with multiple septations.

An 83 year old man with a history of metastatic malignant melanoma and atrial fibrillation on warfarin was admitted for shortness of breath. He underwent a diagnostic and therapeutic thoracentesis for a large right sided pleural effusion, suspected to be malignancy related. Three days later, he had transferred to the ICU for respiratory distress. An ultrasound of the thorax revealed a large loculated effusion with multiple septations (Figure 1). A large bore chest tube was placed and revealed a hemothorax, which may have been related to the previous thoracentesis.

In an observational study of ultrasound characteristics of pleural effusions, complex septations were more commonly seen in non-malignant effusions than malignant effusions (25.4% vs. 7.5%). In non-malignant effusions, the septated pattern was associated with infections, specifically tuberculosis and pneumonia (1).

While metastases in melanoma commonly involve the thoracic cavity, malignant pleural effusions are rare and are seen in about 2% of cases. In very rare instances, effusions from metastatic melanoma can be black in appearance (2). There has also been a case report of a massive hemothorax related to melanoma implants on the pleura (3).

Candy Wong, MD¹; Soyoung Park, MD²; Courtney Walker, DO²; and Laura Meinke, MD¹

¹Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine.

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Bugalho A, Ferreira D, Dias SS, Schuhmann M, Branco JC, Marques Gomes MJ, Eberhardt R. The diagnostic value of transthoracic ultrasonographic features in predicting malignancy in undiagnosed pleural effusions: a prospective observational study. Respiration. 2014;87:270-8. [CrossRef] [PubMed]
2. Liao WC, Chen CH, Tu CY. Black pleural effusion in melanoma. CMAJ. 2010;182(8):E314. [CrossRef] [PubMed]
3. Gibbons JA, Devig PM. Massive hemothorax due to metastatic malignant melanoma. Chest. 1978;73(1):123. [CrossRef] [PubMed]

Cite as: Wong C, Park S, Walker C, Meinke L. Medical image of the week: septated pleural effusion. Southwest J Pulm Crit Care. 2015;11:110-1. doi: http://dx.doi.org/10.13175/swjpcc085-15 PDF

March 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 35-year-old man presented with a history of Von Hippel-Lindau syndrome, including prior right-sided renal cell carcinomas, cerebellar hemangioblastomas, and retinal hemangiomas. The patient’s renal malignancies were treated with laparoscopic radiofrequency ablations 6 and 8 years prior to presentation, and subsequently with percutaneous microwave ablations in the interim between 2008 and presentation. The latest percutaneous microwave ablation procedure (Figure 1) was performed to address two nodular enhancing foci in the posterior superior pole of the right kidney and one interpolar enhancing, septated lesion that were noted to have enlarged slightly on a recent MRI examination (Figure 2) of the abdomen compared with one year earlier.

 Figure 1. Percutaneous microwave of three right-sided renal lesions, 2 posterior-superior pole, the other lateral interpolar in location, shows two NeuWave microwave antennas inserted into suspicious lesions in the right kidney.

 

Figure 2. MRI of abdomen (A and B, axial steady-state free precession fat saturation images and, C and D, coronal subtraction contrast-enhanced images) shows three potentially solid, enhancing foci, two in the posterior and superior pole of the right kidney (arrowheads), and one in the lateral interpolar kidney, the latter with thick septations (arrow) that have shown slight enlargement from MR. performed one year previously.

A CT of the abdomen (Figure 3), performed 2 years earlier, is shown as a baseline comparison.

Figure 3.  Upper panel: selected image from the CT of the abdomen performed 2 years prior to presentation shows enlargement of the bilateral kidneys with numerous, bilateral renal cystic lesions. No pleural or lung base abnormality is evident. Lower panel: movie of CT scan performed 2 years prior to presentation.

Several days following the percutaneous microwave ablation procedure, the patient complained of right-sided chest pain, and frontal chest radiography was performed (Figure 4). 

Figure 4. Frontal and lateral chest radiography performed several days following the right-sided percutaneous microwave ablation procedure.

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

1. The frontal chest radiograph shows a large right pleural effusion
2. The frontal chest radiograph shows diffuse lung opacities suggesting diffuse alveolar damage
3. The frontal chest radiograph shows mediastinal widening
4. The frontal chest radiograph shows pneumomediastinum
5. The frontal chest radiograph shows pneumothorax 

Reference as: Gotway MB. March 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;10(3):112-24. doi: http://dx.doi.org/10.13175/swjpcc031-15 PDF

Medical Image of the Week: Hepatic Hydrothorax

Figure 1. Panel A: Chest x-ray showing right pleural effusion. Panel B: Coronal view of the thoracic CT scan in soft tissue windows showing right pleural effusion.

Figure 2. Nuclear scan after intraperitoneal injection of technetium 99mTc albumin aggregated (99mTc-MAA). After less than one hour most of the tracer migrated into the right hemithorax consistent with hepatic hydrothorax.

A 63 year-old woman, with known alcoholic liver cirrhosis, esophageal varices with history of banding presented to an outside hospital with progressive shortness of breath, and was found to have a large right transudative pleural effusion. The patient underwent 2 diagnostic and therapeutic thoracenteses within 3 days, removing 1100 ml and 1500 ml respectively. No ascites was present. At the time of admission the patient had recurrent right effusion (Figure 1). Abdominal ultrasound showed minimal free intrabdominal fluid and she had signs of third spacing on her lower extremities. The patient underwent intraperitoneal injection of Technetium 99mTc albumin aggregated (99mTc-MAA). After less than one hour most of the tracer migrated into the right hemithorax consistent with hepatic hydrothorax (Figure 2).

While the exact mechanism involved in the development of hepatic hydrothorax is incompletely understood, it probably results from the passage of ascitic fluid from the peritoneal into the pleural cavity through small diaphragmatic defects. These are typically < 1 cm (and may be microscopic) and are generally located in the tendinous portion of the diaphragm. The negative intrathoracic pressure generated during inspiration favors the passage of the fluid into the pleural space. Thus, patients may have only mild or clinically undetectable ascites.

Once the diagnosis is made treatment follows algorithms for treatment of refractory ascites and include salt and water restriction, diuretics, and other validated options for portal hypertension. Repeated thoracentesis and chest tube placement is discouraged.

Huthayfa Ateeli, Justin Lee, Irbaz Riaz, Meenal Misal

Department of Internal Medicine

University of Arizona

Tucson, AZ

References

1. Huang PM, Chang YL,Yang CY,Lee YC.The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. J Thorac Cardiovasc Surg. 2005;130:141-5. [CrossRef] [PubMed]
2. Lieberman FL, Hidemura R, Peters RL, Reynolds TB. Pathogenesis and treatment of hydrothorax complicating cirrhosis with ascites. Ann Intern Med. 1966;64:341-51. [CrossRef] [PubMed]
3. Emerson PA, Davies JH. Hydrothorax complicating ascites. Lancet. 1955; 268:487-8. [CrossRef] [PubMed]
4. Mouroux J, Perrin C, Venissac N, Blaive B, Richelme H. Management of pleural effusion of cirrhotic origin. Chest. 1996;109:1093-6. [CrossRef] [PubMed]
5. Chen A, Ho YS, Tu YC, Tang HS, Cheng TC. Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol. 1988;10:663-6. [CrossRef] [PubMed] 

Reference as: Ateeli H, Lee J, Riaz I, Misal M. Medical image of the week: hepatic hydrothorax. Southwest J Pulm Crit Care. 2015;10(1):47-8. doi: http://dx.doi.org/10.13175/swjpcc004-15 PDF

Medical Image of the Week: Metastatic Collecting Duct Carcinoma

C

Figure 1. Transverse section of CT chest and abdomen shows enhancing pleural nodularity (yellow arrows) with a pleural effusion.

Figure 2.  Transverse section of CT abdomen shows heterogeneous enhancing mass in the right kidney (red arrow).

Figure 3. Coronal section of CT chest and abdomen showing a large right pleural effusion (yellow arrow) and atelectatic lung with mediastinal shift to the left. Red arrow points to the heterogeneous mass in the right kidney.

A 40-year-old woman home health nurse presented to the ED with intermittent right sided sharp chest pain and progressive dyspnea for 2 weeks. On admission she was found to be in respiratory distress. Chest x-ray revealed a massive right sided pleural effusion. Thoracic CT scan with contrast confirmed a large right pleural effusion with associated enhancing pleural nodularity also involving the diaphragmatic surface (Figure 1).  The visualized part of the abdomen revealed a mass in the midpole of right kidney (Figure 2). Subsequent CT scan of the abdomen with contrast revealed a heterogeneous enhancing mass in the right kidney suspicious for malignancy (Figure 3) and multiple paracaval lymph nodes. Thoracentesis revealed a hemorrhagic pleural effusion and during subsequent right video-assisted thoracoscopy showed disseminated tumorlets along the diaphragm and pleura. Pleural biopsy and fluid cytology was consistent with metastatic poorly differentiated collecting duct carcinoma of the kidney. The patient is currently getting outpatient chemotherapy. Collecting duct carcinoma of the kidney is an unusual variant of renal cell carcinoma and accounts for about 1% of all renal cell carcinomas (1). This variant has a poor prognosis and frequently metastasizes to the lung and liver.

Chandramohan Meenakshisundaram, MD

Nanditha Malakkla, MD

St. Francis Hospital.

Evanston, IL

Reference

1. Wang X, Hao J, Zhou R, Zhang X, Yan T, Ding D, Shan L, Liu Z. Collecting duct carcinoma of the kidney: a clinicopathological study of five cases. Diagn Pathol. 2013;8:96. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N. Medical image of the week: metastatic collecting duct carcinoma. Southwest J Pulm Crit Care. 2014;9(6):348-9. doi: http://dx.doi.org/10.13175/swjpcc160-14 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1. Acute aortic dissection presenting with the following radiographic signs: rightward deviation of the trachea (red arrow); left apical pleural capping (blue arrow); aortic “double-calcium” sign (between white arrows); depression of the left bronchus (purple arrow); pleural effusion (green arrow); widened mediastinum and loss of the aorto-pulmonary window (not labeled).

The patient was a 75 year old woman with a past medical history of uncontrolled hypertension and recent type-A aortic dissection post graft repair. She presented with a sudden onset of sharp mid-back pain which awoke her from sleep. In the emergency room a chest x-ray revealed numerous features consistent with a de novo type B aortic dissection which was ultimately confirmed by magnetic resonance angiography of the chest and abdomen. This dissection extended from the left subclavian artery to the right renal artery. There was no evidence of end-organ mal-perfusion and the patient was medically managed by way of blood pressure control.

Seth Assar, MD; Thien Vo, MD; Jarrod Mosier, MD

The University of Arizona College of Medicine, Tucson, Arizona

Reference

Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007;6(1):64-7. [CrossRef]

Reference as: Assar S, Vo T, Mosier J. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2014;8(4):234. doi: http://dx.doi.org/10.13175/swjpcc039-14 PDF

March 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man with a history of severe asthmatic bronchitis presented with a 6 week history of intermittent fever, productive cough, shortness of breath, and decreased appetite. Four weeks earlier the patient was presumptively treated with amoxicillin for presumed community-acquired pneumonia, with some improvement, but his symptoms recurred 10 days following completion of his course of therapy. The patient also thought he was diagnosed with a COPD exacerbation during this time period and was treated with a short course of corticosteroids without improvement.

The patient was seen by his pulmonologist who noted decreased breath sounds over the right thorax, and referred the patient to the emergency room.

In the emergency room, a leukocytosis (white blood cell count = 17.4 x 10⁹ / L with neutrophilia) was noted. Broad-spectrum antibiotic coverage was re-instituted and 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? (Click on the correct answer to move to the next panel)

1. The chest radiograph homogeneous complete right lung consolidation
2. The chest radiograph shows a right-sided mediastinal mass
3. The chest radiograph shows homogeneous right lung opacity suggesting right lung collapse
4. The chest radiograph shows homogeneous right lung opacity suggesting a large right pleural effusion
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. March 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014:8(3):161-9. doi: http://dx.doi.org/10.13175/swjpcc015-14 PDF

Medical Image of the Week: Empyema

Figure 1. Admission thoracic CT showing a low density collection in the right lung likely from necrosis (*).

Figure 2. Selected views from the thoracic CT obtained 1 week after admission. Panel A: Architectural distortion (white circle) suggests necrotizing pneumonia. Note fluid within the bronchus intermedius (*). Panel B: Defect in visceral pleura (arrow) with decompression of parenchymal necrosis into the pleural space.  Note enhancement and thickening of both pleural layers. Panel C: Defect in parietal pleura (black arrow) with fluid extending into the extrapleural space. Pericardial effusion (*), new left pleural effusion and left parietal pleura enhancement (white arrow) suggests spread of infection. Incidental hiatal hernia (+).

A 71 year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department complaining of dyspnea after recent admission for pneumonia. Chest CT shows a low density collection in the right lung suggesting necrosis (Figure 1). A CT obtained 1 week after admission (Figure 2) shows progression to empyema.

Management of empyema can be difficult. If the fluid cannot be removed with a therapeutic thoracentesis, a chest tube should be inserted and consideration be given to the intrapleural instillation of fibrinolytics (1). If the loculated effusion persists, the patient should be subjected to video-assisted thoracoscopic surgery. If the lung cannot be expanded with this procedure, a full thoracotomy with decortication should be performed. The definitive procedure should be performed within fourteen days.

Jason R. Young MD and David L. August, MD

Department of Radiology

Maricopa Integrated Health System

Phoenix, AZ

Reference

1. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006;3(1):75-80. [CrossRef] [PubMed]

Reference as: Young JR, August DL. Medical image of the week: empyema. Southwest J Pulm Crit Care. 2013;7(5):300-1. http://dx.doi.org/10.13175/swjpcc143-13 PDF

Medical Image of the Week: Metastatic Colon Cancer to the Pleura

Figure 1. Pleuroscopy showing visceral (star) and parietal pleura (arrow) adenocarcinoma lesions.

A 55 year old man presented with recurrent exudative effusion of unexplained etiology. After non-diagnostic thoracentesis, pleuroscopy was performed.  Visceral (star) and parietal pleura (arrow) lesions were found (Figure 1).  Biopsies were performed and showed adenocarcinoma consistent with colon cancer on immunohistochemical staining.  Subsequent colonoscopy confirmed an asymptomatic colon cancer.

James L. Knepler, Jr. MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona 

Tucson, Arizona

Reference as: Knepler JL. Medical image of the week: metastatic colon cancer to the pleura. Southwest J Pulm Crit Care 2013(1);6:4. PDF

November 2011 Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Reference as: Gotway MB. November 2011 Case of the month. Southwest J Pulm Crit Care 2011;3: 154-8. (Click here for PDF version of manuscript)

Clinical History

A 47-year-old woman presents with complaints of hemoptysis. The hemoptysis was witnessed and was massive, resulting in anemia. A frontal and lateral chest radiograph (Figures 1A and B) was performed.

Figure 1: Frontal and lateral chest radiograph

What is the main finding on the chest radiograph? How would you describe the finding?

1. A solitary pulmonary nodule
2. An anterior mediastinal mass
3. Basal predominant linear and reticular abnormalities suggesting fibrotic lung disease
4. An intracavitary mass superimposed on a background of interstitial abnormality
5. Bilateral pleural effusions and thickening

A Case of Mislabeled Identity

Reference as: Singarajah C, Park K. A case of mislabeled identity. Southwest J Pulm Crit Care 2010;1:22-27. (Click here for PDF version)

A 60-year-old man in the surgical intensive care unit for atrial fibrillation with rapid ventricular response, on his second post-operative day following colectomy, complained of worsening shortness of breath. A chest radiograph (Figure 1) was obtained. A chest radiograph performed one day previous to Figure 1 showed clear lungs, no pleural effusions, and no volume loss.

Question 1 and Figure 1: What are the abnormal findings on the chest radiograph? In particular, what technical error has occurred? 

The frontal chest radiograph shows increased opacity in the bases bilaterally, greater on the side labeled left (see “L” in the image- this is the technologist’s marker). Note the shift of the trachea towards the side labeled left. However, note also the opacity along the superior mediastinum on the right side; this opacity has the appearance of the aortic arch. Note the appearance of the stomach below the diaphragm, ipsilateral to the aortic arch. Also, the opacity at the left lung base shows a configuration resembling the heart. Taken together, these findings raise the possibility that the radiograph is mislabeled, with the “Left” marker (“L”, Figure 1) improperly placed on the patient’s right side. Prior chest radiographs not shown) confirm the patient did not have situs inversus.

There is evidence of volume loss in the right thorax (labeled incorrectly as left in this image). Note the shift of the trachea towards the side with increased lung opacity. The entire left right thorax (again, incorrectly labeled left in this image) is small, and the air column in the right mainstem bronchus abruptly terminated, suggesting endobronchial obstruction.

Furthermore, the patient had no clinical reasons for a new large pleural effusion, and recent prior films showed no pleural fluid.

Surgery was consulted and a procedure was performed. The results of this procedure are shown in Figure 2.

Question 2: What procedure was performed by the surgery team?

The surgery team improperly placed a thoracostomy tube in the left thorax because they misinterpreted Figure 1 as showing a large left pleural effusion. Figure 2 shows the tip of the thoracostomy tube in the medial superior left thorax, associated with subcutaneous emphysema. Progressive volume loss is seen on the right side, again suggesting endobronchial obstruction- note that the residual air in the right upper thorax in Figure 1 is no longer present in Figure 2. The surgery team then improperly placed a thoracostomy tube on the right side, mistaking the small, opacified right thorax for pleural effusion on that side. Figure 3 shows the new right thoracostomy tube tip located over the cranial right thorax.

The surgical team was concerned that the thoracostomy tube showed little fluid output and a second thoracotomy tube was placed on the contralateral side (Figure 3).

 

This tube also did not show significant output. The pulmonary / critical care medicine team was then consulted. The pulmonary / critical care medicine physician performed a procedure which partially corrected the cause of the patient’s original complaints. The chest radiograph following this procedure is shown in Figure 4. 

Question 3: What procedure (s) was performed by the pulmonary / critical care medicine team?

Bronchoscopy was performed, and showed significant mucous plugging. The mucous plugs were removed resulting in improved right lung aeration (Figure 4).

Learning Points:

• Physical exam would have identified improperly labeled chest radiograph
• The chest radiograph shows volume loss, suggesting endobronchial obstruction due to mucous plugging- the side of the thorax showing increased attenuation shows reduced volume. In contrast, pleural effusion would show increased opacity associated with mass effect and shift of the cardiomediastinal structures away from the side of the thorax showing increased attenuation
• Time-outs are no substitute for clinical skills.The patient had two thoracostomy tubes, both placed for incorrect reasons, one of which was placed on the wrong side all together.
• Therapy for atelectasis and mucous plugging includes the following:
  •  Patient mobilization, ambulation, sitting up;
  • Minimize anti-tussive meds (narcotics, etc), minimizes sedation;
  • Chest physiotherapy for the affected lung;
  • Continuous lateral rotation therapy for patients with altered mental status who cannot mobilize  (for example, a Triadyne bed  made by KCI or manual turning);
  • Bronchoscopy, and;
  • Mucolytics are of equivocal benefit

Clement Singarajah MD.  Associate Chief Pulmonary and Critical Care Fellowship, Phoenix VA Hospital and Good Samaritan Regional Medical Center, Phoenix AZ.

Kevin Park, MD, Pulmonary and Critical Care Medicine fellow, Phoenix VA Hospital and Good Samaritan Regional Medical Center, Phoenix AZ.

Email csingarajah@earthlink.net