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

Medical Image of the Week: Asbestosis

Figure 1. Thoracic CT scan in soft tissue windows showing pleural plaques (arrows).

Figure 2. Thoracic CT scan in soft tissue windows showing subpleural curvilinear opacities (arrows).

Figure 3. Panel A: ground glass opacity (arrow). Panel B: parenchymal band (arrow).

A 76-year-old man with a past medical history of diabetes mellitus, hypertension, and an unspecified industrial-related asbestos exposure presented to the hospital after a syncopal episode and a ground level fall. A computed tomography (CT) of the chest was performed on admission which revealed several abnormalities including multiple bilateral calcified pleural plaques, pleural thickening, peripheral groundglass opacities (GGO) in the nondependent portion of the lungs and subpleural reticular and band like opacities. The patient unfortunately developed alcohol withdrawal and aspiration pneumonia requiring prolonged mechanical ventilation and was unable to provide additional details regarding his lung disease.

Asbestos is a naturally occurring mineral that historically was praised for its versatility. Its properties including heat and electrical resistance, tensile strength, and insulating capabilities made it a common component in materials used in both commercial and domestic settings.  Exposure to asbestos is linked to numerous respiratory diseases, including pleural and parenchymal disease, both malignant and nonmalignant. Pleural plaques are the most common manifestation of asbestos exposure (1,2). These are distinct areas of fibrosis that usually arise from the parietal pleura. Figure 1 shows bilateral pleural plaques located over the lateral and posterior chest walls as well as along the diaphragms, which is essentially pathognomonic for this disease. Asbestosis refers to lung fibrosis caused by asbestos dusts. Regional involvement of the lung parenchyma may be more pronounced in the subpleural and basilar locations.  An early finding of asbestosis is subpleural curvilinear opacities which are felt to represent peribronchial fibrosis (Figure 2). Additional features of asbestosis include ground glass opacities in the nondependent regions (Figure 3A), bilateral parenchymal bands (Figure  3B) and small nodular opacities, particularly suggestive when present with coexistent pleural disease. Honeycombing is a finding seen in more advanced disease.

Christopher Strawter MD¹, Veronica Arteaga MD², Jarrod Mosier MD^1,3

¹Pulmonary, Allergy, Critical Care, & Sleep Medicine; ²Radiology; ³Emergency Medicine

University of Arizona

Tucson, Arizona

References

1. Roach HD, Davies GJ, Attanoos R, Crane M, Adams H, Phillips S. Asbestos: when the dust settles an imaging review of asbestos-related disease. Radiographics. 2002;22(Spec No):S167–84. [CrossRef] [PubMed]
2. Peacock C, Copley SJ, Hansell DM. Asbestos-related benign pleural disease. Clin Radiol. 2000;55:422-32. [CrossRef] [PubMed]

Reference as: Strawter C, Arteaga V, Mosier J. Medical image of the week: asbestosis. Southwest J Pulm Crit Care. 2014;9(6):309-10. doi: http://dx.doi.org/10.13175/swjpcc156-14 PDF