February 2022 Imaging Case of the Month: Between A Rock and a Hard Place

Michael B. Gotway MD

Department of Radiology, Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona USA

Clinical History: A 46-year-old woman presented to her primary care physician with longstanding complaints of difficulty with aerobic exercise, near syncope, headache, poor sleep, and pain in both legs and arms, exacerbated when flying in commercial aircraft. The patient had also complained of several gastrointestinal disturbances recently that prompted evaluation, revealing a normal colonoscopy. The patient was diagnosed with probable food intolerance by breath testing showing fructose intolerance, managed with a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet with positive results.

PMH, SH, FH: The patient’s past medical history was remarkable for a history of Raynaud’s phenomenon and head trauma at age 16. She noted that her presenting complaints have been present since childhood to some extent. Her poor sleep was characterized as frequent awakenings, daytime somnolence, mouth dryness, and waking up with severe headaches. The patient had been diagnosed with COVID-19 4 months earlier, with her presenting complaints all exacerbated and accompanied by shortness of breath, but she recovered uneventfully. The patient denied other significant past medical history and had no surgical history. Her family history was remarkable for a sister diagnosed with obstructive sleep apnea, diabetes, and thyroid carcinoma, and hypertension in a number of her 13 siblings. The patient’s mother had been diagnosed with colonic malignancy and her father died of melanoma. The patient’s social history was remarkable for abuse during childhood by a male sibling. The patient denied tobacco, alcohol, and illicit drug use.

Physical Examination: The patient’s physical examination showed her to be slender and in no distress although anxious, afebrile, pulse rate= 73, normal respiratory rate, with a blood pressure of 116/95 mmHg. Her cardiovascular, pulmonary, musculoskeletal, and neurologic examinations were within normal limits.

Results from prior outside examinations, including funduscopic, abdominal MRI, and brain MRI and MRA were within normal limits. An outside audiology consultation when the patient complained of hearing loss several months after her SARS-CoV-2 infection showed normal findings. Her complete blood count, coagulation parameters, electrolytes, and liver panel showed no abnormal values. A frontal chest radiograph from an outside institution (Figure 1) from 4 months prior to her primary care appointment, around the time when the patient was diagnosed with COVID-19.

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Figure 1. Frontal (A) and lateral (B) chest radiography obtained around the time the patient was diagnosed with COVID-19.

Which of the following represents an appropriate interpretation of her frontal chest radiograph? (Click on the correct answer to be directed to the second of 11 pages)

1. Frontal chest radiography shows findings typical for coronavirus (SARS-CoV-2) pulmonary infection
2. Frontal chest radiograph shows bilateral peribronchial lymphadenopathy
3. Frontal chest radiography shows focal consolidation
4. Frontal chest radiography shows multiple lung nodules
5. Frontal chest radiography shows pleural effusion

Cite as: Gotway MB. February 2022 Imaging Case of the Month: Between A Rock in a Hard Place. Southwest J Pulm Crit Care Sleep. 2022;24(2): 12- . doi: https://doi.org/10.13175/swjpccs004-22  PDF

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

Medical Image of the Month: Buffalo Chest Identified at the Time of Lung Nodule Biopsy

Figure 1. Buffalo chest, peripheral cavitary lesions, and pneumothorax contralateral to the biopsy site. A) Outpatient CT scan showing a right pneumothorax (blue arrow) and right-sided cavitary lesion (blue arrowhead). B) Subsequent pre-procedural planning CT scan done right lateral decubitus, showing again the cavitary lesion (blue arrowhead) but now with left pneumothorax (red arrow), suggesting buffalo chest. C) Intra-procedural CT showing needle at the periphery of the cavitary lesion (blue arrowhead) and similar-sized left pneumothorax (red arrow). D) 5-minute post-procedural CT demonstrating expected alveolar hemorrhage in the site of the biopsied cavitary lesion (blue arrowhead), but worsening left pneumothorax (red arrow). E & F) Multiple peripheral left lung cavitary lesions (red arrowheads) felt to be possible culprits for the worsened pneumothorax following coughing from the right-sided biopsy.

A gentleman in his late 50s with a past medical history of squamous cell carcinoma at the base of the tongue had numerous slowly-growing pneumocyst-like lesions despite clinical remission status post surgery and chemoradiation. Biopsy of one of these lesions was recommended by a multidisciplinary tumor board.

An outpatient pre-procedural supine chest CT revealed a right pneumothorax above the lesion targeted for biopsy. A subsequent pre-procedural right lateral decubitus chest CT three weeks later demonstrated a left-sided pneumothorax, raising concern for buffalo chest. (A less likely possibility would be spontaneous resolution of the right pneumothorax and development of a new left pneumothorax in the less than 4-week interval.) Intraprocedural imaging continued to demonstrate the left-sided pneumothorax. A biopsy touch preparation of the first sample obtained did not demonstrate malignancy. Therefore, an attempt was made at obtaining another sample. However, the patient developed a brief but forceful coughing fit, resulting in the termination of the procedure after only 2 passes of a 20g needle. Post-procedural scans demonstrated expected right-sided alveolar hemorrhage near the biopsy tract but slight worsening of the contralateral pneumothorax. The patient was again scanned five minutes later for concerns of a worsening pneumothorax. CT imaging demonstrated stable right-sided alveolar hemorrhage near the biopsy tract, but also severe left sided pneumothorax with multiple peripheral cavitary lesions. A left anterior chest tube was placed and the patient was discharged a few days later. Biopsy results showed granulomatous tissue only and cultures were negative.

Buffalo chest refers to the abnormal presence of a pleuro-pleural communication in humans. This phenomenon derives its name from the fact that buffalo and similar species possess one contiguous pleural space, while humans ordinarily have two independent pleural spaces corresponding to each lung (1). This pleuro-pleural communication can develop iatrogenically, congenitally, or as a result of trauma. Cases of buffalo chest developing after median sternotomy, laparoscopic surgery and heart-lung transplantation have been described in the literature (2). It is unknown if the worsening of our patient’s left-sided pneumothorax occurred in the setting of underlying buffalo chest, with biopsy producing a right sided pneumothorax that subsequently communicated with the left pleural space. Alternatively, our patient’s episode of forceful coughing could have increased the intrathoracic pressure and caused barotrauma to one of the many peripheral cavitary lesions previously described, leading to a worsening of the left-sided pneumothorax. Cases of bilateral pneumothoraces where interpleural connections exist have been successfully treated with a unilateral chest tube (2, 3). A second chest tube may be necessary in cases where the contralateral lung fails to re-expand. Our patient was able to be discharged after placement of a unilateral chest tube (contralateral to the biopsy side), reaffirming the general recommendation to treat pneumothoraces this patient population with a unilateral pleural catheter.

Phillip Belone MS4, Jason Lee MD, and Michael Craig Larson MD PhD

University of Arizona/Banner University Medical Center-Tucson

Department of Medical Imaging

Tucson, AZ USA

References

1. Jacobi A, Eber C, Weinberger A, Friedman SN. Bilateral Pneumothoraces after Unilateral Lung Biopsy. A Case of "Buffalo Chest"? Am J Respir Crit Care Med. 2016 Apr 15;193(8):e36. [CrossRef] [PubMed]
2. Sawalha L, Gibbons WJ. Iatrogenic "buffalo chest" bilateral pneumothoraces following unilateral transbronchial lung biopsies in a bilateral lung transplant recipient. Respir Med Case Rep. 2015 May 16;15:57-8. [CrossRef] [PubMed]
3. Groarke J, Breen D, O'Connell F, O'Donnell R. Bilateral pneumothorax resulting from a diagnostic thoracentesis. Eur Respir J. 2007 Nov;30(5):1018-9; diagnosis 1020. [CrossRef] [PubMed]

Cite as: Belone P, Lee J, Larson MC. Medical Image of the Month: Buffalo Chest Identified at the Time of Lung Nodule Biopsy. Southwest J Pulm Crit Care. 2020;21(5):121-3. doi: https://doi.org/10.13175/swjpcc056-20 PDF

Medical Image of the Week: Atypical Deep Sulcus Sign

Figure 1.  Chest X-ray showing hyper inflated lungs with no clear evidence of pneumothorax.

Figure 2. Atypical deep sulcus sign on the left side.

Figure 3. Complete resolution of left sided pneumothorax after chest tube placement.

The deep sulcus sign is a radiolucent lateral sulcus where the chest wall meets the diaphragm. The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign (1). Here, we present a 42-year-old man with a history of asthma who was admitted with status asthmaticus requiring intubation. On hospital day 3, the patient developed subcutaneous emphysema surrounding his entire neck and extending into left side of the chest wall. Chest X-ray after this episode showed an atypical deep sulcus sign (Figure 2) concerning for left sided pneumothorax that was also confirmed by bedside ultrasound. A surgical chest tube was placed immediately and a repeat chest X-ray (Figure 3) showed complete resolution of the pneumothorax and the deep sulcus sign. In critically ill patients where it is difficult to obtain an upright film, it is important to pay attention to the costophrenic angles when concern for pneumothorax arises. In a supine film, a deep sulcus sign may be the only indication of a pneumothorax because air collects anteriorly and basally within the nondependent portions of the pleural space, as opposed to the apex when the patient is upright (2).

Hasan Ali MD¹, Huthayfa Ateeli MBBS², Bhupinder Natt MD FACP², Sachin Chaudhary MD².

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

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Kim HK, Park CY, Cho HM. Deep sulcus sign. Trauma Image & Procedure. 2016;1(1):12-3. [CrossRef]
2. Liu SY, Tsai IT, Yang PJ. Pneumothorax and deep sulcus sign. QJM. 2016;109(9):621-2. [CrossRef] [PubMed]  

Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: atypical deep sulcus sign. Southwest J Pulm Crit Care. 2018;16(4):224-5. doi: https://doi.org/10.13175/swjpcc044-18 PDF 

Medical Image of the Week: Spontaneous Pneumothorax in End Stage Fibrotic Lung Disease

Figure 1. Chest x-ray showing moderate-sized right pneumothorax with a pigtail chest tube in place, diffuse reticular interstitial opacities.

Figure 2. Chest CT showing extensive centrilobular emphysema, moderate right pneumothorax with pigtail chest drain on the right, subpleural reticular opacities with peripheral and basilar preponderance suggesting interstitial fibrotic lung disease, and diffuse lung cysts - heterogenous in size.

A 61-year-old nonsmoking man with chronic obstructive lung disease, pulmonary hypertension, pulmonary fibrosis, hypertension, coronary artery disease with congestive heart failure, presented with recurrent pneumothorax, pneumomediastinum, extensive subcutaneous emphysema and bronchopleural fistula.

The patient reported ongoing symptoms of exertional dyspnea, fatigue, and coughing for years. His environmental exposures were notable for exposure to birds since early childhood. He had 6 cockatiels and 2 doves living inside his home and is directly responsible for their care. Former occupational exposures include painting and sandblasting. Family history was notable for early onset non specified lung disease in his father, and rheumatoid arthritis in his mother.

Lung function testing performed prior to the bronchopleural fistula revealed moderate obstructive ventilatory defect with severely limited DLCO. Chest x-ray (Figure 1) revealed a moderate-sized right pneumothorax with a pigtail chest tube in place and diffuse reticular interstitial opacities. His CT chest (figure 2) revealed extensive subcutaneous emphysema, diffuse lung cysts that are heterogenous in size, and subpleural reticular opacities with peripheral and basilar preponderance. Bronchoalveolar lavage revealed no infection, with predominant monocyte/ macrophages. Alpha-1 antitrypsin (A1AT) was normal, as were autoimmune panels. A hypersensitivity pneumonitis panel revealed positive IgG to Aureobasidium pullulans. A presumptive diagnosis of chronic hypersensitivity pneumonitis was made.

Spontaneous pneumothorax (SP), a potentially life-threatening complication, is defined by the accumulation of air in the pleural space with secondary lung collapse, and can be categorized as primary (without apparent lung disease) or secondary pneumothorax. While chronic obstructive pulmonary disease and Pneumocystitis jirovecii pneumonia are the most common causes of secondary spontaneous pneumothorax, other structural lung diseases such as fibrotic lung diseases have also been linked to SP. Interstitial lung diseases distort lung architecture and trigger formation of subpleural blebs that are susceptible to rupture leading to extra-alveolar air collection and air leakage in the pleural space. Presence of persistent air leak, as in our case, mandates surgical consideration to accelerate recovery and prevent recurrence of secondary SP.

Roula Altisheh MD and Tara Carr MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

Banner-University Medical Center

Tucson, AZ USA

References

1. Sahn S, Heffiner J. Spontaneous Pneumothorax. N Engl J Med 2000; 342:868-74 [CrossRef] [PubMed]
2. Onuki T, Ueda S, Yamaoka M, Sek iya Y, Yamada H, Kawakami N, Araki Y, Wakai Y, Saito K, Inagaki M, Matsumiya N. Primary and secondary spontaneous pneumothorax: prevalence, clinical features, and in-hospital mortality. Can Respir J. 2017: 6014967.  [CrossRef] [PubMed]
3. Koschel D, Handzhiev S, Cardoso C, Rolle A, Holotiuk O, Höffken G. Pneumomediastinum as a primary manifestation of chronic hypersensitivity pneumonitis. Med Sci Monit. 2011 Dec;17(12):CS152-5. [PubMed]
4. Ichinose J, Nagayama K, Hino H, et al. Results of surgical treatment for secondary spontaneous pneumothorax according to underlying diseases. Eur J Cardiothorac Surg. 2016;49(4):1132–6. [CrossRef] [PubMed]

Cite as: Altisheh R, Carr T. Medical image of the week: spontaneous pneumothorax in end stage fibrotic lung disease. Southwest J Pulm Crit Care. 2017;14(6):308-10. doi: https://doi.org/10.13175/swjpcc065-17 PDF 

Medical Image of the Week: NG Tube Misplacement with a Pneumothorax

Figure 1.  CXR AP view showing misplaced NG tube in the right lung with small pneumothorax.

Figure 2. Follow up CXR AP view showing enlarged right pneumothorax after withdrawal of the NG tube.

Figure 3. CXR AP view post chest tube placement showing reinflation of the right lung.

Nasogastric tube (NG) placement is a common procedure performed in the inpatient hospital setting. They are often challenging to insert and therefore carry a risk of tracheobronchopleural, intravascular and enteral complications.

Our patient is a 90-year-old man who was admitted to the hospital with complaints of productive cough, fever, worsening of shortness of breath and confusion. He was diagnosed with viral upper respiratory tract infection, Legionella pneumonia and exacerbation of heart failure. Throughout his hospitalization patient had repeated episodes of delirium and had failed a swallowing evaluation. A NG was inserted for administration of enteral feeds and medications. There was no resistance to the passage of the tube when initially placed. However, post procedure CXR showed a misplaced nasogastric tube going into the right main bronchus and down into right lower lobe with a small apical pneumothorax (Figure 1). Follow up chest X-ray two hours later showed enlargement of the pneumothorax (Figure 2).  A 14 Fr pigtail catheter was promptly inserted in right pleural space. A repeat chest X-ray confirmed placement of the chest tube and showed re-inflation of the lung (Figure 3).

The reported incidence of misplacement of nasogastric tubes into the airways ranges from 0.3% to 15% and is more common after chest trauma or mechanical ventilation (1). This may be because of the need for adequate coordination of swallowing. Nasogastric tubes are generally considered safe, but there is a risk of significant pulmonary complications from blind insertion of small-caliber nasogastric tubes with a stiff stylet, particularly in elderly patients with altered mental status as well as with poor swallowing function (2).

Santhosh G. John MD, Vivian Keenan MD, Naveen Tyagi MD, and Priya Agarwala MD

Division of Pulmonary and Critical Care Medicine

Winthrop University Hospital

Mineola, New York USA

References

1. Agha R, Siddiqui MR. Pneumothorax after nasogastric tube insertion. JRSM Short Rep. 2011 Apr 6;2(4):28. [CrossRef] [PubMed]
2. Nazir T, Punekar S. Images in clinical medicine. Pneumothorax--an uncommon complication of a common procedure. N Engl J Med. 2010 Jul 29;363(5):462. [CrossRef] [PubMed] 

Cite as: John SG, Keenan V, Tyagi N, Agarwala P. Medical image of the week: NG tube misplacement with a pneumothorax. Southwest J Pulm Crit Care. 2017:14(1):14-5. doi: https://dx.doi/10.13175/swjpcc133-16 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: Spontaneous Pneumomediastinum

Figure 1. Upright chest radiograph showing pneumomediastinum tracking into neck and small right apical pneumothorax (arrows).

Figure 2. Coronal slice of CT chest showing extensive pneumomediastinum and subcutaneous emphysema (arrows).

Figure 3. CT scan of chest showing the Macklin effect with air tracking along the bronchovascular sheath in the left lower lobe.

A 24-year-old man with a past medical history significant for type I diabetes mellitus presented to the emergency department with complaints of nausea and vomiting for several days. He reported he had been on drinking alcohol heavily 4 days prior to presentation and subsequently had multiple episodes of vomiting. Initial laboratory evaluation was consistent with diabetic ketoacidosis (DKA). A routine chest x-ray was obtained to evaluate for an infectious etiology of his DKA and revealed pneumomediastinum and a small right apical pneumothorax (Figure 1). A CT scan of the chest was done and showed extensive pneumomediastinum as well as air tracking along the bronchovascular sheaths in the left lower lobe (Figure 2 and 3). It did not reveal evidence of esophageal injury.

Spontaneous pneumomediastinum (SPM) refers to pneumomediastinum that is not associated with noticeable cause such as esophageal rupture or trauma. It is typically a benign condition thought to be due to alveolar rupture and subsequent air tracking along the bronchial tree (1). It has been associated with a number of conditions including asthma, DKA, anorexia nervosa, and other conditions that lead to excessive coughing or vomiting. The radiographic appearance of air dissecting through the pulmonary intersitium along the bronchovascular sheath is known as the Macklin effect and can be seen in Figure 3.

Spontaneous pneumomediastinum typically resolves without complications but must be differentiated from the much more serious diagnosis of esophageal rupture, or Boerrhaave’s syndrome. Boerrhaave’s syndrome is more likely to present with fever, hemodynamic instability, and hydropneumothorax. All patients presenting with suspected SPM should be evaluated for esophageal perforation with a radiographic contrast swallow (2). In our case it was negative for evidence of esophageal disruption and the patient recovered completely.

Lucie Griffin DO and Erik Kraai MD

Division of Pulmonary, Critical Car, and Sleep Medicine

University of New Mexico Health Sciences Center

Albuquerque, NM USA

References

1. Murayama S, Gibo S. Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography. World J Radiol. 2014 Nov 28;6(11):850-4. [CrossRef] [PubMed]
2. Kelly S, Hughes S, Nixon S, Paterson-Brown S. Spontaneous pneumomediastinum (Hamman's syndrome). Surgeon. 2010 Apr;8(2):63-6. [CrossRef] [PubMed] 

Cite as: Griffin L, Kraai E. Medical image of the week: spontaneous pneumomediastinum. Southwest J Pulm Crit Care. 2016 Mar;12(3):115-6. doi: http://dx.doi.org/10.13175/swjpcc015-16 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

November 2015 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 48-year-old non-smoking woman with a history of hysterectomy and right oophorectomy, and cholecystectomy, otherwise previously healthy, presented with right-sided chest pain. 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 eight panels)

1. The frontal chest radiograph shows a right-sided pneumothorax
2. The frontal chest radiograph shows abnormal mediastinal contours
3. The frontal chest radiograph shows bilateral pleural thickening
4. The frontal chest radiograph shows no abnormal findings
5. The frontal chest radiograph shows small lung volumes with multiple small nodules

Cite as: Gotway MB. November 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(5):218-25. doi: http://dx.doi.org/10.13175/swjpcc140-15 PDF

Medical Image of the Week: Kartagener Syndrome

Figure 1. Panel A: AP chest x-ray showing dextrocardia with left sided pneumothorax. Panel B: CT Chest lung windows showing diffuse bronchiectasis. Panel C: CT Abdomen consistent with situs inversus.

A 65-year-old woman presented with 7 days of productive cough and the new onset sharp central chest pain. She has a known history of chronic sinusitis and COPD after being a 50 pack-year smoker. On examination, her blood pressure was 116/70 with a heart rate of 86 (sinus rhythm) and oxygen saturations were 93% on 4L/min by nasal cannula. She had bilateral expiratory wheezes with reduced air entry on the left side.

An AP chest x-ray revealed dextrocardia with a left sided tension pneumothorax (Figure 1A). Our patient was stabilized with an urgent chest tube insertion and taken for a CT chest and abdomen. CT chest indicated diffuse bronchiectasis (Figure 1B, arrow) with a CT of the abdomen showing reversal of major abdominal organs (Figure 1C).

First described in 1933, the triad of chronic sinusitis, bronchiectasis, and situs inversus is classic for Kartagener syndrome (1). Otherwise known as primary ciliary dyskinesia, it is an autosomal recessive disorder affecting the dynein motor protein on microtubules. Ciliary dysfunction from an embryonic stage is the underlying cause for 50% of patients with situs inversus (2). Ongoing difficulties clearing mucous and secretions from abnormal ciliary movements accelerates the development of rhinosinusitis and bronchiectasis (3). Fertility is also a common concern with most males being infertile and females having a lower likelihood of successful pregnancy (4).

Confirmatory testing requires electron microscopy to determine ultrastructure and high-speed video microscopy to determine abnormal movement of cilia (4). Long-term management involves control of respiratory complications with regular spirometry and pulmonary follow up.

Debraj Das, MD

Department of Medicine

Faculty of Medicine and Dentistry

University of Alberta

Edmonton, AB, Canada

References 

1. Kartagener M. Zur pathogenese der bronchiectasien. I Mitteilung: bronchiectasien bei situs viscerum inversus. Betr Klin Tuberk. 1933; 83:498-501.
2. Noone PG, Leigh MW, Sannuti A, et al. Primary ciliary dyskinesia: diagnostic and phenotypic features. Am J Respir Crit Care Med. 2004; 169:459-467. [CrossRef] [PubMed]
3. Bush A, Cole P, Hariri M, et al. Primary ciliary dyskinesia: diagnosis and standards of care. Eur Respir J. 1998; 12:982-988. [CrossRef] [PubMed]
4. Knowles MR, Daniels LA, Davis SD, et al. Primary ciliary dyskinesia. Recent advances in diagnostics, genetics, and characterization of clinical disease. Am J Respir Crit Care Med. 2013; 188:913-22. [CrossRef] [PubMed] 

Reference as: Das D. Medical image of the week: Kartagener syndrome. Southwest J Pulm Crit Care. 2015;10(6):343-4. doi: http://dx.doi.org/10.13175/swjpcc057-15 PDF

Medical Image of the Week: Bilateral Pneumothorax, Pneumomediastinum, and Massive Subcutaneous Emphysema

Figure 1.  Computed tomography of the thorax showing subcutaneous air dispersed in the adipose tissue, separating the fascia of the pectoralis major, and the delineation of its fibers (top arrow), pneumothorax compressing the lung (middle arrow), and pneumomediastinum compressing the trachea (bottom arrow).

An 80 year old man with chronic obstructive pulmonary disease (COPD) presented to the emergency department with respiratory distress and poor oxygen saturation. Physical exam revealed an obese male in respiratory distress with poor air entry bilaterally and scattered wheezing. His chest, neck, tongue, and lips were swollen. The patient was intubated for respiratory failure, felt to be due to angioedema. His oxygen saturation immediately improved, however the patient developed progressive swelling throughout his body including his eyelids, fingers and toes. Diffuse crepitus was felt on palpation. Chest radiography and computed tomography (CT) of the chest revealed large bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema (Figure 1). Bilateral chest tubes were inserted with re-expansion of both lungs. Over the next several days his respiratory parameters improved, with full re-expansion of the lungs and reabsorption of the pneumomediastinum and subcutaneous emphysema. The patient was extubated successfully and was discharged in good health.

Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema (SCE) are complications that may occur individually or rarely concomitantly, as in our case, during COPD exacerbations (the exact occurrence rate has not been described in the literature) (1-3). Bilateral spontaneous pneumthorax occurs in 1.9% of all spontaneous pneumothorax (4). The diagnosis is made with physical exam and appropriate imaging. Depending on the tension physiology, these conditions may lead to rapid respiratory failure and decreased cardiac output, especially when complicated by pulmonary barotrauma during mechanical ventilation (5,6).  In severe cases, SCE may involve respiratory compromise by compressing the trachea.

The early diagnosis with meticulous physical exam and relevant testing is essential, in order to immediately initiate appropriate management, and hence avoid the life-threatening complications associated with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema.

Zavier Ahmed MD, Manpreet Singh MD, Ricardo Lopez, MD

Icahn School of Medicine at Mount Sinai

Queens Hospital Center

82-68 164th Street

Queens, NY

References

1. Williams-Johnson J, Williams EW, Hart N, Maycock C, Bullock K, Ramphal P. Simultaneous spontaneous bilateral pneumothoraces in an asthmatic. West Indian Med J. 2008;57(5):508-10.[PubMed] 
2. Karakaya Z, Demir S, Sagay SS, Karakaya O, Ozdinc S. Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema: rare and fatal complications of asthma. Case Rep Emerg Med. 2012; 242579. [PubMed] 
3. Limthongkul S, Wongthim S, Udompanich V, Charoenlap P, Nuchprayoon C. Spontaneous pneumothorax in chronic obstructive pulmonary disease. J Med Assoc Thai. 1992;75(4):204-12. [PubMed] 
4. Athanassiadi K, Kalavrouziotis G, Loutsidis A, Hatzimichalis A, Bellenis I, Exarchos N. Treatment of spontaneous pneumothorax: ten-year experience. World J Surg, 1998;22: 803–6. [CrossRef] [PubMed] 
5. Hashim T, Chaudry AH, Ahmad K, Imhoff J, Khouzam R. Pneumomediastinum from a severe asthma attack. JAAPA. 2013;26(7):29-32. [CrossRef] [PubMed] 
6. Sakamoto A, Kogou Y, Matsumoto N, Nakazato M. Massive subcutaneous emphysema and pneumomediastinum following endotracheal intubation. Intern Med. 2013;52(15):1759. [CrossRef] [PubMed]

Reference as: Ahmed Z, Singh M, Lopez R. Medical image of the week: bilateral pneumothorax, pneumomediastinum, and massive subcutaneous emphysema. Southwest J Pulm Crit Care. 2014;8(3):181-2. doi: http://dx.doi.org/10.13175/swjpcc020-14 PDF

Medical Image of the Week: Coccidioidomycosis Pneumothorax

Figure 1. Right-sided pneumothorax (A) with subsequent placement of pigtail catheter and re-expansion of right lung (B).  CT shows bilateral multifocal airspace consolidation with nodules and cavitary interstitial disease (C).

Figure 2. PAP stain (A) and GMS stain (B) demonstrating Coccidioidomycosis from BAL (magnification, 400x).

A 36-year-old man with AIDS and disseminated coccidioidomycosis presented with severe right chest pain, shortness of breath, and a right-sided pneumothorax on CXR. A pigtail catheter was placed with near resolution of the pneumothorax. A bronchoscopy with bronchoalveolar lavage revealed spherules on cytology as well as coccidioidomycosis on culture. No other pathogens were identified. The pigtail catheter was removed three days later with resolution of the pneumothorax.

Rupture of subpleural coccidioidomycosis cavity into the pleural space resulting in pyopneumothorax and/or bronchopleural fistula is rare with reported rates of 1.4 – 2.6% for cavitary lesions (1).  Despite antiretroviral therapy and an undetectable viral load, disease was unresponsive to fluconazole.  Therapy was subsequently initiated with amphotericin B lipid complex, which resulted in significant improvement of his disease.

Ishna Poojary MD,  Christopher Geffre MD PhD,  Tirdad Zangeneh DO MA and Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

1. Tiu CT, Cook J, Pineros DF, Rankin LF, Lin YS, Ghitan M, Brichkov I, Shaw JP, Chapnick EK. Pneumothorax in a young man in Brooklyn, New York. Clin Inf Dis. 2011;53(12);1296-7. [CrossRef] [PubMed] 

Reference as: Poojary I, Geffre C, Zangeneh T, Campion J. Medical image of the week: coccidioidomycosis pneumothorax. Southwest J Pulm Crit Care. 2013;7(4):251-2. doi: http://dx.doi.org/10.13175/swjpcc140-13 PDF

Medical Image of the Week: Septic Emboli from Elbow Abscess

Figure 1. Panel A: Multiple thick wall cavities. Panel B: pneumothorax (arrows).

A 45 year old man with past medical history of rheumatoid arthritis and intravenous drug use presented with a several week history of progressive right elbow pain. He underwent incision and drainage with an operative diagnosis of septic arthritis.  He developed postoperative respiratory failure requiring prolonged mechanical ventilation.  Wound and blood cultures grew methacillin-resistant Staphylococcus aureus.  CT Chest revealed multiple thick walled cavities (A) from septic emboli as well as rupture of a pneumatocele causing a pneumothorax (B, arrows) necessitating chest tube insertion.

John F. Rosell, MD, Janet Campion, MD and Philip Factor, DO

Departments of Medicine and Emergency Medicine

University of Arizona

Tucson, AZ

Reference as: Rosell JF, Campion J, Factor P. Medical image of the week: septic emboli from elbow abscess. Southwest J Pulm Crit Care. 2013;7(1):27. doi: http://dx.doi.org/10.13175/swjpcc088-13 PDF

Medical Image of the Week: Iatrogenic Pneumothorax

Figure 1: AP Chest X Ray showing an unfortunate placement of a feeding tube (yellow tracing) as it passes through the left mainstem bronchus and loops into the left pleural space causing a moderate size pneumothorax (arrows).

Aarthi Ganesh, MD; Ryan Nahapetian, MD; Prathima Guruguri, MD, and Carmen Luraschi-Monjagatta, MD

Department of Medicine

University of Arizona, South Campus

Tucson, Arizona

Reference as: Ganesh A, Nahapetian R, Guruguri P, Luraschi-Monjagatta C. Medical image of the week: iatrogenic pneumothorax. Southwest J Pulm Crit Care. 2013;6(3):150. PDF