Medical Image of the Week: PE with Infarct and Pulmonary Cavitation

Figure 1. Panels A & B: thoracic CT scan showing multiple pulmonary emboli (arrows). Panel C: frontal chest radiograph showed extensive left lung opacification most dense in the left upper lobe. Panel D: frontal chest radiograph taken 3 weeks later showing mild volume loss of the left upper lobe with a large lucency suggestive of cavitation (arrow). Panel E: thoracic CT scan confirming the cavitation.

A 49 year old man with a history of COPD presented to the ER with the sudden onset of chest pain at 3:30 AM waking him from sleep. His pain was left sided, felt like broken ribs, and was worse with deep inspiration. He acknowledged some shortness of breath which was worse over baseline for the past couple days without cough or hemoptysis. The patient was tachycardic but comfortable with SpO2 saturation 98% on 2 liters. He had trace edema and pleurisy. Laboratory evaluation was unremarkable except for a WBC count 13,000 X 10⁶ cells/L. Chest x-ray was unremarkable but thoracic CT scan showed pulmonary emboli (PE) involving left upper and lower lobar arteries (Figure 1A and 1B, arrows). Anticoagulation was started and the patient experienced increasing shortness of breath, worsening oxygenation and fever to 102ºF. On Day 2, frontal chest radiograph showed extensive left lung opacification most dense in the left upper lobe (Figure 1C). Hemoglobin dropped from 12 to 9.8 g/dL suggesting alveolar hemorrhage. He improved over the next week but low grade fevers persisted and a chest x-ray taken 3 weeks later showed mild volume loss of the left upper lobe with a large lucency suggestive of cavitation (Figure 1D, Arrow). Thoracic CT confirmed a cavitary lesion in the left apex in the region of prior thrombus with adjacent consolidated atelectasis within a background of emphysema (Figure 1E).  The patient was lost to follow up after 6 months of anticoagulation.

Pulmonary infarction is relatively uncommon, occurring in less than 10% of PE, due to dual and collateral blood supply to the lung. Cavitary infarcts are even less common (4% in autopsy studies) and are more likely in those with pulmonary venous hypertension (1). Cavitary infarcts are more likely to occur when the infarct size in larger than 4 cm and most often occurs in the mid and upper lung zones. Despite alveolar hemorrhage, anticoagulation should be continued.

Kenneth S. Knox, MD and Veronica A. Arteaga, MD

Divisions of Pulmonary and Critical Care Medicine and Thoracic Imaging

University of Arizona

Tucson, AZ

Reference 

1. Libby LS, King TE, LaForce FM, Schwarz MI. Pulmonary cavitation following pulmonary infarction. Medicine (Baltimore). 1985;64(5):342-8. [CrossRef] [PubMed]

Reference as: Knox KS, Arteaga VA. Medical image of the week: PE with infarct and pulmonary cavitation. Southwest J Pulm Crit Care. 2014;9(6):333-4. doi: http://dx.doi.org/10.13175/swjpcc158-14 PDF 

Medical Image of the Week: Aspergilloma

Figure 1.  Axial thoracic computed tomography (CT) image showing emphysematous disease throughout with prominent bullous disease in the upper lobes.  Areas of consolidation were concerning for infection.  Large cavitation with particulate matter (arrow) was seen in the left upper lobe. 

A 69-year-old woman, a current smoker, with very severe chronic obstructive pulmonary disease and prior atypical mycobacterium, was found unresponsive by her family and intubated in the field by emergency medical services for respiratory distress.  Her CT thorax showed severe emphysematous disease, apical bullous disease, and a large left upper lobe cavitation with debris (Figure 1).  She was treated with broad-spectrum antibiotics and anti-fungal medications.  Hemoptysis was never seen.  Sputum cultures over a span of two weeks repeatedly showed Aspergillus fumigatus and outside medical records confirmed the patient had a known history of stable aspergilloma not requiring therapy. 

Aspergillomas usually arises in cavitary areas of the lung damaged by previous infections.  The fungus ball is a combination of colonization by Aspergillus hyphae and cellular debris.  Individuals with aspergillomas are usually asymptomatic or have mild symptoms (chronic cough) and do not require treatment unless it begins to invade into the cavity wall.  When bleeding complications arise, surgical resection is curative but in high-risk patients, embolization may be considered as a stabilizing measure. 

Wendy Hsu, MD, Carmen Luraschi-Monjagatta, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

University of Arizona 

Tucson, AZ 

Reference 

Kousha M1, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011;20(121):156-74. [CrossRef] [PubMed]

Reference as: Hsu W, Luraschi-Monjagatta C, Carr G. Medical image of the week: aspergilloma. Southwest J Pulm Crit Care. 2014;8(5):282-3. doi: http://dx.doi.org/10.13175/swjpcc044-14 PDF 

January 2013 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 40-year-old previously healthy man presented with complaints of cough with blood-streaked sputum. 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?

1. The chest radiograph shows focal consolidation
2. The chest radiograph shows a loculated left pleural effusion
3. The chest radiograph shows pulmonary cavities
4. The chest radiograph shows tubular opacities suggesting arteriovenous malformations
5. The chest radiograph shows a left diaphragmatic hernia

Reference as: Gotway MB. January 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(1):15-21. PDF