Medical Image of the Month: Idiopathic Right Lower Lobe Pulmonary Vein Thrombus

Figure 1. CT angiogram chest sagittal view: showing low density filling defect consistent with pulmonary vein thrombus (yellow arrow).

Figure 2. A: CT angiogram chest axial view showing right lower lobe pulmonary vein thrombus. B: the vein (red arrow) is well differentiated by his lower contrast than the adjacent artery (blue arrows).

A 62-year-old man with a medical history notable only for a seasonal allergy, presented to the emergency department with complaints of shortness of breath with productive cough for 2 months which were worsening for the last 2 weeks. CTA chest revealed low density filling defect in the RLL vein consistent with RLL vein thrombus (Figures 1 and 2). After a comprehensive work up to rule out malignancy and hypercoagulable disorders, a diagnosis of idiopathic pulmonary vein thrombosis was made. The patient received heparin and was discharged with rivaroxaban.

Pulmonary vein thrombosis is a rare disease but can be fatal, usually patient presents with non-specific symptoms such as cough and shortness of breath (1). The etiology in most of cases is hypercoagulable disorders, malignancies, atrial fibrillation, post lung operations such as lobectomy and lung transplantation, or could be idiopathic as in our patient.

Timothy Jon Rolle MD¹ and Mohammad Abdelaziz Mahmoud MD, DO^2
1Department of Radiology and the ²Internal Medicine Residency

Midwestern University Arizona College of Osteopathic Medicine

Canyon Vista Medical Center
Tucson, AZ USA

Reference

1. Chaaya G, Vishnubhotla P. Pulmonary vein thrombosis: a recent systematic review. Cureus. 2017 Jan 23;9(1):e993. [CrossRef] [PubMed]

Cite as: Rolle TJ, Mahmoud MA. Medical image of the month: idiopathic right lower lobe pulmonary vein thrombus. Southwest J Pulm Crit Care. 2020;20(1):7-8. doi: https://doi.org/10.13175/swjpcc048-19 PDF

September 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Clinical History: A 48-year-old woman with no previous medical history presented with complaints of intermittent cough persisting several months following a recent upper respiratory tract infection. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. Upon close inspection, the right thorax appeared slightly asymmetrically smaller than the left.

Laboratory evaluation was unremarkable. Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. 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 nine pages)

1. The chest radiograph shows asymmetric reticulation and interlobular septal thickening
2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes
3. The chest radiograph shows large lung volumes
4. The chest radiograph shows multifocal consolidation and pleural effusion
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Gotway MB. September 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(3):104-13. doi: https://doi.org/10.13175/swjpcc109-17 PDF 

Medical Image of the Week: Partial Anomalous Pulmonary Venous Return

Figure 1. Chest radiograph status post left internal jugular central line placement with arrow pointing to tip of catheter.

   

Figure 2. Axial (Panel A) and coronal (Panel B) views of contrast CT chest showing anomalous pulmonary venous return (yellow arrow). Middle Panel: Video of selected axial sections. Lower Panel: Video of selected coronal sections.

A 69 year old woman presented with septic shock secondary to a urinary tract infection. A chest radiograph (Figure 1) done after uneventful placement of a left internal jugular central line showed  aberrant position of the catheter.

Review of a past contrast-enhanced CT chest (Figure 2) revealed an anomalous pulmonary venous return with a pulmonary vein draining to the brachiocephalic vein.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital defect which results in a left-to-right shunt. The prevalence was 0.1% in one retrospective study of 45,538 contrast-enhanced chest CT scans (1). Diagnosis can be made with echocardiography, angiography, right heart catheterization, or computed tomography. PAPVR is traditionally associated with atrial septal defects, and patients are often asymptomatic. Clinical manifestations occur when there is significant shunting and include syncope, right heart failure, and pulmonary hypertension (2).

Candy Wong MD¹; Tammer Elaini MD²; Naser  Mahmoud MD¹, and Josh Malo MD¹

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

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Ho M, Bhalla S, Bierhals A,Gutierrez F. MDCT of partial anomalous pulmonary venous return (PAPVR) in adults. J Thorac Imaging. 2009;24(2):89-95. [CrossRef] [PubMed]
2. Kivisto S, Hanninen H, Holmstrom M. Partial anomalous pulmonary venous return and atrial septal defect in adult patients detected with 128-slice multidetector computed tomography. J Cardiothorac Surg. 2011;6:126. [CrossRef] [PubMed]

Reference as: Wong C, Elaini T, Mahmoud N, Malo J. Medical image of the week: partial anomalous pulmonary venous return. Southwest J Pulm Crit Care. 2014;9(4):219-20. doi: http://dx.doi.org/10.13175/swjpcc129-14 PDF