Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
August 2024 Imaging Case of the Month: An Unexplained Pleural Effusion
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)
- Frontal chest radiography shows normal findings
- Frontal chest radiography shows a moderate-to-large right pleural effusion
- Frontal chest radiography shows mediastinal lymphadenopathy
- Frontal chest radiography shows pneumothorax
- Frontal chest radiography shows numerous small nodules
April 2024 Medical Image of the Month: Wind Instruments Player Exhibiting Exceptional Pulmonary Function
Figure 1. Representative view from computed tomography (CT) scan (axial plane) showing clear lungs.
Figure 2. Pulmonary function testing results demonstrating exceptional pulmonary function
A 64-year-old man was referred to our pulmonary clinic for evaluation of his pulmonary status. He had a 7-year history of rheumatoid arthritis and was treated initially with steroids and subsequently maintained on methotrexate and monthly adalimumab injections. The patient reported that his rheumatoid arthritis symptoms were controlled. He experienced no joint pain or morning stiffness at the time of evaluation. From a pulmonary perspective, he denied respiratory symptoms such as exertional shortness of breath, cough, wheezing, or chest tightness. He reported no limitations in physical activities. The patient has an occupational history of 45-years as a welder, with exposure to dust, metal fumes, benzene, and sulfur gas. The patient also has a 15 pack-year smoking history but quit 35 years ago.
A high-resolution chest CT (Figure 1) ordered by his rheumatologist showed normal lung parenchyma. The first pulmonary function test (PFT), conducted on the initial pulmonary clinic visit, revealed lung volumes significantly higher than the reference range. This is despite the patient’s occupational history, smoking history, and the fact that he is currently on methotrexate and adalimumab therapy. The patient remained asymptomatic from a pulmonary standpoint on annual checkups. Three years later, a repeat PFT (Figure-2) demonstrated similar results. Further history revealed that the patient had regularly used wind instruments, including the saxophone and harmonica, since high school. Initially, he played at irregular intervals, but for the last 15 years, he consistently practiced 1-2 hours daily and performed weekly at local venues.
Several studies have investigated the pulmonary effects of wind instrument playing, offering insights into the relationship between musical activities and respiratory function. Fiz et al. (1) found that maximum respiratory pressures were elevated in trumpet players. Munn et al. (2) reported on the pulmonary function of commercial glass blowers [2]. Barbenel et al. (3) explored mouthpiece forces during trumpet playing and Kahane et al. (4) evaluated the upper airway and larynx in professional bassoon players. Cossette et al. (5) examined chest wall dynamics during flute playing. Schorr-Lesnick et al. (6) studied pulmonary function in singers and wind-instrument players [6], and Navratil et al. (7) assessed lung function in wind instrument players and glass blowers. Borgia et al. (8) provided physiological observations on French horn musicians. While existing studies present conflicting findings on the impact of wind instrument playing on respiratory function, our case adds to the growing body of evidence suggesting a potential positive correlation between long-term wind instrument training and enhanced respiratory muscle strength.
This observation prompts further exploration and investigation into the field of pulmonary rehabilitation with the hope of uncovering therapeutic benefits for individuals with chronic pulmonary conditions.
Abdulmonam Ali, MD
Pulmonary & Critical Care
SSM Health
Danville, IL USA
References
- Fiz JA, Aguilar J, Carreras A, Teixido A, Haro M, Rodenstein DO, Morera J. Maximum respiratory pressures in trumpet players. Chest. 1993 Oct;104(4):1203-4. [CrossRef] [PubMed]
- Munn NJ, Thomas SW, DeMesquita S. Pulmonary function in commercial glass blowers. Chest. 1990 Oct;98(4):871-4. [CrossRef] [PubMed]
- Barbenel JC, Kenny P, Davies JB. Mouthpiece forces produced while playing the trumpet. J Biomech. 1988;21(5):417-24. [CrossRef] [PubMed]
- Kahane JC, Beckford NS, Chorna LB, Teachey JC, McClelland DK. Videofluoroscopic and laryngoscopic evaluation of the upper airway and larynx of professional bassoon players. J Voice. 2006 Jun;20(2):297-307. [CrossRef] [PubMed]
- Cossette I, Monaco P, Aliverti A, Macklem PT. Chest wall dynamics and muscle recruitment during professional flute playing. Respir Physiol Neurobiol. 2008 Feb 1;160(2):187-95. [CrossRef] [PubMed]
- Schorr-Lesnick B, Teirstein AS, Brown LK, Miller A. Pulmonary function in singers and wind-instrument players. Chest. 1985 Aug;88(2):201-5. [CrossRef] [PubMed]
- Navratil M, Bejsek K. Lung function in wind instrument players and glass blowers. Ann NY Acad Sci. 1968; 155:276-83.
- Borgia JF, Horvath SM, Dunn FR, von Phul PV, Nizet PM. Some physiological observations on French horn musicians. J Occup Med. 1975 Nov;17(11):696-701. [PubMed]
Medical Image of the Week: Massive Spontaneous Intra-Abdominal Bleeding
Figure 1. CT scan of the abdomen and pelvis showing diffuse intra-abdominal bleeding.
A 67 year-old female with RA, on anti-TNF and steroids, was admitted to the ICU with severe shock, likely hemorrhagic. She was on Coumadin for atrial fibrillation. She was found to have severe coagulopathy and diffuse spontaneous abdominal bleeding (Figure 1). She also developed left popliteal artery thrombosis, with compartment syndrome requiring surgical intervention. DIC was the final diagnosis.
Mohammed Alzoubaidi MD, Carmen Luraschi-Monjagatta MD, Sridhar Reddy MD, Robert McAtee MD.
Departments of Pulmonary and Critical Care, Internal Medicine and Emergency Medicine
South Campus
Tucson, Arizona
Reference as: Alzoubaidi M, Luraschi-Monjagatta C, Reddy S, McAtee R. Medical image of the week: massive spontaneous intra-abdominal bleeding. Southwest J Pulm Crit Care. 2014;8(2):135. doi: http://dx.doi.org/10.13175/swjpcc018-14 PDF