February 2019 Imaging Case of the Month: Recurrent Bronchitis and Pneumonia in a 66-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 66–year old woman presented with complaints of a non-productive cough worsening over the previous several weeks. She complained that her cough had also occurred several months earlier, but resolved, and then subsequently returned.

The patient indicated that she has had bouts of bronchitis off and on for many years. Her smoking history included only 3 cigarettes / day for two years, quitting 20 years earlier. She did not note any allergies and her list of medications included only vitamin supplements, baby aspirin, omeprazole, and lisinopril. Her surgical history was remarkable only for remote tonsillectomy and hysterectomy.

Her physical examination was largely unremarkable, although some course breath sounds were detected over the medial right base. Her vital signs showed normal pulse rate and blood pressure, breathing at 12 breaths / minute. Her room air oxygen saturation was 97%.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Initial frontal chest x-ray.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to be directed to the second of sixteen pages)

1. Chest radiography shows a vague solitary pulmonary opacity
2. Chest radiography shows basilar fibrotic opacities
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows marked cardiomegaly
5. Chest radiography shows numerous small nodular opacities

Cite as: Gotway MB. February 2016 imaging case of the month: Recurrent bronchitis and pneumonia in a 66-year-old woman. Southwest J Pulm Crit Care. 2019;18(2):31-49. doi: https://doi.org/10.13175/swjpcc006-19 PDF

Medical Image of the Week: Bronchopulmonary Sequestration

Figure 1. A) Chest x-ray PA view demonstrating an oblong soft tissue density in the retrocardiac region overlying the medical aspect of the left hemidiaphragm. B) Chest x-ray lateral view demonstrating the same opacity anterior to a lower thoracic vertebral body, suspicious for a lung mass.

Figure 2. Chest computed tomography A) axial and B) coronal sections demonstrating a lobulated, cystic structure within the left lower lobe with a feeding artery off the aorta, consistent with a pulmonary sequestration.

A 49-year-old woman was incidentally found to have a lung mass on a pre-operative chest x-ray done prior to an elective cholecystectomy (Figure 1). Chest computed tomography, ordered to further characterize this mass revealed a left lower lobe lobulated, cystic opacity with a feeding artery from the aorta, consistent with bronchopulmonary sequestration (BPS) (Figure 2). Given that she has not had any complications of BPS we elected to manage her conservatively with observation.

BPS is a rare congenital malformation of the lower airways characterized by abnormal lung tissue that does not communicate with the tracheobronchial tree and receives its blood supply from the systemic circulation (1). Our patient’s BPS was intralobar in location, occurring within a normal lobe but lacking its own visceral pleura. The posterior basal left lower lobe is the most common intralobar location. Among cases that escape clinical detection in infancy, BPS comes to light in childhood or adulthood as either an incidental radiographic finding or as a symptomatic presentation of a lung infection. While surgical resection is generally considered to be the treatment of choice given the risk of developing infection, hemorrhage or malignancy (2), some asymptomatic adults with BPS may be managed conservatively with observation with serial imaging (3).

Udit Chaddha MD¹, Niusha Damaghi MD¹, Ashley Prosper MD², and Ching-Fei Chang MD¹

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

Keck School of Medicine

University of Southern California

Los Angeles, CA USA

References

1. Biyyam DR, Chapman T, Ferguson MR, Deutsch G, Dighe MK. Congenital lung abnormalities: embryologic features, prenatal diagnosis, and postnatal radiologic-pathologic correlation. Radiographics. 2010 Oct;30(6):1721-38. [CrossRef] [PubMed]
2. Azizkhan RG, Crombleholme TM. Congenital cystic lung disease: contemporary antenatal and postnatal management. Pediatr Surg Int. 2008 Jun;24(6):643-57. [CrossRef] [PubMed]
3. Stanton M, Njere I, Ade-Ajayi N, Patel S, Davenport M. Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg. 2009 May;44(5):1027-33. [CrossRef] [PubMed]

Cite as: Chaddha U, Damaghi N, Prosper A, Cha C-F. Medical image of the week: bronchopulmonary sequestration. Southwest J Pulm Crit Care. 2017;14(4):168-9. doi: https://doi.org/10.13175/swjpcc036-17 PDF

Medical Image of the Week: Scimitar Syndrome

Figure 1. Axial CT in lung windows at the level of the right atrium shows a dilated anomalous vein (arrow) coursing in close proximity to the major fissure (star).

Figure 2. Coronal CT in soft tissue windows at the level of the right hemi diaphragm shows evidence of post surgical repair with the anomalous vein draining into the left atrium (arrow).  Note the right hemi-diaphragm is elevated suggesting some degree of pulmonary hypoplasia.

A 38 year-old woman presented for evaluation of palpitations and chronic progressive dyspnea on exertion accompanied by chest tightness and fatigue. Chest radiograph was normal except for low lung volumes. An echocardiogram revealed normal left ventricular size and function with an ejection fraction of 60%, normal right ventricular size and function and moderate tricuspid insufficiency with an estimated right ventricular systolic pressure of 36 mm Hg plus central venous pressure and a mildly enlarged right atrium. Computed tomography (CT) of the heart with contrast showed normal coronary arteries, enlarged right atrium and partial anomalous pulmonary venous return from the right lung to the inferior vena cava (IVC) (Figure 1). Cardiac catheterization with selective angiography confirmed anomalous pulmonary venous drainage from the right upper and right lower lobe to the hepatic portion of the inferior vena cava with obstruction (8 mm Hg gradient between the anomalous vein and the right atrium). The calculated pulmonary to systemic flow ratio (Qp:Qs) was 1.3:1. The pulmonary vascular resistance was 7.6 Woods units and the mean pulmonary artery pressure was 24 mmHg.  The diagnosis of Scimitar syndrome was made.

The patient underwent surgical repair of partial anomalous pulmonary drainage and pulmonary vein stenosis as well as ligation of an aortopulmonary collateral artery found intraoperatively. The anomalous pulmonary vein was divided from the IVC, the caval end was oversewn and the anomalous vein was anastomosed to the left atrium with a CorMatrix patch (Figure 2). The patient recovered from surgery, however, her symptoms continued and Doppler pattern on a follow-up transthoracic echocardiogram suggested residual obstruction at the site of anastomosis to the left atrium.  Catheterization confirmed obstruction of the anastomosed vein at the level of insertion into the left atrium.  The patient underwent repeat sternotomy and repair of pulmonary vein obstruction using a CorMatrix patch and sutureless reconstruction of the right-sided pulmonary vein obstruction.  She recovered from this procedure with some improvement of her symptoms.

Scimitar syndrome is a rare congenital anomaly characterized by partial anomalous pulmonary venous connection of the right pulmonary veins to the IVC, anomalous systemic arterial supply to the right lung and a variable degree of right lung hypoplasia with or without sequestration (1).  Partial anomalous pulmonary venous return (PAPVR) is an uncommon congenital anomaly and accounts for less than 1% of congenital heart lesions. Scimitar syndrome comprises 3-5% of PAPVR (2). The term refers to the distinctively shaped vein, which resembles a short, curved Turkish sword called a scimitar (Figure 2). Most cases present in infancy and childhood and diagnosis in adulthood is quite rare. In adults, the clinical presentation is variable and the lesion may be discovered incidentally or patients can present with dyspnea, pulmonary hypertension and recurrent right-sided lung infection (1). The treatment of isolated PAPVR in adults is controversial due to rare occurrence of the disease, complexity of surgical repair and risk of re-stenosis. Surgical repair involves re-implantation of the anomalous vein into the left atrium and can be a complex and difficult procedure, however it can be accomplished with low morbidity and mortality at specialized centers (3). Thrombosis or stenosis of the scimitar vein is a serious complication of surgery. Our patient demonstrates some of the challenges in diagnosis and treatment and illustrates some of the post-operative complications of this rare disease.

Jamie Colombo, DO¹

Linda Snyder, MD²

Veronica Arteaga, MD³

Daniela Lax, MD⁴

¹Department of Pediatrics

²Department of Medicine, Division of Pulmonary/Critical Care Medicine

³Department of Medical Imaging

⁴Department of Pediatrics, Division of Pediatric Cardiology

University of Arizona

Tucson, AZ

References

1. Yehia BR, Bachmann JM, Traill TA. Scimitar syndrome: a rare cause of dyspnea in adults. South Med J. 2010;103:578-580. [CrossRef] [PubMed]
2. Haest RJ, van den Berg CJ, Goei R, Baur LH. Scimitar syndrome; an unusual congenital abnormality occasionally seen in adults. Int J Cardiovasc Imaging. 2006;22:565-568. [CrossRef] [PubMed]
3. Majdalany DS, Phillips SD, Dearani JA, Connolly HM, Warnes CA. Isolated partial anomalous venous connections in adults: twenty-year experience. Congenit Heart Dis. 2010;5:537-545. [CrossRef] [PubMed]

Reference as: Colombo J, Snyder L, Arteaga V, Lax D. Medical image of the week: scimitar syndrome. Southwest J Pulm Crit Care. 2014;9(2):137-9. doi: http://dx.doi.org/10.13175/swjpcc111-14 PDF

July 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 24-year-old non-smoking man presents to the emergency room with hemoptysis, cough, fever, and chest pain. Frontal and lateral chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography shows opacity in the medial left lung base. No clear evidence of air bronchograms is evident, no pleural abnormality is seen, and no lymphadenopathy is present.

Which of the differential diagnostic considerations listed below is the most likely consideration for the appearance of the lesion on the chest radiograph?

1. Bronchogenic carcinoma
2. A congenital pulmonary lesion
3. A mediastinal germ cell neoplasm
4. A Morgagni diaphragmatic hernia
5. Pneumocystis jiroveci pneumonia

Reference as: Gotway MB. July 2012 imaging case of the month. Soutwest J Pulm Crit Care 2012;5:24-32. (click here for a PDF version of the case)