Medical Image of the Week: Thoracic Splenosis

Figure 1. A: Axial CT of the chest without intravenous contrast demonstrates a cluster of soft tissue nodules adjacent to the left posterior hemi-diaphragm (blue arrows). B: Axial CT of the chest without intravenous contrast demonstrates absence of the spleen and a surgical clip (blue arrow) consistent with a prior splenectomy.

Figure 2. Fused technetium 99m-label sulfur colloid uptake study and axial CT of the chest without intravenous contrast demonstrates uptake of radiotracer in the previously seen soft tissue nodules adjacent to the posterior aspect of the left hemi-diaphragm (red arrows) which confirms the diagnosis of thoracic splenosis.

A 38-year-old man with a history of a motor vehicle collision about 20 years prior to presentation which resulted in multiple left-sided rib fractures, a left-sided pneumothorax requiring chest tube placement, and a high-grade splenic laceration necessitating an emergent splenectomy that presents to outpatient pulmonary clinic for evaluation of pulmonary nodules at the request of his primary care physician. He is asymptomatic. He has a 20-pack-year of smoking history and currently smokes 6 cigarettes per day. He denies any significant exposures or recent infections. He has a family history significant for heart disease and depression, but no history of malignancy. His vital signs and physical examination are normal. He had a CT of the chest performed with representative images from the study shown in Figure 1.

A nuclear medicine scan was subsequently requested which demonstrated uptake of the technetium 99m-labeled sulfur colloid in the soft tissue nodules adjacent to left hemi-diaphragm (Figure 2) confirming the diagnosis of thoracic splenosis. No further treatment or diagnostic work up was required.

Splenosis is defined as auto-transplantation of splenic tissue following traumatic or surgical disruption of the spleen. Splenosis usually occurs in the abdomen, most commonly in the left upper quadrant (1,2). However, with disruption of the diaphragm in the setting of trauma, splenic tissue can migrate into the thoracic cavity, and most often settles in the inferior, posterior left pleural space (as in our patient).  The diagnosis of thoracic splenosis should be suspected when one sees left basilar pleural nodules/masses in the setting of a previous trauma necessitating a splenectomy. A technetium 99m-labeled sulfur colloid study will demonstrate uptake of the radiotracer in the auto-transplanted splenic tissue as this radiotracer has a strong affinity for tissue arising from the reticuloendothelial system.

Gregory Gardner MD¹, Kevin Breen¹, Tammer Elaini MD², and Tiffany Ynosencio MD²

¹Department of Internal Medicine

²Division of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Khosravi MR, Margulies DR, Alsabeh R, Nissen N, Phillips EH, Morgenstern L. Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury. Am Surg. 2004 Nov;70(11):967-70. [PubMed]
2. Rosado-de-Christenson ML, Abbott GF. Diagnostic Imaging: Chest. 2^nd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 30-1.

Cite as: Gardner G, Breen K, Elaini T, Ynosencio T. Medical image of the week: thoracic splenosis. Southwest J Pulm Crit Care. 2018;16(5):285-6. doi: https://doi.org/10.13175/swjpcc066-18 PDF

Medical Image of the Week: Cutaneous Coccidioidomycosis

Figure 1. Right distal anterior thigh. Fungal culture grew Coccidioides immitis from biopsy.

A 46-year-old Hispanic man with no known past medical history presents to his primary care physician for a progressively worsening “rash” located over his right thigh. Patient described the lesion as raised, scaly, and itchy. It has been “growing” for the past one year and started out as a small “pimple”. Patient denied any trauma to the effected region over this time period. Surgical history was significant for a splenectomy 15 years prior that was needed after a traumatic accident. He works in construction and lives in southern Arizona. He denied alcohol, tobacco and or illicit drug use. Patient has attempted to treat this skin lesion with over the counter hydrocortisone ointment with no relief. He denied any other associated symptoms including fever/chills, headache, vision changes, night sweats, weight loss, cough, shortness of breath, and or joint pains. Vital signs were stable upon presentation. Physical exam was entirely benign other than the isolated skin lesion shown above (Figure 1). It measured roughly 5cm at its greatest dimension and was located just superior the right knee on the anterior portion of the distal thigh. Nodularity was appreciated upon palpation but no tenderness was noted. Areas of erythema were non-blanching. Small satellite lesions were seen on the perimeter.

He was sent to a dermatologist and biopsies were performed. Light microscopy and culture confirmed the diagnosis of cutaneous coccidioidomycosis. Initial laboratory work revealed a normal complete blood count and complete metabolic panel. Serum coccidioides IgM antibody was negative but IgG was confirmed to be positive with a reflex complement fixation titer of 1:16. Chest X-ray was normal. Patient was started on oral fluconazole 400mg daily. Repeat coccidioides IgG titers decreased to 1:8 at a four- week follow-up. Patient has been tolerating the medication well and skin lesion has begun to regress.

Norman Beatty MD¹ and Mayar Al Mohajer MD²

¹Departments of Internal Medicine and ²Infectious Diseases

University of Arizona College of Medicine

Tucson, AZ

Cite as: Beatty N, Al Mohajer M. Medical image of the week: cutaenous coccidioidomycosis. Southwest J Pulm Crit Care. 2015;11(5):226-7. doi: http://dx.doi.org/10.13175/swjpcc110-15 PDF