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.
Medical Image of the Month: Aspergilloma – Monod’s Sign
Figure 1 (A) Contrast-enhanced CT of chest showing irregular shape, thick wall cavity with oval heterogeneous soft tissue lesion (black arrow) at the posterior inferior aspect of this cavity. Figure 1 (B) Computed tomography of the chest in the prone position showing the mass moving to dependent region of the cavity (black arrow), known as Monod sign.
A 58-year-old man with a history of human immunodeficiency virus on antiretroviral therapy, bullous emphysematous lung with right upper lobe cavity presented with hemoptysis for three days. On presentation, he was afebrile, with normal oxygen saturation on room air and reduced bilateral breath sounds. Computed tomography (CT) of the chest showed a thick wall cavity at the right upper lobe, with a 3 cm heterogeneous mass at the posterior aspect of the cavity (Figure 1 A). When the patient was placed in the prone position, the soft tissue lesion displaced anteriorly (Figure 1B) showing gravity-dependency (Monod's sign). His serum Aspergillus fumigatus antibodies were also positive. The patient was diagnosed with aspergilloma and started on voriconazole initially. However, because of recurrent hemoptysis, the patient was scheduled to undergo surgical excision. Saprophytic aspergillosis is the causative organism for the development of an aspergilloma (1). It results from colonization of fungus in a preexisting pulmonary cavity which can lead to the formation of a fungus ball within the cavity (1,2). Hemoptysis is the most common presentation. CT scan should be performed in the supine as well as in the prone position to help differentiate from other conditions. In the case of recurrent or life-threatening hemoptysis, surgical excision remains the gold standard option (1).
Kulothungan Gunasekaran MD, Nageshwari Palanisamy MBBS, Sandra Patrucco Reyes MD, Safal Shetty MD
Division of Pulmonary Diseases and Critical Care
Yale New Haven Health Bridgeport Hospital
Bridgeport, CT USA
References
- Sharma S, Dubey S, Kumar N, Sundriyal D. 'Monod' and 'air crescent' sign in aspergilloma. BMJ Case Rep. 2013 Sep 13;2013:bcr2013200936. [CrossRef] [PubMed]
- Grech R. Images in clinical medicine. Aspergilloma. N Engl J Med. 2010 Mar 18;362(11):1030. [CrossRef] [PubMed]
Cite as: Gunasekaran K, Palanisamy N, Patrucco Reyes S, Shetty S. Medical image of the month: aspergilloma – Monod’s sign. Southwest J Pulm Crit Care. 2020;20(6):188-9. doi: https://doi.org/10.13175/swjpcc032-20 PDF
Medical Image of the Week: Atypical Deep Sulcus Sign
Figure 1. Chest X-ray showing hyper inflated lungs with no clear evidence of pneumothorax.
Figure 2. Atypical deep sulcus sign on the left side.
Figure 3. Complete resolution of left sided pneumothorax after chest tube placement.
The deep sulcus sign is a radiolucent lateral sulcus where the chest wall meets the diaphragm. The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign (1). Here, we present a 42-year-old man with a history of asthma who was admitted with status asthmaticus requiring intubation. On hospital day 3, the patient developed subcutaneous emphysema surrounding his entire neck and extending into left side of the chest wall. Chest X-ray after this episode showed an atypical deep sulcus sign (Figure 2) concerning for left sided pneumothorax that was also confirmed by bedside ultrasound. A surgical chest tube was placed immediately and a repeat chest X-ray (Figure 3) showed complete resolution of the pneumothorax and the deep sulcus sign. In critically ill patients where it is difficult to obtain an upright film, it is important to pay attention to the costophrenic angles when concern for pneumothorax arises. In a supine film, a deep sulcus sign may be the only indication of a pneumothorax because air collects anteriorly and basally within the nondependent portions of the pleural space, as opposed to the apex when the patient is upright (2).
Hasan Ali MD1, Huthayfa Ateeli MBBS2, Bhupinder Natt MD FACP2, Sachin Chaudhary MD2.
1Department of Medicine and 2Division of Pulmonary, Critical Care, Sleep and Allergy
University of Arizona College of Medicine
Tucson, AZ USA
References
- Kim HK, Park CY, Cho HM. Deep sulcus sign. Trauma Image & Procedure. 2016;1(1):12-3. [CrossRef]
- Liu SY, Tsai IT, Yang PJ. Pneumothorax and deep sulcus sign. QJM. 2016;109(9):621-2. [CrossRef] [PubMed]
Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: atypical deep sulcus sign. Southwest J Pulm Crit Care. 2018;16(4):224-5. doi: https://doi.org/10.13175/swjpcc044-18 PDF