Medical Image of the Month: Hepatic Abscess Secondary to Diverticulitis Resulting in Sepsis

 

Figure 1. An axial, post-contrast CT of the abdomen and pelvis demonstrates an ill-defined, multiloculated, hypodense lesion in the right hepatic lobe most consistent with a hepatic abscess (red circle).

       Figure 2. Coronal and axial reconstructions of the post-contrast CT of the abdomen and pelvis demonstrate extensive diverticulosis of the descending and sigmoid colon (blue arrows) with a focal area of fat-stranding in the descending colon consistent with diverticulitis (red arrow) – likely the source of the patient’s hepatic abscess.

Clinical Scenario: A 73-year-old man with a previous history of hypertension presented to the hospital with a 4-day history of malaise, myalgias, syncope, nausea, and vomiting. He denied having any fevers, chills, diarrhea, abdominal pain, or recent travel. Upon arrival to the hospital, he was found to be febrile to 103.4°F, and hypotensive with systolic blood pressures in the 80’s. His baseline documented systolic blood pressures from numerous outpatient clinics were in the 110’s. In addition, he was hypoxemic requiring 6 L/min of supplemental oxygen to maintain an adequate oxygen saturation. Physical examination was significant for alteration of his mental status. He denied any abdominal pain with palpation, and there was no rebound tenderness or guarding. His lab work was significant for a leukopenia and thrombocytopenia - new from his previous lab work in our system. A CT of the abdomen and pelvis with contrast demonstrated a multiloculated abscess in the right hepatic lobe (Figure 1). He also had extensive diverticular disease of the descending and sigmoid colon with a focal area of diverticulitis in the descending colon (Figure 2). A CT-guided, percutaneous drain was placed in the right hepatic lobe abscess which grew Streptococcus anginosus and Bacteroides fragilis. With the combination of antibiotics and drainage of the abscess, his clinical condition markedly improved. He was discharged approximately 1 week after admission at his normal baseline.

Discussion: Liver abscess is the most common type of visceral abscess (1). Clinical manifestations include a broad spectrum of symptoms, but the most common are fever (70%–90% of patients) and abdominal pain, usually in the right upper quadrant (50%–75%) (2-4). Liver abscesses can occur because of multiple etiologies to include ascending cholangitis, hematogenous spread from the gastrointestinal tract via portal venous drainage of infectious entities such as diverticulitis and appendicitis, and from hematogenous spread via the hepatic artery. Other etiologies for the development of hepatic abscesses include penetrating trauma or after an invasive procedure (for example biliary instrumentation, transcatheter arterial chemoembolization, percutaneous liver biopsy, or abdominal surgery) (5).

Many bacteria have been described in the pathogenesis of pyogenic abscesses, reflecting the variability among patients and geographic areas. Many aspirated fluid cultures are positive, whereas blood cultures are positive in only 50% of cases (4). Most pyogenic liver abscesses are polymicrobial (4). Traditionally, Escherichia coli has been reported as the most common isolated microbe; however, recent data show that Klebsiella pneumoniae is the most common pathogen in pyogenic liver abscesses (3,4,6).

Management of pyogenic liver abscesses includes imaging-guided drainage and antibiotic therapy. There is considerable variation in clinical practice regarding total antibiotic duration (7). It is recommended that antibiotic therapy be continued for at least 4–6 weeks, but the optimal duration is still unclear (7). Although drainage of single abscesses with a diameter of 5 cm or less can be achieved in some cases, it may not improve outcomes compared with antibiotic treatment alone. In isolated abscesses with a diameter greater than 5 cm, catheter drainage should be considered and is preferred over needle aspiration, although some favor surgical intervention (8). Prompt diagnosis and imaging-guided drainage have been reported to reduce mortality from 65% to 2%–12% (2-4).

Reubender Randhawa MD¹, Alan Nyquist MD², and Tammer El-Aini MD²

¹Banner University Medical Center – South Campus, Department of Internal Medicine, Tucson, AZ USA

²Banner University Medical Center – Tucson Campus, Department of Pulmonary and Critical Care

References

1. Altemeier WA, Culbertson WR, Fullen WD, Shook CD. Intra-abdominal abscesses. Am J Surg. 1973 Jan;125(1):70-9. [CrossRef] [PubMed]
2. Mohsen AH, Green ST, Read RC, McKendrick MW. Liver abscess in adults: ten years experience in a UK centre. QJM. 2002 Dec;95(12):797-802. [CrossRef] [PubMed]
3. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. [CrossRef] [PubMed]
4. Huang CJ, Pitt HA, Lipsett PA, Osterman FA Jr, Lillemoe KD, Cameron JL, Zuidema GD. Pyogenic hepatic abscess. Changing trends over 42 years. Ann Surg. 1996 May;223(5):600-7; discussion 607-9. [CrossRef] [PubMed]
5. Wisplinghoff H, Appleton DL. Bacterial infections of the liver. In: Weber O, Protzer U, eds. Comparative hepatitis. Basel, Switzerland: Birkhäuser, 2008; 143–160. [CrossRef]
6. Liu Y, Wang JY, Jiang W. An Increasing Prominent Disease of Klebsiella pneumoniae Liver Abscess: Etiology, Diagnosis, and Treatment. Gastroenterol Res Pract. 2013;2013:258514. [CrossRef] [PubMed]
7. Molton J, Phillips R, Gandhi M, Yoong J, Lye D, Tan TT, Fisher D, Archuleta S. Oral versus intravenous antibiotics for patients with Klebsiella pneumoniae liver abscess: study protocol for a randomized controlled trial. Trials. 2013 Oct 31;14:364. [CrossRef] [PubMed]
8. Zerem E, Hadzic A. Sonographically guided percutaneous catheter drainage versus needle aspiration in the management of pyogenic liver abscess. AJR Am J Roentgenol. 2007 Sep;189(3):W138-42. [CrossRef] [PubMed]

Cite as: Randhawa R, Nyquist A, El-Aini T. Medical image of the month: hepatic abscess secondary to diverticulitis resulting in sepsis. Southwest J Pulm Crit Care. 2021;23(1):5-7. doi: https://doi.org/10.13175/swjpcc019-21 PDF 

Medical Image of the Month: Glioblastoma Multiforme

Figure 1. Non-contrast CT axial views of what was later identified as glioblastoma multiforme demonstrates heterogeneous left frontal lobe mass with foci of hemorrhage (black arrows, A), mass effect (gray arrow, A & B), central necrosis (gray arrowhead, C), invasion of the corpus callosum (gray arrowhead, C), and vasogenic edema (white arrow, D).

A patient in their 60's presented with headaches for approximately 2 weeks followed by acutely worsening mental status with confusion. CT of the head is shown (Figure 1). Glioblastoma multiforme was high on the differential diagnosis.

Glioblastoma multiforme (GBM) is classified as a grade IV astrocytoma and is the most common malignant primary brain tumor. It has an incidence of 3.19 cases per 100,000 persons per year. Astrocytomas are the most invasive type of glial tumor, directly reflecting the remarkably poor prognosis with a 5-year survival rate of approximately 4% and a 26-33% survival rate at 2 years in clinical trials. Symptoms develop relatively rapidly due to edema and mass effect of the tumor. Increased intracranial pressure and swelling manifests as nausea, vomiting, seizures and headaches that are typically worse in the morning. Neurological symptoms are dependent on the location of the cerebrum that is affected (ex. sensory, motor, visual changes, gait disturbances). Conventional gadolinium-enhanced MR imaging is the standard technique for the evaluation of GBM. GBM is characterized by a large, heterogeneous mass in the cerebral hemisphere exhibiting hemorrhage, necrosis and enhancement. In addition, magnetic resonance tomography (MRS) and positron emission tomography (PET) can be used to examine the chemical profile and assist in detecting tumor recurrence, respectively. The current gold standard treatment for GBM is temozolomide in combination with radiation therapy. Two potential new treatment modalities currently under investigation are gene therapy and immunotherapy.

Biopsy of the patient’s mass confirmed glioblastoma multiforme, which was successfully treated without recurrence on MRI 18 months later.

Cassandra Ann Roose and Michael Craig Larson MD, PhD

Medical Imaging Department

Banner University Medical Center/University of Arizona

Tucson, AZ UA

References

1. Stoyanov GS, Dzhenkov DL. On the Concepts and History of Glioblastoma Multiforme - Morphology, Genetics and Epigenetics. Folia Med (Plovdiv). 2018;60(1):48-66. [CrossRef] [PubMed]
2. Altman DA, Atkinson DS Jr, Brat DJ. Best cases from the AFIP: glioblastoma multiforme. Radiographics. 2007;27(3):883-888. [CrossRef] [PubMed]
3. American Association of Neurological Surgeons. Glioblastoma Multiforme. Available from: https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Glioblastoma-Multiforme (accessed 8/24/20).

Cite as: Roose CA, Larson MC. Medical image of the month: glioblastoma multiforme. Southwest J Pulm Crit Care. 2020;21(3):64-5. doi: https://doi.org/10.13175/swjpcc046-20 PDF 

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

Medical Image of the Month: Emphysematous Cystitis

Figure 1. Abdominal CT with contrast showing a thickened, trabeculated bladder wall containing pockets of gas consistent with emphysematous cystitis due to E. coli infection.

Emphysematous cystitis is a rare infection of the urinary bladder caused by gas producing organisms which can be bacterial or fungal characterized by gas collections inside the bladder wall (1). Most common organisms are E. coli, Klebsiella and Proteus are also commonly isolated. Fungi, such as Candida, have also been reported as causative organisms. Presentation range from asymptomatic up to septic shock.

Jonathon P. Mahn DO¹ and Mohammad A. Mahmoud MD, DO²

¹Canyon Vista Medical Center and ²Internal Medicine Residency, Midwestern University, Arizona College of Osteopathic Medicine, Canyon Vista Medical Center

Tucson, AZ USA

Reference

1. Amano M, Shimizu T. Emphysematous cystitis: a review of the literature. Intern Med. 2014;53(2):79-82. [CrossRef] [PubMed]

Cite as: Mahn JP,  Mahmoud MA. Medical Image of the month: emphysematous cystitis. Southwest J Pulm Crit Care. 2019;19(5):148. doi: https://doi.org/10.13175/swjpcc045-19 PDF 

Medical Image of the Month: Incarcerated Morgagni Hernia

Figure 1. Lateral view of abdominal-thoracic CT in soft tissue windows.

Figure 2. Coronal view of thoracic CT scan in lung windows.

A Morgagni hernia is a congenital diaphragmatic hernia in which abdominal viscera herniate into the thorax via a defect within an anterior attachment of the diaphragm. As with any bowel-containing hernia, the most feared complication is strangulation with subsequent bowel necrosis. In the present case, a 67-year-old woman presented with a five-day history of acute onset and progressively worsening upper abdominal pain and inability to tolerate oral intake, associated with nausea, vomiting, and mild shortness of breath. A CT revealed a large defect in the right hemidiaphragm consistent with a Morgagni hernia with herniation of the omentum, vessels, and a segment of transverse colon (Figure 1). Findings of bowel ischemia were observed, including (a) pneumatosis intestinalis, seen as cystic foci of air lining the bowel wall, and (b) fluid and fat-stranding adjacent to the affected bowel (Figure 2). Evidence of bowel wall perforation include large volume free air adjacent to the bowel in the right hemithorax and within the abdomen (Figures 1 and 2). Bowel ischemia and necrosis can occur with any hernia and requires prompt diagnosis and management.

Samandip Hothi MD¹ and Viral Patel MD²

¹Department of Medicine, Division of Internal Medicine and ²Department of Medical Imaging

University of Arizona College of Medicine-Tucson

Tucson, AZ USA

References

1. Arora S, Haji A, Ng P. Adult Morgagni Hernia: The Need for Clinical Awareness, Early Diagnosis and Prompt Surgical Intervention. Ann R Coll Surg Engl. 2008 Nov;90(8):694-5. [CrossRef] [PubMed]
2. Ly JQ. The Rigler Sign. Radiology. 2003;228(3):706-7. [CrossRef] [PubMed]
3. Morgan TB, Nguyen DN, Tran CD, Maheshwary RK, Mickus TJ. Morgagni Hernia Causing Incarcerated Bowel and Contributing to Cardiac Arrest. Curr Probl Diagn Radiol. 2018 Jul 31. pii: S0363-0188(18)30181-6. [CrossRef]

Cite as: Hothi S, Patel V. Medical image of the month: Incarcerated Morgagni hernia. Southwest J Pulm Crit Care. 2019;18:59-60. doi: https://doi.org/10.13175/swjpcc001-19 PDF 

Medical Image of the Week: Bronchogenic Cysts

Figure 1. Posterior-anterior (A) and lateral (B) chest radiographs showing a large cyst with an air-fluid level in the right lung.

Figure 2. Representative image from thoracic CT scan in lung windows showing large right lung cyst.

Bronchogenic cysts are congenital foregut malformations forming from abnormal budding of the bronchial tree between the 4^th and 6^th weeks of embryonic development. While identified primarily in children, the cysts are often asymptomatic and may not be identified until adulthood. Most (70%) are within the middle mediastinum and contain fluid or proteinaceous material. When involving the parenchyma, they generally do not communicate with the tracheobronchial tree. Communication with the airways may develop following infection, procedures, or trauma and may result in lesions with an air-fluid level (Figures 1 and 2). Bronchogenic cysts may be complicated by infection, bleeding, fistula formation, or most concerning, by malignant transformation. Unless the cyst contains air, it may manifest as a solitary pulmonary nodule on plain radiographs. Computed tomography or T2-weighted MRI images are used to confirm the diagnosis. 

Steven P. Sears DO¹ and Diana Maria Palacio MD²

¹Division of Pulmonary, Allergy, Critical Care and Sleep and ²Department of Medical Imaging

University of Arizona College of Medicine

Tucson, AZ USA

References

1. McAdams HP, Kirejczyk WM, Rosado-de-Christenson ML, et al. Bronchogenic cyst: Imaging features with clinical and histopathologic correlation. Radiology. 2000 Nov;217(2):441-6. [CrossRef] [PubMed]
2. St-Georges R. Deslauriers J, Duranceau A, et al. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult. Ann Thorac Surg. 1991;52:6-13. [CrossRef] [PubMed]
3. Cardinale L, Ardissone F, Cataldi A, et al. Bronchogenic cysts in the adult: Diagnostic criteria derived from the correct use of standard radiography and computed tomography. Radiol Med. 2008;113(3): 385-94. [CrossRef] [PubMed]

Cite as: Sears SP, Palacio DM. Medical image of the week: Bronchogenic cysts. Southwest J Pulm Crit Care. 2018;16(3):141-2. doi: https://doi.org/10.13175/swjpcc026-18 PDF 

Medical Image of the Week: Pulmonary Artery Sling

Figure 1. Computerized tomography (CT) of the chest showing the aberrant origin of the left pulmonary artery from the right pulmonary artery creating a pulmonary artery sling with mild tracheal narrowing (arrow).

Figure 2. Cardiac magnetic resonance imaging (MRI) confirming the presence of a pulmonary artery sling with aberrant origin of the left pulmonary artery from the right pulmonary artery.

A 42-year-old year woman with asthma was admitted to the hospital with an asthma exacerbation. The patient complained of dyspnea on exertion, two-pillow orthopnea and bipedal edema. An echocardiogram showed a severely dilated right ventricle (RV) with elevated right ventricular systolic pressure of 71 mmHg. The systolic left ventricular (LV) function was also reduced with an ejection fraction of 45%. Computerized tomography (CT) of the chest showed an aberrant origin of the left pulmonary artery (PA) creating a pulmonary artery sling with mild tracheal narrowing (Figure 1, arrow). Cardiac magnetic resonance imaging (MRI) confirmed the presence of a pulmonary artery sling with the aberrant origin of the left PA from the right PA (Figure 2). Cardiac catheterization showed a mean PA pressure of 46mmHg with LV end diastolic pressure of 12mm Hg. The patient was diagnosed with WHO Group I pulmonary hypertension and started on treatment with sildenafil with a stable outpatient course.

Pulmonary artery sling is an uncommon form of vascular ring. The anomaly is a result of formation of the left PA from the right sixth vascular arch (rather than the left), leading to the left PA arising from the posterior aspect of the right PA (1). Pulmonary artery slings may produce symptoms of airway compression and esophageal compression and usually presents in childhood (2). In asymptomatic cases, a PA sling may mimic a mediastinal mass on chest radiographs and CT and MRI may be used to establish the diagnosis (3).

Abhinav Agrawal MD¹, Stuart L Cohen MD², Rakesh Shah MD², Arunabh Talwar MD FCCP¹

¹Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine

²Division of Thoracic Radiology, Department of Radiology

Hofstra-Northwell School of Medicine

New Hyde Park, NY USA

References

1. Casta-er E, Gallardo X, Rimola J, Pallardó Y, Mata JM, Perendreu J, Martin C, Gil D. Congenital and acquired pulmonary artery anomalies in the adult: radiologic overview. Radiographics. 2006 Mar-Apr;26(2):349-71. [CrossRef] [PubMed]
2. Odell DD, Gangadharan SP, Majid A. Pulmonary artery sling: a rare cause of tracheomalacia in the adult. J Bronchology Interv Pulmonol. 2011 Jul;18(3):278-80. [CrossRef] [PubMed]
3. Ganesh V, Hoey ET, Gopalan D. Pulmonary artery sling: an unexpected finding on cardiac multidetector CT. Postgrad Med J. 2009 Mar;85(1001):128. [CrossRef] [PubMed] 

Cite as: Agrawal A, Cohen SL, Shah R, Talwar A. Medical image of the week: pulmonary artery sling. Southwest J Pulm Crit Care. 2017;15:160-61. doi: https://doi.org/10.13175/swjpcc116-17 PDF

Medical Image of the Week: Spontaneous Pneumothorax in End Stage Fibrotic Lung Disease

Figure 1. Chest x-ray showing moderate-sized right pneumothorax with a pigtail chest tube in place, diffuse reticular interstitial opacities.

Figure 2. Chest CT showing extensive centrilobular emphysema, moderate right pneumothorax with pigtail chest drain on the right, subpleural reticular opacities with peripheral and basilar preponderance suggesting interstitial fibrotic lung disease, and diffuse lung cysts - heterogenous in size.

A 61-year-old nonsmoking man with chronic obstructive lung disease, pulmonary hypertension, pulmonary fibrosis, hypertension, coronary artery disease with congestive heart failure, presented with recurrent pneumothorax, pneumomediastinum, extensive subcutaneous emphysema and bronchopleural fistula.

The patient reported ongoing symptoms of exertional dyspnea, fatigue, and coughing for years. His environmental exposures were notable for exposure to birds since early childhood. He had 6 cockatiels and 2 doves living inside his home and is directly responsible for their care. Former occupational exposures include painting and sandblasting. Family history was notable for early onset non specified lung disease in his father, and rheumatoid arthritis in his mother.

Lung function testing performed prior to the bronchopleural fistula revealed moderate obstructive ventilatory defect with severely limited DLCO. Chest x-ray (Figure 1) revealed a moderate-sized right pneumothorax with a pigtail chest tube in place and diffuse reticular interstitial opacities. His CT chest (figure 2) revealed extensive subcutaneous emphysema, diffuse lung cysts that are heterogenous in size, and subpleural reticular opacities with peripheral and basilar preponderance. Bronchoalveolar lavage revealed no infection, with predominant monocyte/ macrophages. Alpha-1 antitrypsin (A1AT) was normal, as were autoimmune panels. A hypersensitivity pneumonitis panel revealed positive IgG to Aureobasidium pullulans. A presumptive diagnosis of chronic hypersensitivity pneumonitis was made.

Spontaneous pneumothorax (SP), a potentially life-threatening complication, is defined by the accumulation of air in the pleural space with secondary lung collapse, and can be categorized as primary (without apparent lung disease) or secondary pneumothorax. While chronic obstructive pulmonary disease and Pneumocystitis jirovecii pneumonia are the most common causes of secondary spontaneous pneumothorax, other structural lung diseases such as fibrotic lung diseases have also been linked to SP. Interstitial lung diseases distort lung architecture and trigger formation of subpleural blebs that are susceptible to rupture leading to extra-alveolar air collection and air leakage in the pleural space. Presence of persistent air leak, as in our case, mandates surgical consideration to accelerate recovery and prevent recurrence of secondary SP.

Roula Altisheh MD and Tara Carr MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

Banner-University Medical Center

Tucson, AZ USA

References

1. Sahn S, Heffiner J. Spontaneous Pneumothorax. N Engl J Med 2000; 342:868-74 [CrossRef] [PubMed]
2. Onuki T, Ueda S, Yamaoka M, Sek iya Y, Yamada H, Kawakami N, Araki Y, Wakai Y, Saito K, Inagaki M, Matsumiya N. Primary and secondary spontaneous pneumothorax: prevalence, clinical features, and in-hospital mortality. Can Respir J. 2017: 6014967.  [CrossRef] [PubMed]
3. Koschel D, Handzhiev S, Cardoso C, Rolle A, Holotiuk O, Höffken G. Pneumomediastinum as a primary manifestation of chronic hypersensitivity pneumonitis. Med Sci Monit. 2011 Dec;17(12):CS152-5. [PubMed]
4. Ichinose J, Nagayama K, Hino H, et al. Results of surgical treatment for secondary spontaneous pneumothorax according to underlying diseases. Eur J Cardiothorac Surg. 2016;49(4):1132–6. [CrossRef] [PubMed]

Cite as: Altisheh R, Carr T. Medical image of the week: spontaneous pneumothorax in end stage fibrotic lung disease. Southwest J Pulm Crit Care. 2017;14(6):308-10. doi: https://doi.org/10.13175/swjpcc065-17 PDF 

Medical Image of the Week: Arachnoid Cyst

Figure 1. Axial T1 MRI of mass.

Figure 2. Coronal T2 weighted MRI demonstrating compressions onto mesial temporal lobes and stretching of the optic chiasm and tracts; upward displacement of the hypothalamus, third ventricle small in caliber and mild posterior displacement of the midbrain.

A 40 year-old woman with adult attention deficit hyperactive and bipolar 1 disorder presents with an altered mental status.  Per her family, she had been non-verbal, with reduced oral intake, confusion and sedated for the past three days. Per her husband, she had episodes of diarrhea and abdominal discomfort. She was on multiple medications including ramelteon 8mg nightly, atomoxetine 40mg daily, hydroxyzine 25mg twice daily, bupropion 75mg twice daily and risperidone 2mg daily with recent addition of lithium ER 1200mg/daily started one month prior to presentation with unknown adherence.

Upon arrival, vital signs were within normal limits. Physical exam revealed an overweight Caucasian woman with a significant coarse tremor visible at rest, restlessness and diaphoresis. Neurological examination was limited by patient hesitancy, however, it did not demonstrate focal deficits except for altered consciousness with Glasgow Coma Scale of 10. Notable laboratory findings were Na⁺ 134 mEq/L, K⁺ 3.2 mEq/L, and lithium level of 3.9 mmol/L, urine toxicology positive for cocaine, and EKG showed QT prolongation. Toxicology and psychiatry were consulted.

CT of her head without contrast showed a large midline lesion in the sellar/suprasellar estimated to be 5.2x 2.1x 3.2cm. On hospital day number 2 the patient was more somnolent with down trending lithium level of 2.6 mmol/L. Later that day the patient had an observed generalized tonic clonic seizure which required abortive therapy with lorazepam and levetiracetam. A MRI revealed large arachnoid cyst measuring 3.6x3.1x3.5cm causing mass effect on adjacent tissue. (Figures 1 and 2). Neurology was consulted and recommended neurosurgery evaluation who deferred intervention to an outpatient basis given her lithium overdose as a more likely etiology of her seizure and not the arachnoid cyst.

Arachnoid cysts are cerebral spinal fluid filled sacs located between the brain or spinal cord and the arachnoid membrane. They can be either primary, which are present at birth due to developmental abnormalities of the brain and spinal cord, or they may be secondary, which are the result of head injury, meningitis, tumors, or a complication of brain surgery. Symptoms are based on the size and location of the cyst and include headache, nausea and vomiting, seizures, hearing and visual disturbances, vertigo, and difficulties with balance and walking. If the cyst compresses the spinal cord or nerve roots, then individual may experience progressive back and leg pain and tingling or numbness in the legs or arms.

Diagnosis is usually via MRI which distinguishes between fluid-filled arachnoid cysts from other types of cysts. The treatment depends on the location and the size of the cyst. If the cyst is small and does not compress any of the surrounding structures, with an absence of symptoms, no treatment is necessary. The two main ways of treating symptomatic cysts include surgery or placing a permanent shunt to drain the fluid. Surgical approaches include microscopic open surgical fenestration procedure in which the neurosurgeon opens the skull to gain access to the cyst, then opens the cyst to release pressure, allowing contents to be absorbed by the brain. Another surgical approach involves endoscopic cyst fenestration in which an endoscope is used to drain the cyst internally without having to perform an open surgery. In some instances, formal craniotomy with excision/marsupialization of the cyst into the subarachnoid space is performed. The procedure performed depends on the surgeon’s comfort with the technique and the size/location of the cyst.

Matthew Erisman MD, Rozina Parbtani MS IV, and Faraz Jaffer MD.

Department of Internal Medicine

University of Arizona at South Campus

Tucson, Arizona USA

References

1. Al-Holou WN, Terman S, Kilburg C, Garton HJ, Muraszko KM, Maher CO. Prevalence and natural history of arachnoid cysts in adults. J Neurosurg. 2013 Feb;118(2):222-31. [CrossRef] [PubMed]
2. Eidlitz-Markus T, Zeharia A, Cohen YH, Konen O. Characteristics and management of arachnoid cyst in the pediatric headache clinic setting. Headache. 2014 Nov-Dec;54(10):1583-90. [CrossRef] [PubMed]

Cite as: Erisman M, Parbtani R, Jaffer F. Medical image of the week: arachnoid cyst. Southwest J Pulm Crit Care. 2016;13(4):181-3. doi: http://dx.doi.org/10.13175/swjpcc074-16 PDF

Medical Image of the Week: Renal Cell Carcinoma Metastasis

Figure 1. Panel A: Axial CT image noncontrast showing small pulmonary nodules concerning for metastasis. Panel B: Axial CT image depicting 15 cm mass, originating from the right acetabulum and adjacent iliac bone. Panel C: Coronal CT image showing prominent left renal cyst measuring almost 40 mm. Panel D: Coronal CT image displaying femoral head intact but surrounded by abnormal soft tissue, concerning for neoplasm. There is bony destruction and lytic process in the anterior and posterior pillars of the right acetabulum.

A 65-year-old man was complaining of progressive weakness and right knee pain with limping since November 2014 was admitted recently to a local hospital and treated for chronic kidney disease related anemia, Klebsiella urinary tract infection and methicillin-sensitive Staphylococcus aureus wound infections. He was discharged to rehab, but continued to have progressive weakness, pain and limping. He was sent to our hospital for further evaluation and imaging.

CT of the abdomen and pelvis non contrast, due to decreased glomerular filtration rate, revealed a 15 cm mass originating from the right acetabulum and adjacent iliac bone with bony destruction and lytic processes (Figure 1). The femoral head is also surrounded by abnormal soft tissue (Figure 1D). There were also small pulmonary nodules (Figure 1A), small lymph nodes in the transverse mesocolon and retroperitoneum, and an enlarged left adrenal gland concerning for other metastasis.

CT guided biopsy of the lesion revealed a neoplastic process composed of atypical cells with centrally placed nuclei, abundant clear cytoplasm arranged in a vascular network. Immunohistochemical stains demonstrated positivity for the following: vimentin, low molecular weight keratin, CD10, RCCA, and PAX-8. These findings are consistent with metastatic renal cell carcinoma.

A total body bone scan with Tc-99m methylene diphosphonate, performed to locate other osseous metastasis, was negative for distant metastasis other than the large destructive lesion destroying the right ileum previously noted on CT.

Renal cell carcinoma (RCC) is a cortical tumor with malignant cells originating from the epithelial lining of the proximal tubules. Renal cancer is amongst the 10 most common cancers in both men and women, with RCC accounting for about 80% of the total incidence and mortality (1). RCC has been referred to as “the internist’s tumor” as it can cause systemic symptoms unrelated to the renal cancer. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in at most 9 percent of patients (1). Most cases of RCC are diagnosed incidentally on radiographic investigation done for other reasons. Unfortunately, many patients are asymptomatic until the disease is advanced. At presentation, approximately 25% of individuals either have distant metastases or advanced local disease (2). Biopsy is not usually required to diagnose RCC. Contrast-enhanced CT can be used to diagnosis and stage RCC. 

Stage IV disease has a median survival of about 12 months with systemic cytokine therapy and 28 months with targeted therapies, based on analyses from the International Metastatic RCC Database Consortium (IMDC) (1,3).

Erin Yen MS¹, Benjamin Rayikanti MD², Yunuen Valenzuela MD³, Jennifer Segar MD³

¹ Midwestern University Arizona College of Osteopathic Medicine, Phoenix

² Tucson Hospitals Medical Education Program

³ Department of Internal Medicine, Banner University Medical Center Tucson

Tucson AZ USA

References

1. American Cancer Society. Cancer Facts & Figures 2016. Atlanta, GA: American Cancer Society; 2016. Available at: http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/ (accessed 9/14/16).
2. DeKernion JB. Real numbers. In: Campbell's Urology, Walsh PC, Gittes RF, Perlmutter AD (Eds), WB Saunders, Philadelphia 1986. p.1294.
3. Heng DY, Choueiri TK, Rini BI, et al. Outcomes of patients with metastatic renal cell carcinoma that do not meet eligibility criteria for clinical trials. Ann Oncol. 2014 Jan;25(1):149-54. [CrossRef] [PubMed]

Cite as: Yen E, Rayikanti B, Valenzuela Y, Segar J. Medical image of the week: renal cell carcinoma metastasis. Southwest J Pulm Crit Care. 2016;13(3):135-6. doi: http://dx.doi.org/10.13175/swjpcc068-16 PDF

Medical Image of the Week: Tracheobronchopathia Osteochondroplastica

Figure 1: Panels (A and B) show the lumpy, bumpy nodules of tracheobronchopathia osteochondroplastica affecting the anterior tracheal wall with sparing of the posterior membrane. In this patient, copious amounts of white secretions can be seen in the distal trachea and the posterior membrane from her current MRSA pneumonia. 

Tracheobronchopathia osteochondroplastica (TO) is a rare, idiopathic tracheobronchial abnormality that is seen during 0.7% of bronchscopies. It is usually diagnosed in the 5th to 6th decades of life with a male preponderance (1,2)^. Here, we present the case of a 62-year-old woman with history of bronchial asthma with recurrent exacerbations who was admitted with pneumonia and a new mass-like consolidation on imaging. She underwent bronchoscopy for further work up and was found to have methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Incidental nodules were found in her trachea during the bronchoscopy (Figure 1). Most patients with TO are asymptomatic but can rarely present with cough, shortness of breath, and even non-massive hemoptysis due to ulceration of nodular mucosa. Secondary airway narrowing has also been reported. The lumpy, bumpy nodules typically are 3-8 mm in size, localize in the sub-mucosa of the trachea, and are difficult to biopsy due to their cartilaginous or osseous nature. Diagnosis can be made by chest CT or bronchoscopy. A very important distinctive feature is sparing of the posterior membranous wall of the trachea, differentiating it from other nodular airway diseases. TO is a benign disease that generally doesn’t need any specific treatment or intervention (1,2).

Huthayfa Ateeli, MBBS, Elaine Cristan, MD, and Afshin Sam, MD.

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

University of Arizona, Tucson, AZ USA

References

1. Lundgren R, Stjernberg NL. Tracheobronchopathia osteochondroplastica. A clinical bronchoscopic and spirometric study. Chest. 1981 Dec;80(6):706-9. [CrossRef] [PubMed]
2. Prince JS, Duhamel DR, Levin DL, Harrell JH, Friedman PJ. Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation. Radiographics. 2002 Oct;22 Spec No:S215-30. [CrossRef] [PubMed] 

Cite as: Ateeli H, Cristan E, Sam A. Medical image of the week: tracheobronchopathia osteochondroplastica. Southwest J Pulm Crit Care. 2016;13(3):131-2. doi: http://dx.doi.org/10.13175/swjpcc067-16 PDF

Medical Image Of The Week: Tricuspid Valve Vegetation with Septic Pulmonary Emboli

Figure 1. Chest radiograph on presentation consistent with septic pulmonary embolic and cavitation.

Figure 2. Echocardiogram demonstrating a highly mobile echo-dense vegetation attached to the atrial side of the tricuspid valve.

A 28-year-old woman with a history of extensive intravenous heroin use presented to the hospital with generalized chest and abdominal pain. Vital signs were remarkable for hypotension, tachypnea, and tachycardia. Laboratory studies revealed leukocytosis, hyponatremia, acute kidney injury, and lactic acidosis. A radiograph of the chest demonstrated multiple airspace opacities throughout the bilateral lungs with associated cavitary lesions and a small right-sided pleural effusion (Figure 1). A transthoracic echocardiogram was obtained, which demonstrated a 3.6 cm x 2.0 cm tricuspid valve vegetation (Figure 2). Blood cultures identified methicillin-sensitive Staphylococcus aureus.

Infective endocarditis, valvular vegetation, and septic pulmonary emboli are common complications of intravenous drug use. Staphylococcus aureus is the most common bacterial cause of infective endocarditis among intravenous drug users (1). Like endocarditis, patients with septic pulmonary emboli often present with non-specific clinical manifestations such as fever (86%), dyspnea (48%), and chest pain (49%) (2). Management may be surgical or medical, and determining the best course is complicated by social and psychiatric factors affecting adherence to treatment. Cardiac valve surgery has been advocated early for large right-sided vegetations but carries high morbidity and expense, as well as risk of compromised recovery, in the setting of ongoing IV drug use. Even for patients with valvular vegetations ≥ 1cm, medical therapy alone may be a safe option under some circumstances in the absence of other surgical indications (3).

Sarah Harris BA¹, Kady Goldlist MD², Maria Tumanik DO², Cameron Hypes MD MPH^3,4

¹ University of Arizona College of Medicine

² Department of Internal Medicine, Banner University Medical Center – South Campus

³ Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

 ⁴Department of Emergency Medicine

University of Arizona

Tucson, AZ USA

References

1. Ortiz-Bautista C, López J, García-Granja PE, et al. Current profile of infective endocarditis in intravenous drug users: The prognostic relevance of the valves involved. Int J Cardiol. 2015;187:472-4. [CrossRef] [PubMed]
2. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med. 2014 Jan;108(1):1-8. [CrossRef] [PubMed]
3. Otome O, Guy S, Tramontana A, Lane G, Karunajeewa H. A retrospective review: significance of vegetation size in injection drug users with right-sided infective endocarditis. Heart Lung Circ. 2016 May;25(5):466-70. [CrossRef] [PubMed] 

Cite as: Harris S, Goldlist K, Tumanik M, Hypes C. Medical image of the week: tricuspid valve vegetation with septic pulmonary emboli. Southwest J Pulm Crit Care. 2016:12(6):253-4. doi: http://dx.doi.org/10.13175/swjpcc042-16 PDF

Medical Image of the Week: Left Ventricular Non-compaction

Figure 1. Cardiac MRI showing severely enlarged and remodeled left ventricle (LV) and moderately enlarged right ventricle (RV) with severe global hypokinesis and akinesis of the interventricular septum. Significant trabeculation was noted in the apical, antero-lateral and anterior segments of the LV (red arrows), consistent with LV non-compaction.

A 38-year-old woman with history of type 2diabetes mellitus and hypertension presented to emergency department with worsening exertional dyspnea and orthopnea for the past 2-3 months. She also reported a 14 pound weight gain within the 2 weeks prior to presentation. She denied any prior history of cardiac or pulmonary disease. Also, there was no family history of heart disease. She denies any recent sick contacts, smoking, alcohol drinking, or substance abuse.

Physical exam revealed jugular venous pressure of 10 cm H₂O and significant bilateral lower extremity pitting edema. Chest x-ray showed an enlarged cardiac silhouette. Brain naturetic peptide (BNP) was 2,917 pg/mL. A subsequent echocardiogram revealed a left ventricular (LV) ejection fraction of 23% with severe global LV hypokinesia with moderate mitral regurgitation. Thyroid panel as well as iron panel were within normal range. Other laboratories were unremarkable. For the new onset systolic heart failure, a coronary angiography was performed, which demonstrated normal coronary arteries. The patient was diagnosed with non-ischemic cardiomyopathy and underwent a cardiac MRI, which showed severely enlarged and remodeled LV and moderately enlarged right ventricle (RV) with severe global hypokinesis and akinesis of the intraventricular septum. Moreover, a significant trabeculation was noted in the apical, antero-lateral and anterior segments of the left ventricle (Figure 1), consistent with “LV non-compaction” without any evidence of LV thrombus. The patient was started on diuretics and safely discharged with significant symptoms improvement.  

LV non-compaction is a cardiomyopathy characterized by altered myocardial wall with prominent left ventricular trabeculae and deep intertrabecular recesses (1). Some authors believe that non-compaction of the ventricular myocardium results from abnormal persistence of the trabecular layer  while others believe that altered regulation in cell proliferation, differentiation, and maturation during ventricular wall formation, resulting in hyper-trabeculation (2). Its prevalence in the general population is unknown but among patients undergoing echocardiography is estimated at 0.014 to 1.3 percent. In patients with heart failure, its prevalence has been reported as 3 to 4 percent (3). Patients with LV non-compaction may present with heart failure, arrhythmias, sudden cardiac arrest, syncope, and thromboembolic events. The diagnosis is usually established by transthoracic echocardiography. When echocardiography is indeterminate, cardiac MRI, computed tomography, or left ventriculography could be an alternative diagnostic modality. Data on treatment of LV non-compaction are limited, and there is no standard therapy established for this condition. Medical management depends on the clinical manifestations, LV ejection fraction, presence of arrhythmias, and risk of thromboembolism.

Rostam Khoubyari MD^1,2 and Seongseok Yun MD PhD³

¹Department of Cardiology, ²Sarver Heart Center; and the ³Department of Medicine, University of Arizona

Tucson, AZ USA

References

1. Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation. 2006 Apr 11;113(14):1807-16. [CrossRef] [PubMed]
2. Henderson DJ, Anderson RH. The development and structure of the ventricles in the human heart. Pediatr Cardiol. 2009 Jul;30(5):588-96. [CrossRef] [PubMed]
3. Kovacevic-Preradovic T, Jenni R, Oechslin EN, Noll G, Seifert B, Attenhofer Jost CH. Isolated left ventricular noncompaction as a cause for heart failure and heart transplantation: a single center experience. Cardiology. 2009;112(2):158-64. [CrossRef] [PubMed]

Cite as: Khoubyari R, Yun S. Medical Image of the week: left ventricular non-compaction. Southwest J Pulm Crit Care. 2016;12(6):229-30. doi: http://dx.doi.org/10.13175/swjpcc036-16 PDF

Medical Image of the Week: Bochdalek Hernia

Figure 1. PA (A) and lateral (B) chest radiograph demonstrating a lobulated homogenous opacity in the  posterior left lung base-blue arrows.

Figure 2. Chest CT (axial image) demonstrating fat-containing opacity consistent with a Bochdalek hernia- red arrow.

A 61 year-old man presented for an evaluation of a nonproductive cough. He has a history of well-controlled asthma, allergic rhinitis and nasal polyposis, hypertension, gastro-esophageal reflux and obstructive sleep apnea. The ACE inhibitor used to treat hypertension was discontinued. The physical exam was unremarkable. Pulmonary function testing was normal.

A PA and lateral chest radiograph was performed and revealed an abnormal contour of the left hemidiaphragm with a large lobulated opacity (Figure 1- blue arrows). Computed chest tomography revealed the lobulated opacity in the left lower lobe contained fat and was consistent with a Bochdalek hernia (Figure 2).

Congenital diaphragmatic hernia is a major malformation in newborns and in the perinatal period. The diagnosis of congenital diaphragmatic hernia in adults is rare. There are three types of congenital diaphragmatic hernias: posterolateral (Bochdalek) diaphragmatic hernia, subcostosternal (Morgagni) hernia and esophageal hiatal hernia. The Bochdalek diaphragmatic hernia is the result of a congenital diaphragmatic defect in the posterior costal part of the diaphragm in the region of 10th and 11th ribs, which allows free communication between the thoracic and abdominal cavity. The defect is usually found at the left side (90%) but may occur on the right side, where the liver often prevents detection.

A review of 173 adult patients with Bochdalek hernias revealed several important features:  55% of patients were male with an average age of 40 years, the hernia defect was located on the left side in 78% of patients and most patients were symptomatic (1,2). The most common presenting symptoms were pain or pressure in the chest or abdomen and obstruction. Pulmonary symptoms occurred in 37% of patients in this review. Of note, patients with Bochdalek hernias can develop symptoms precipitated by factors that increase intra-abdominal pressure and failure to promptly treat a symptomatic Bochdalek hernia may lead to bowel strangulation. A chest CT is an excellent diagnostic study, as a Bochdalek hernia can be difficult to appreciate on a chest radiograph (3).

Management of a Bochdalek hernia includes reducing the abdominal contents and repairing the defect through a laparotomy or thoracotomy. Successful laparoscopic and thoracoscopic repairs of Bochdalek hernias have both been described.

Muna Omar, M.D. and Linda Snyder, M.D.

Pulmonary, Critical Care, Sleep and Allergy Medicine

Banner University Medical Center-Tucson

Tucson, AZ USA

References

1. Brown SR, Horton JD, Trivette E, Hofmann LJ, Johnson JM. Bochdalek hernia in the adult: demographics, presentation, and surgical management. Hernia. 2011 Feb;15(1):23-30. [CrossRef] [PubMed]
2. Bianchi E, Mancini P, De Vito S, Pompili E, Taurone S, Guerrisi I, Guerrisi A, D'Andrea V, Cantisani V, Artico M. Congenital asymptomatic diaphragmatic hernias in adults: a case series. J Med Case Rep. 2013 May 13;7:125. [CrossRef] [PubMed]
3. Sandstrom CK, Stern EJ. Diaphragmatic hernias: a spectrum of radiographic appearances. Curr Probl Diagn Radiol. 2011 May-Jun;40(3):95-115. [CrossRef] [PubMed]

Cite as: Omar M, Snyder L. Medical image of the week: Bochdalek hernia. Southwest J Pulm Crit Care. 2016 Jun;12(6):203-4. doi: http://dx.doi.org/10.13175/swjpcc031-16 PDF

Medical Image of the Week: Right Middle Lobe Syndrome

Figure 1. Panel A: PA chest x-ray showing calcified mediastinal lymphadenopathy. Panel B:  Lateral view showing a triangle of increased density between the minor fissure and the lower half of the major fissure seen on the lateral view (blue arrow) .

Figure 2. Image from the thoracic CT scan in lung windows showing calcified mediastinal lymph notes (green arrows).

A 73 year-old woman, a lifetime non-smoker, presented to the pulmonary clinic with chronic dyspnea on exertion and cough. Physical exam was unremarkable and pulmonary function testing showed normal spirometry. A chest radiograph revealed calcified mediastinal adenopathy and increased density in the right middle lobe region (Figure 1).  A computed tomography scan of the chest revealed significant narrowing of the right middle lobe bronchus with partial atelectasis and prominent calcified mediastinal lymphadenopathy (Figure 2).  Bronchoscopy showed no endobronchial lesions but there was evidence of extrinsic compression surrounding the right middle lobe orifice.  An endobronchial biopsy revealed noncaseating granulomas. Bronchoscopy cultures and cytology were negative and this was presumed to be from a previous infection with histoplasmosis given the patient’s long-term residence in an endemic area. Given chronic narrowing of right middle lobe bronchus with persistent atelectasis of the right middle lobe, the patient was diagnosed with right middle lobe syndrome.  She was started on combination therapy with a long-acting beta agonist and inhaled corticosteroid with complete resolution of her symptoms.

Right middle lobe syndrome (RMLS) is defined as recurrent or chronic atelectasis of the right middle lobe.  Although more commonly described in children, it is becoming more prevalent in adults with a predilection for women.  There are two distinct types of pathophysiology- obstructive and non-obstructive.  Obstructive pathophysiology is defined when there is an endobronchial lesion or extrinsic compression of the middle lobe bronchus by lymphadenopathy (as in our case) or a tumor.  Non-obstructive pathophysiology occurs when there is recurrent infection or inflammation leading to bronchiectasis and scarring.  Certain anatomical characteristics, including the acute take-off angle of the right middle lobe bronchus create poor conditions for drainage and collateral ventilation (1).

Symptoms of RMLS include chronic or recurrent cough, dyspnea, wheezing and recurrent infections.  High resolution computed tomography of the chest is the gold standard for imaging, as this will show narrowing of the right middle lobe orifice along with etiologies of extrinsic compression (Figure 2).  Patients suspected of having RMLS warrant a bronchoscopy to evaluate for patency of right middle lobe bronchus, to exclude malignancy and for evaluation of infectious etiologies (1).  The treatment of RMLS includes bronchodilator therapy along with mucolytics, chest physiotherapy and antibiotics if bronchiectasis is problematic.  Lobectomy may be warranted if malignancy is diagnosed, aggressive medical management fails or hemoptysis occurs (2). 

Elaine A. Cristan, MD and Linda Snyder, MD

Department of Medicine

Division of Pulmonary, Critical Care, Sleep and Allergy Medicine

Banner University Medical Center

Tucson, AZ USA

References

1. Gudbjartsson T, Gudmundsson G. Middle lobe syndrome: a review of clinicopathological features, diagnosis and treatment. Respiration. 2012;84(1):80-6. [CrossRef] [PubMed]
2. Einarsson JT, Einarsson JG, Isaksson H, Gudbjartsson T, Gudmundsson G. Middle lobe syndrome: a nationwide study on clinicopathological features and surgical treatment. Clin Respir J. 2009 Apr;3(2):77-81. [CrossRef] [PubMed] 

Cite as: Cristan EA, Snyder L. Medical image of the week: right middle lobe syndrome. Southwest J Pulm Crit Care. 2016; May;12(5):199-200. doi: http://dx.doi.org/10.13175/swjpcc030-16 PDF 

Medical Image of the Week: Complex Arteriovenous Malformation

Figure 1. Initial chest radiograph demonstrating right mid lung field process.

Figure 2. Panel A: Contrast enhanced thoracic CT scan axial view demonstrating very large, complex AVM. Panel B: Sagittal view.

Figure 3. Chest radiograph after coil embolization.

A 62-year-old man presented to the emergency department complaining of shortness of breath with exertion and mild non-productive cough. The patient was afebrile and physical exam was remarkable only for scattered bilateral rhonchi. White blood cell count was 8,800 K/uL and hematocrit was 51.5%. Room air arterial blood gas (at 1520 meters altitude) was pH 7.41, pCO2 42 mm Hg, PO2 45 mm Hg, and O2 saturation 78%. D-dimer was normal at 0.36 ug/ml. Chest radiograph (Figure 1) demonstrated what was interpreted as a right-sided mid/lower lung field infiltrate. The patient was placed on high-flow supplemental oxygen and treatment was initiated with intravenous levofloxacin, methylprednisilone and nebulized beta-agonists. The patient’s oxygenation failed to improve over a period of several days, and a CAT of the chest (Figures 2) was obtained, which demonstrated a very large, right middle lobe, complex pulmonary arteriovenous malformation. The patient was referred to interventional radiology for catheter directed coil embolization (Figure 3). Following that procedure the patient’s oxygen requirement decreased from 15 l/m via nasal cannula to 3 l/m.

Pulmonary arteriovenous malformations (PAVM’s) are rare, with an incidence of 2-3 per 100,000, and are associated with hereditary hemorrhagic telangiectasia (HHT), in approximately 80% of cases (1). The intrapulmonary shunt associated with PAVM’s may result in significant hypoxemia, cerebrovascular accident or embolic brain abscess. The preferred screening tool is transthoracic contrast echocardiography, which demonstrates extra-cardiac shunt. Chest CT scan may be used to both confirm the diagnosis of PAVM and to define the vascular anatomy. Patients who meet three of the four Curacao criteria (epistaxis, family history, telangiectasia, and visceral lesions) are recognized as suffering from HHT (2). Catheter directed coil embolization is an effective and well-tolerated treatment method for PAVM; and generally results in reduced shunt fraction and improved oxygenation (3).

Kathleen Monahan and Charles J. VanHook MD

Longmont United Hospital

Longmont, Colorado USA

References

1. Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arteriovenous malformations. Chest. 2013 Sep;144(3):1033-44. [CrossRef] [PubMed]
2. Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet. 2000 Mar 6;91(1):66-7. [CrossRef] [PubMed]
3. Dutton JA, Jackson JE, Hughes JM, Whyte MK, Peters AM, Ussov W, Allison DJ.Pulmonary arteriovenous malformations: results of treatment with coil embolization in 53 patients. AJR Am J Roentgenol. 1995 Nov;165(5):1119-25. [CrossRef] [PubMed]

Cite as: Monahan K, VanHook CJ. Medical image of the week: complex arteriovenous malformation. Southwest J Pulm Crit Care. 2016 May;12(5):197-8. doi: http://dx.doi.org/10.13175/swjpcc027-16 PDF

Medical Image of the Week: Achalasia with Lung Abscess

Figure 1. CT coronal view showing a left lower lobe lung abscess measuring approximately 8 x 5 cm.

Figure 2. Barium swallow study showed dilated esophagus with tapering off at the lower esophageal sphincter junction, demonstrating the classic bird-beak like appearance.

Figure 3. Upper endoscopy showing diffuse whitish plaque suggestive of candidiasis likely due to chronic stasis of food.

An 80-year old woman with past medical history of high grade serous fallopian tube carcinoma presented with 2 months history of productive cough. This was associated with shortness of breath and subjective fever, chills and weight loss of 5 pounds over 2 months. She was treated with outpatient antibiotics without improvement of symptoms. Patient was afebrile on presentation, hemodynamically stable, and saturating at 99% on room air. Lung examinations revealed dullness on percussion of left lower lung field and reduced breath sounds on the same area.

Computed tomographic imaging revealed a large lung abscess on left lower lobe (Figure 1) and moderately dilated esophagus and fluid filled to the level of gastro-esophagus junction. Barium swallow study showed a classic bird-beak like appearance (Figure 2). There was no contrast that passed through the gastro-esophagus junction during the entire course of the barium study. Upper endoscopy was performed to rule out intraluminal pathology that may contribute to the obstruction which revealed a large amount of barium and retained food in the entire esophagus with diffuse whitish plaque suggestive of candidiasis and a benign appearing intrinsic mild stenosis at lower third of esophagus (Figure 3). Pneumatic dilation and botulinum toxin injection were performed and she was started on pantoprazole. She was also started on broad-spectrum antibiotics (vancomycin, cefepime, metronidazole) for the lung abscess. A chest tube was inserted under computed tomography (CT) guidance. Subsequently, cultures from the chest tube drainage grew Streptococcus intermedius. She was discharged to a skilled nursing facility with additional 3-weeks of ampicillin-sulbactam. Repeat imaging at 3-weeks showed improvement of the lung abscess.

Achalasia is a rare primary esophageal motor disorder, with incidence of approximately 1 in 100,000 people annually and prevalence of 10 in 100,000 (1). Common presentations of achalasia includes gradual dysphagia to solid and liquids, heartburn symptoms unrelieved by adequate proton pump inhibitor therapy and weight loss. Achalasia presenting with respiratory symptoms without dysphagia is rare as this disease entity is gradual and patient will normally present with different degrees of dysphagia or regurgitation of food. This case report is a good reminder that aspiration should be considered as a cause for pneumonia in the elderly. Our patient could have been aspirating for a period of time, leading to the development of a large lung abscess. Kikuchi et al. (2) demonstrated the high incidence of silent aspiration in the elderly population. A more detailed assessment by trained swallowing therapist may aid in detecting dysphagia.

Kai Rou Tey MD¹ and Naser Mahmoud MD²

¹Department of Internal Medicine University of Arizona College of Medicine- South Campus

²Department of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona College of Medicine

Tucson, AZ USA

References

1. Francis DL, Katzka DA. Achalasia: update on the disease and its treatment. Gastroenterology. 2010 Aug;139(2):369-74. [CrossRef] [PubMed]
2. Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med. 1994 Jul;150(1):251-3. [CrossRef] [PubMed]

Cite as: Tey KR, Mahmoud N. Medical image of the week: achalasia with lung abscess. Southwest J Pulm Crit Care. 2016 May;12(5):194-6. doi: http://dx.doi.org/10.13175/swjpcc025-16 PDF

Medical Image of the Week: Necrotizing Soft Tissue Infection

Figure 1. Axial view showing extensive gluteal and perineal soft tissue inflammation with gas formation (arrow).

Figure 2. Saggital view showing gas formation (arrow).

A 70-year-old man with a history of coronary artery disease, chronic back pain, and general debilitation presented to the emergency department with complaints of fever, weakness and right buttock discomfort. Physical exam was remarkable for a temperature of 101.7º F, and for moderate erythema of the skin of the right inguinal area and right buttock, with associated tenderness. Laboratory exam was significant for a WBC of 22.7 K/ɥL, erythrocyte sedimentation rate of 82 mm, and serum creatinine phosphokinase of 2856 U/L. CAT of the abdomen and pelvis demonstrated extensive gluteal and perineal soft tissue inflammation with gas formation, consistent with a necrotizing soft tissue infection (Figures 1 and 2).

Three basic subsets of necrotizing soft tissue infections (NSTIs) have been described. Type I infections are the most common form and are characterized by a polymicrobial process typically involving gram positive cocci, gram negative rods, and anaerobes. Type I infections occur most commonly in diabetics, in patients with severe peripheral vascular disease, or in the presence of other immune compromising conditions.  Type II infections involve Group A Streptococcus, either alone or in combination with Staphylococcus aureus. Type II NSTI’s occur most commonly in immunocompetent hosts. Type III NSTI’s, caused by Vibrio vulnoficus, are found in patients with exposure to warm sea water, with liver disease being the most common predisposing condition (1-3). Fournier’s gangrene is a NSTI that involves the perineum (2).

Physical examination often reveals fever and local erythema or tenderness. Gas formation may be present on imaging studies, with CAT scans more sensitive than plain films (1). Treatment relies on early antibiotic therapy with anaerobic coverage, fluid resuscitation, and aggressive debridement. Hyperbaric oxygen therapy may have a role as well (1). Mortality is high, in the range of 40%, and recovery is often prolonged (1,3).

Angela Taylor MD, Milena Beer PA, and Charles J. VanHook MD

Longmont United Hospital

Longmont, Colorado USA

References

1. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. [CrossRef] [PubMed]
2. Pucket Y, Fisher B, Dissanaike S. Clinical comparison of Fournier's gangrene to other necrotizing soft tissue infections. Research Journal of Infectious Diseases. 2015;3:1. [CrossRef]
3. Khamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Yodluangfun S, Tantraworasin A. Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthc Policy. 2015 Feb 16;8:1-7. [CrossRef] [PubMed] 

Cite as: Taylor A, Beer M, VanHook CJ. Medical image of the week: necrotizing soft tissue infection. Southwest J Pulm Crit Care. 2016 Mar;12(3):102-3. doi: http://dx.doi.org/10.13175/swjpcc005-16 PDF

Medical Image of the Week: Necrotizing Pancreatitis

Figure 1. Contrast-enhanced CT of the abdomen and pelvis demonstrates innumerable foci of gas adjacent to the pancreatic head/body junction (red arrow) with marked inflammation of the pancreatic head (blue arrow). These findings are consistent with necrotizing pancreatitis.

A 60-year-old man with a past medical history significant for coronary artery disease status post percutaneous coronary intervention was admitted to Banner University Medical Center for acute pancreatitis complicated by a pericardial effusion requiring pericardiocentesis. The following day, the patient developed severe shortness of breath requiring increasing amounts of supplemental oxygen. The patient was emergently transferred to ICU for noninvasive bilevel positive airway pressure ventilation, but he subsequently required intubation. Throughout his worsening condition, he denied any abdominal pain, only relaying ongoing substernal chest pain. His troponins, however, remained negative and echocardiography failed to show any reaccumulation of the pericardial effusion.

CT scan of the chest failed to show any pulmonary embolism. But, CT abdomen displayed acute pancreatitis complicated by peripancreatic gas consistent with necrotizing pancreatitis (Figure 1). Emergent laparotomy was completed. There were no signs of stomach or duodenal perforation. Purulent fluid was removed from the lesser sac and an irrigating stump was placed.

Hem Desai MD¹, Tammer Elani MD¹, Nour Alhoda Parsa MD¹ and Kareem Ahmad MD²

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

University of Arizona

Tucson, AZ

Reference

1. Thoeni RF. The revised Atlanta classification of acute pancreatitis: Its importance for the radiologist and its effect on treatment. Radiology. 2012;262(3):751-64. [CrossRef] [PubMed]

Reference as: Desai H, Elani T, Parsa NA, Ahmad K. Medical image of the week: necrotizing pancreatitis. Southwest J Pulm Crit Care. 2015;11(2):84-5. doi: http://dx.doi.org/10.13175/swjpcc080-15 PDF

Medical Image of the Week: Teenage Tonsils

Figure 1. Tonsils showing shallow ulcers (arrows) secondary to coxsakievirus.

Figure 2. Enlarged tonsils R>L secondary to infectious mononucleosis.

An 18 year old woman complained of gradual onset throat pain and symptoms of a viral URI with nasal congestion, conjunctivitis and coryza. Later, faint macular rash appeared on her hands. Shallow ulcers developed on her tonsils (Figure 1). She was diagnosed with coxsakie viral infection and treated conservatively with ibuprofen.

A 19 year old man was seen for fatigue, malaise and odynophagia. Because of concern for peritonsilar abscess due to R>L tonsil enlargement (Figure 2) he was given intravenous steroids and antibiotics. His pain improved dramatically and he tested positive for infectious mononucleosis.

Adam M. Knox and Alexander G. Chiu, MD

Department of Otolaryngology

University of Arizona, Tucson

Reference as: Knox AM, Chiu AG. Medical image of the week: teenage tonsils. Southwest J Pulm Crit Care. 2015;11(1):51-2. doi: http://dx.doi.org/10.13175/swjpcc071-15 PDF