August 2022 Imaging Case of the Month: It’s All About Location

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

A 78–year–old man with a history of hyperlipidemia, hypertension, paroxysmal atrial fibrillation, and transcatheter aortic valve replacement on anticoagulation presented to the Emergency Room with a 2-month history of cough and exertional shortness of breath. He denied fever, chills, nausea, and chest pain. The patient had undergone three COVID-19 vaccines, the most recent 3 months earlier. He had noted some recent bruising, but denied any recent trauma.

The patient’s past medical history also included a history of prostate carcinoma 10 years earlier treated with radiation therapy. The patient’s past surgical history was remarkable for remote vasectomy, endoscopic sinus surgery and percutaneous aortic valve replacement. He was a former smoker and reported no allergies or illicit drug use; alcohol use was at most moderate, consisting of an occasional beer. The patient’s medications included a statin, warfarin, and metoprolol.

The patient’s physical examination showed normal vital signs and was remarkable only for some decreased breath sounds over the left lower thorax. The patient was afebrile. Bruising was noted involving the right hand and right abdominal wall, but without limitations in range of motion or associated pain.

A complete blood count showed a hemoglobin and hematocrit value of 7.7 gm/dL (normal, 13.2-16.6 gm/dL) and 23.9% (normal, 38.3–48.6%) and a platelet count of <2 x x10⁹/L (normal, 135-317 x10⁹/L). The white blood cell count was minimally abnormal at 9.7 x10⁹/L (normal, 3.4-9.6 x10⁹/L), with a mild left shift with a neutrophil level of 7.11 x10⁹/L (normal, 1.56-6.45 x10⁹/L). The eosinophil count was normal, but reticulocytes were elevated at 4.06% (normal, 0.60-2.71%). The INR was elevated at 2.3, with a prolonged prothrombin time of 25.8 sec (normal, 9.4-12.5 sec). Fibrinogen was also mildly abnormally elevated. Serum chemistries were largely within normal limits, with a mild elevation in lactate dehydrogenase at 273 U/L (normal, 122–222 U/L). Serum iron values were low at 30 mg/dL (normal, 50-150 mg/dL), with the total iron binding capacity abnormally decreased also. An ECG was unremarkable. A serum NT-Pro BNP value was elevated at 1174 pg/mL (normal, ≤122 pg/mL). Liver and renal function were within normal limits.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest.

Which of the following represents an appropriate interpretation of the frontal chest and lateral radiograph? (Click on the correct answer to be directed to the second of twelve pages)

1. Frontal chest radiography shows a large left pleural effusion
2. Frontal chest radiograph shows focal right lung opacity
3. Frontal chest radiography shows pleural calcification
4. Frontal chest radiography shows right peribronchial lymph node enlargement
5. More than one of the above

Cite as: Gotway MB. August 2022 Imaging Case of the Month: It’s All About Location. Southwest J Pulm Crit Care Sleep. 2022;25(2):15-22. doi: https://doi.org/10.13175/swjpccs034-22 PDF

Medical Image of the Month: Reexpansion Pulmonary Edema

 

Figure 1. Large right hydrothorax with mild mediastinal shift to the left.

Figure 2. Status post right pleural pigtail drain placement with interval improvement of the now small right pleural effusion with re-expansion of the right lung and early edema.

Figure 3. Moderate right pleural effusion and worsening reexpansion pulmonary edema.

A 54-year-old woman with decompensated alcoholic liver cirrhosis presented to the emergency department with exertional dyspnea. She was afebrile, tachycardic (110), with oxygen saturation of 74% on 5 liters/minute (L/min), in moderate respiratory distress and was subsequently placed on a non-rebreather. On examination, she had absent breath sounds throughout her right lung with chest radiograph revealing large right-sided pleural effusion (Figure 1). A pigtail catheter was placed, draining approximately 4 liters of fluid (Figure 2), resulting in improved oxygenation to 93% on 3 L/min. On admission to internal medicine, the chest tube was clamped immediately. In the next 24 hours, patient developed increased oxygen requirements, with worsening tachypnea and tachycardia, requiring bilevel positive airway pressure and admission to the medical intensive care unit for reexpansion pulmonary edema (Figure 3).

Hepatic hydrothorax is a complication of cirrhosis and portal hypertension, defined as pleural effusion without any underlying pulmonary or cardiac etiologies. Though the pathophysiology is not completely understood, it is widely believed that the pleural effusion is caused by negative intrathoracic pressures allowing peritoneal fluid to enter the pleural cavity through diaphragmatic defects. Management of hepatic hydrothorax includes sodium restriction, diuresis, therapeutic thoracentesis, and transjugular intrahepatic portosystemic shunt. Repeated thoracentesis is the routine procedure to remove pleural fluid in refractory hepatic hydrothorax (1).

Though relatively safe, thoracentesis is associated with reexpansion pulmonary edema (RPE). RPE is believed to occur due to increased permeability of the pulmonary capillaries as a result of inflammation caused by ventilation and reperfusion of previously collapsed lung. Symptoms of RPE include chest discomfort and cough with onset typically within 24 hours of lung reexpansion. Signs of RPE include tachypnea, tachycardia, lung crackles, and hypoxemia refractory to oxygen therapy. Risk factors are young age (20-40 years), long duration of lung collapse, use of negative pressure during thoracentesis, large volume drainage, and rapid lung reexpansion. Management is largely supportive and ranges from diuresis to endotracheal intubation with mechanical ventilation (2).

Unfortunately, the amount of fluid that can be safely removed from the pleural effusion in order to prevent RPE has not been clearly defined. Feller-Kopman (3) reported that only one patient (0.5%) of 185 participants experienced clinical RPE, while four patients (2.2%) had radiographic RPE without symptoms. Our case demonstrates that removal of large volume from the pleural effusion via the chest tube resulted in clinical and radiographic RPE, thus, necessitating the need for clearly defined guidelines.

Chelsea Takamatsu BS, Aida Siyahian MS, Ella Starobinska MD, and Anthony Witten DO

University of Arizona College of Medicine- Tucson

Tucson, AZ USA

References

1. Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: An update and review of the literature. World J Hepatol. 2017 Nov 8;9(31):1197-1204. [CrossRef] [PubMed]
2. Kasmani R, Irani F, Okoli K, Mahajan V. Re-expansion pulmonary edema following thoracentesis. CMAJ. 2010 Dec 14;182(18):2000-2. [CrossRef] [PubMed]
3. Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007 Nov;84(5):1656-61. [CrossRef] [PubMed]

Cite as: Takamatsu C, Siyahian A, Starobinska E, Witten A. Medical image of the month: reexpansion pulmonary edema. Southwest J Pulm Crit Care. 2019;19(1):12-4. doi: https://doi.org/10.13175/swjpcc024-19 PDF

Medical Image of the Week: Septated Pleural Effusion

Figure 1. Thoracic ultrasound showing pleural effusion with multiple septations.

An 83 year old man with a history of metastatic malignant melanoma and atrial fibrillation on warfarin was admitted for shortness of breath. He underwent a diagnostic and therapeutic thoracentesis for a large right sided pleural effusion, suspected to be malignancy related. Three days later, he had transferred to the ICU for respiratory distress. An ultrasound of the thorax revealed a large loculated effusion with multiple septations (Figure 1). A large bore chest tube was placed and revealed a hemothorax, which may have been related to the previous thoracentesis.

In an observational study of ultrasound characteristics of pleural effusions, complex septations were more commonly seen in non-malignant effusions than malignant effusions (25.4% vs. 7.5%). In non-malignant effusions, the septated pattern was associated with infections, specifically tuberculosis and pneumonia (1).

While metastases in melanoma commonly involve the thoracic cavity, malignant pleural effusions are rare and are seen in about 2% of cases. In very rare instances, effusions from metastatic melanoma can be black in appearance (2). There has also been a case report of a massive hemothorax related to melanoma implants on the pleura (3).

Candy Wong, MD¹; Soyoung Park, MD²; Courtney Walker, DO²; and Laura Meinke, MD¹

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

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Bugalho A, Ferreira D, Dias SS, Schuhmann M, Branco JC, Marques Gomes MJ, Eberhardt R. The diagnostic value of transthoracic ultrasonographic features in predicting malignancy in undiagnosed pleural effusions: a prospective observational study. Respiration. 2014;87:270-8. [CrossRef] [PubMed]
2. Liao WC, Chen CH, Tu CY. Black pleural effusion in melanoma. CMAJ. 2010;182(8):E314. [CrossRef] [PubMed]
3. Gibbons JA, Devig PM. Massive hemothorax due to metastatic malignant melanoma. Chest. 1978;73(1):123. [CrossRef] [PubMed]

Cite as: Wong C, Park S, Walker C, Meinke L. Medical image of the week: septated pleural effusion. Southwest J Pulm Crit Care. 2015;11:110-1. doi: http://dx.doi.org/10.13175/swjpcc085-15 PDF

March 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 35-year-old man presented with a history of Von Hippel-Lindau syndrome, including prior right-sided renal cell carcinomas, cerebellar hemangioblastomas, and retinal hemangiomas. The patient’s renal malignancies were treated with laparoscopic radiofrequency ablations 6 and 8 years prior to presentation, and subsequently with percutaneous microwave ablations in the interim between 2008 and presentation. The latest percutaneous microwave ablation procedure (Figure 1) was performed to address two nodular enhancing foci in the posterior superior pole of the right kidney and one interpolar enhancing, septated lesion that were noted to have enlarged slightly on a recent MRI examination (Figure 2) of the abdomen compared with one year earlier.

 Figure 1. Percutaneous microwave of three right-sided renal lesions, 2 posterior-superior pole, the other lateral interpolar in location, shows two NeuWave microwave antennas inserted into suspicious lesions in the right kidney.

 

Figure 2. MRI of abdomen (A and B, axial steady-state free precession fat saturation images and, C and D, coronal subtraction contrast-enhanced images) shows three potentially solid, enhancing foci, two in the posterior and superior pole of the right kidney (arrowheads), and one in the lateral interpolar kidney, the latter with thick septations (arrow) that have shown slight enlargement from MR. performed one year previously.

A CT of the abdomen (Figure 3), performed 2 years earlier, is shown as a baseline comparison.

Figure 3.  Upper panel: selected image from the CT of the abdomen performed 2 years prior to presentation shows enlargement of the bilateral kidneys with numerous, bilateral renal cystic lesions. No pleural or lung base abnormality is evident. Lower panel: movie of CT scan performed 2 years prior to presentation.

Several days following the percutaneous microwave ablation procedure, the patient complained of right-sided chest pain, and frontal chest radiography was performed (Figure 4). 

Figure 4. Frontal and lateral chest radiography performed several days following the right-sided percutaneous microwave ablation procedure.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven panels)

1. The frontal chest radiograph shows a large right pleural effusion
2. The frontal chest radiograph shows diffuse lung opacities suggesting diffuse alveolar damage
3. The frontal chest radiograph shows mediastinal widening
4. The frontal chest radiograph shows pneumomediastinum
5. The frontal chest radiograph shows pneumothorax 

Reference as: Gotway MB. March 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;10(3):112-24. doi: http://dx.doi.org/10.13175/swjpcc031-15 PDF

Medical Image of the Week: Hepatic Hydrothorax

Figure 1. Panel A: Chest x-ray showing right pleural effusion. Panel B: Coronal view of the thoracic CT scan in soft tissue windows showing right pleural effusion.

Figure 2. Nuclear scan after intraperitoneal injection of technetium 99mTc albumin aggregated (99mTc-MAA). After less than one hour most of the tracer migrated into the right hemithorax consistent with hepatic hydrothorax.

A 63 year-old woman, with known alcoholic liver cirrhosis, esophageal varices with history of banding presented to an outside hospital with progressive shortness of breath, and was found to have a large right transudative pleural effusion. The patient underwent 2 diagnostic and therapeutic thoracenteses within 3 days, removing 1100 ml and 1500 ml respectively. No ascites was present. At the time of admission the patient had recurrent right effusion (Figure 1). Abdominal ultrasound showed minimal free intrabdominal fluid and she had signs of third spacing on her lower extremities. The patient underwent intraperitoneal injection of Technetium 99mTc albumin aggregated (99mTc-MAA). After less than one hour most of the tracer migrated into the right hemithorax consistent with hepatic hydrothorax (Figure 2).

While the exact mechanism involved in the development of hepatic hydrothorax is incompletely understood, it probably results from the passage of ascitic fluid from the peritoneal into the pleural cavity through small diaphragmatic defects. These are typically < 1 cm (and may be microscopic) and are generally located in the tendinous portion of the diaphragm. The negative intrathoracic pressure generated during inspiration favors the passage of the fluid into the pleural space. Thus, patients may have only mild or clinically undetectable ascites.

Once the diagnosis is made treatment follows algorithms for treatment of refractory ascites and include salt and water restriction, diuretics, and other validated options for portal hypertension. Repeated thoracentesis and chest tube placement is discouraged.

Huthayfa Ateeli, Justin Lee, Irbaz Riaz, Meenal Misal

Department of Internal Medicine

University of Arizona

Tucson, AZ

References

1. Huang PM, Chang YL,Yang CY,Lee YC.The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. J Thorac Cardiovasc Surg. 2005;130:141-5. [CrossRef] [PubMed]
2. Lieberman FL, Hidemura R, Peters RL, Reynolds TB. Pathogenesis and treatment of hydrothorax complicating cirrhosis with ascites. Ann Intern Med. 1966;64:341-51. [CrossRef] [PubMed]
3. Emerson PA, Davies JH. Hydrothorax complicating ascites. Lancet. 1955; 268:487-8. [CrossRef] [PubMed]
4. Mouroux J, Perrin C, Venissac N, Blaive B, Richelme H. Management of pleural effusion of cirrhotic origin. Chest. 1996;109:1093-6. [CrossRef] [PubMed]
5. Chen A, Ho YS, Tu YC, Tang HS, Cheng TC. Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol. 1988;10:663-6. [CrossRef] [PubMed] 

Reference as: Ateeli H, Lee J, Riaz I, Misal M. Medical image of the week: hepatic hydrothorax. Southwest J Pulm Crit Care. 2015;10(1):47-8. doi: http://dx.doi.org/10.13175/swjpcc004-15 PDF

March 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man with a history of severe asthmatic bronchitis presented with a 6 week history of intermittent fever, productive cough, shortness of breath, and decreased appetite. Four weeks earlier the patient was presumptively treated with amoxicillin for presumed community-acquired pneumonia, with some improvement, but his symptoms recurred 10 days following completion of his course of therapy. The patient also thought he was diagnosed with a COPD exacerbation during this time period and was treated with a short course of corticosteroids without improvement.

The patient was seen by his pulmonologist who noted decreased breath sounds over the right thorax, and referred the patient to the emergency room.

In the emergency room, a leukocytosis (white blood cell count = 17.4 x 10⁹ / L with neutrophilia) was noted. Broad-spectrum antibiotic coverage was re-instituted and frontal chest radiography (Figure 1) was performed.

Figure 1: Frontal (A) and lateral (B) chest radiography

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to move to the next panel)

1. The chest radiograph homogeneous complete right lung consolidation
2. The chest radiograph shows a right-sided mediastinal mass
3. The chest radiograph shows homogeneous right lung opacity suggesting right lung collapse
4. The chest radiograph shows homogeneous right lung opacity suggesting a large right pleural effusion
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. March 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014:8(3):161-9. doi: http://dx.doi.org/10.13175/swjpcc015-14 PDF