Medical Image of the Week: Neuromyelitis Optica and Sarcoidosis

Figure 1. Magnetic resonance imaging (MRI) showing enhancement of the left optic nerve (circle) consistent with optic neuritis.

Figure 2. Thoracic CT scan showing mediastinal lymphadenopathy (arrow).

A 33-year old woman presented to the emergency room with progressive vision loss of the left eye. A diagnosis of optic neuritis was made clinically and on magnetic resonance imaging MRI (Figure 1). With high anti-aquaporin 4 antibody titers, and compatible lesions on the MRI of the spinal cord, she was diagnosed with neuromyelitis optica (NMO). After dialysis catheter placement for plasmapheresis, an enlarged mediastinal shadow was seen. Fearing a complication of the catheter placement, a CT scan of the chest was obtained, confirming mediastinal lymphadenopathy (Figure 2).

An endobronchial ultrasound (EBUS) guided transbronchial needle aspiration of the mediastinal lymph nodes showed non-caseating granulomas, consistent with sarcoidosis in the absence of infectious work up and no known beryllium exposure.

NMO, also known as Devic's disease or Devic's syndrome, is a heterogeneous condition consisting of the inflammation and demyelination of the optic nerve (optic neuritis) and the spinal cord (myelitis). NMO and sarcoidosis can be difficult to differentiate (1). Our patient had a rarely described co-existing disease.

Tammer El-Aini MD and Bhupinder Natt MD

Division on Pulmonary, Allergy, Critical Care and Sleep

University of Arizona College of Medicine

Tucson AZ USA

Reference

1. Flanagan EP, Kaufmann TJ, Krecke KN, et al. Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol. 2016 Mar;79(3):437-47. [CrossRef] [PubMed]

Cite as: El-Aini T, Natt B. Medical image of the week: neuromyelitis optica and sarcoidosis. Southwest J Pulm Crit Care. 2018;16(6):341-2. doi: https://doi.org/10.13175/swjpcc081-18 PDF

Medical Image of the Week: Healthcare-associated Pneumonia Secondary to Aspiration

Figure 1. Panel A: Axial computed-tomography image demonstrating a foreign body within the right main-stem bronchus, with consolidation and volume loss of right lung. Panel B: Coronal view.

Figure 2. Panel A: bronchoscopy revealing an ingested foreign body in the right main-stem bronchus. Panel B: forceps retrieval yielded a large piece of broccoli.

A 57 year-old bedbound paraplegic man developed a worsening productive cough after being hospitalized for several days. He was brought to the radiology suite for a CT scan of the chest, revealing a soft tissue density within his right main-stem bronchus, with volume loss of his right lung (Figure 1). Bronchoscopy was performed, yielding a 2 cm piece of broccoli, successfully removed with forceps (Figure 2). Culture from the bronchial aspirate was positive for Pseudomonas aeruginosa. The patient’s respiratory status dramatically improved after removal of the foreign body and commencement of pathogen-directed antibiotics. This study illustrates a dramatic example of healthcare-associated pneumonia (HCAP) secondary to aspiration, as described by the American Thoracic Society / Infectious Diseases Society of America (1).

Lavi Nissim MD, Sam Alnajjar MD and Edward Vivio RT

Phoenix Baptist Hospital

2000 W. Bethany Home Road

Phoenix, AZ 85015

Reference

1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]

Reference as: Nissim L, Alnajjar S, Vivio E. Medical image of the week: healthcare-associated pneumonia secondary to aspiration. Southwest J Pulm Crit Care. 2015;11(1):1-2. doi: http://dx.doi.org/10.13175/swjpcc065-15 PDF

Medical Image of the Week: Actinomycosis

Figure 1. Thoracic CT scan showing right-sided necrotizing pneumonia, lung abscess and empyema (arrows).

Figure 2. Cytospin and cell block of right lower lobe bronchoalveolar lavage fluid stained with Grocott-Gomori's (or Gömöri) methenamine silver (GMS) stain showing positive filamentous organisms consistent with Actinomyces species within a background of inflammatory cells.

Figure 3. Low (Panel A) and high power view (Panel B) of the lung showing alveolar septa filled with predominantly acute (neutrophilic) infiltrate.

A 55-year-old man with history of tobacco and alcohol abuse, presented with unresolving pneumonia despite treatment with moxifloxacin. It was thought to be possible coccidioidomycosis and an azole was started. However, he returned with increasing dyspnea and hypoxemia. He had leukocytosis with a thoracic CT revealing a loculated empyema, multifocal necrotizing infection and a large intrapulmonary abscess (Figure 1). He was admitted to MICU, intubated and ventilated. He was in septic shock requiring fluid resuscitation, vasopressors, and broad antibiotics. Bronchoscopy revealed erythematous and edematous airways, with drainage of over one liter of purulent fluid. A chest tube was placed to drain pleural fluid with removal of around two liters of blood-tinged, purulent fluid. His condition worsened with development of disseminated intravascular coagulation leading to hemorrhagic shock. He arrested and died. Gram stain on bronchoalveolar lavage fluid showed mixed gram negative and gram variable rods, and cultures grew lactobacillus species. GMS stain revealed filamentous organisms consistent with Actinomyces (Figure 2).

Necrotizing pneumonia is usually secondary to aspiration of oral bacterial flora, and is usually associated with severe sepsis and acute respiratory failure. The obstruction of the bronchus and blood vessels corresponding to a lung segment leads to decreased perfusion that is often shown on contrast enhanced CT scan. Hence, systemic antibiotic treatment alone is usually not effective. The management of necrotizing pneumonia is multidisciplinary; including adequate antibiotic therapy, mechanical ventilation, closed pleural drainage and supportive care. Despite the serious morbidity, massive parenchymal damage and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is good with multidisciplinary care. If initial medical therapy fails, surgery is a reasonable option. Resection of gangrenous lung parenchyma and drainage of pleural empyema can lead to recovery in up to 80% of patients. Rarely, lobectomy can be a salvage operation. Outcome is affected by the severity of disease and underlying comorbidities. It should be considered once operative risk is acceptable.

Tauseef Afaq Siddiqi MD^1,2, Tracy Lundberg MD³, Jennifer Thorn MD³, and Dena L’heureux MD^1,2

¹Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, The University of Arizona Medical Center, Tucson, AZ

²Department of Medicine, Southern Arizona Veterans Administration Health Sciences Center, Tucson, AZ

³Department of Pathology, The University of Arizona Medical Center, Tucson, AZ

References

1. Alifano M, Lorut C, Lefebvre A, Khattar L, Damotte D, Huchon G, Regnard JF, Rabbat A. Necrotizing pneumonia in adults: multidisciplinary management. Intensive Care Med. 2011;37(11):1888-9. [CrossRef] [PubMed]
2. Schweigert M, Dubecz A, Beron M, Ofner D, Stein HJ. Surgical Therapy for Necrotizing Pneumonia and Lung Gangrene. Thorac Cardiovasc Surg. 2013;61(7):636-41. [CrossRef] [PubMed]
3. Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med. 2012;18(3):246-52. [CrossRef] [PubMed]

Reference as: Siddiqi TA, Lundberg T, Thorn J, L’heureux D. Medical image of the week: actinomycosis. Southwest J Pulm Crit Care. 2015;10(5):302-3. doi: http://dx.doi.org/10.13175/swjpcc050-15 PDF

April 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 73-year-old woman with a history of ovarian malignancy in remission for several years and treated with hysterectomy and oopherectomy, hypothyroidism, and hypertension, presented with rather abrupt onset cough, chest pain, dyspnea and low-grade fever (99.6°F). Her past medical history was otherwise unremarkable. Her medications included thyroid replacement, amlodipine, benazepril, and, recently, calcium and magnesium supplementation. Chest radiography was performed (Figure 1).

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

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

1. Chest radiography shows a large right pleural effusion
2. Chest radiography shows focal lung opacity
3. Chest radiography shows mediastinal widening
4. Chest radiography shows pneumomediastinum
5. Chest radiography shows pneumothorax

Reference as: Gotway MB. April 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;10(4):171-81. doi: http://dx.doi.org/10.13175/swjpcc048-15 PDF

Medical Image Of The Week: Westermark Sign

Figure 1. Chest x-ray showing decrease pulmonary vasculature on the right upper lobe (red circle, Westermark sign).

Figure 2. Coronal section of the CT angiogram showing occlusive thrombosis on the right pulmonary artery. 

A 71 year old man was evaluated in the Emergency Department for acute onset of dyspnea. On exam he was tachypneic, tachycardic and hypoxemic requiring 6 L/min of oxygen. He had recently underwent prostatectomy for prostate cancer. Past medical history was also significant for coronary artery disease treated with coronary bypass.

The chest x-ray (Figure 1) shows unilateral oligemia concerning for a pulmonary embolus and the CT angiogram of the chest (Figure 2) confirms the diagnosis.

While the chest radiograph is normal in the majority of pulmonary emboli, the ‘Westermark sign’ may be seen in up to 2% of the cases (1). It represents a focus of oligemia seen distal to a pulmonary embolism. The finding is a result of a combination of dilation of the pulmonary artery proximal to the thrombus and the collapse of the distal vasculature. 

Muna Omar MD¹, Tammer Elaini MD² and Bhupinder Natt MD¹

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

²Department of Internal Medicine

University of Arizona Medical Center

Tucson, AZ

Reference

1. Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE. Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology. 1993;189(1):133-6. [CrossRef] [PubMed] 

Reference as: Omar M, Elaini T, Natt B. Medical image of the week: Westermark sign. Southwest J Pulm Crit Care. 2015;10(3):125-6. doi: http://dx.doi.org/10.13175/swjpcc015-15 PDF

Medical Image of the Week: Esophageal Cancer

Chandramohan Meenakshisundaram, MD 

Nanditha Malakkla, MD 

Saint Francis Hospital

Evanston, IL

Figure 1. Admission chest x-ray showing hyper-aerated lung fields and consolidation at the left lung base.

Figure 2. Video of selected images from thoracic CT scan in soft tissue windows showing large mediastinal mass with extravasation of contrast.

Figure 3. Views from endoscopy showing a large mass and the perforation site.

A 66-year-old Asian man with no significant past medical history was admitted with 1 week history of worsening retrosternal sharp chest pain, dyspnea on moderate exertion, and cough productive of brownish sputum. He also complained of some difficulty swallowing, decreased appetite and weight loss for the past 3 months. PPD was negative in the past. Vitals signs were significant for tachycardia and low grade fever. On physical exam he was cachectic and lung auscultation revealed bilateral scattered wheezes. Basic labs including complete blood count and comprehensive metabolic panel were unremarkable. EKG showed sinus tachycardia, serial troponin I was negative and chest x-ray revealed bilateral hyper-aerated lung fields and consolidation over the left lung base (Figure 1). He was started on antibiotics and bronchodilators. Since he continued to have chest pain and remained tachycardic, CT angiography of chest and abdomen (with IV and oral contrast) was done which revealed extravasation of contrast material into the mediastinum in the mid esophageal region representing rupture, a large mediastinal mass concerning for an abscess, and extensive infiltrates in the left lower lobe (Figure 2). During left thoracotomy, a large amount of necrotic material and phlegmon was seen in the mediastinum with adjacent area of lung necrosis which was drained and debrided. Upper GI endoscopy revealed a large mass in the mid-esophagus with perforation for which stenting was done (Figure 3). Pathology of phlegmon revealed squamous cell carcinoma with extensive necrosis. Culture of the fluid grew both viridians streptococci and anaerobes and he was started on broad spectrum antibiotics. His post-operative course was complicated and later he elected hospice care.

Reference as: Meenakshisundaram C, Malakkla N. Medical image of the week: eosphageal cancer. Southwest J Pulm Crit Care. 2014;9(5):295-6. doi: http://dx.doi.org/10.13175/swjpcc151-14 PDF

November 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 38-year-old non-smoking woman presented with complaints of intermittent dry cough, occasional vomiting, and dyspnea, occasionally with fever and chills. She indicated that she has suffered recurrent bouts of bronchitis and pneumonia annually over the previous 10 years. The patient had a history of upper arm localized melanoma resection 10 years earlier. She had smoked for 10 years, but quit one year prior to presentation. Her past medical and surgical histories were otherwise unremarkable.

Frontal and lateral 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 proceed to the next panel)

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows mild, bilateral, streaky central opacities, possibly reflecting airway thickening
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows volume loss involving the right thorax with a mass-like opacity projected over the right hilum

Reference as: Gotway MB. November 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(5):264-77. doi: http://dx.doi.org/10.13175/swjpcc147-14 PDF

Medical Image of the Week: Persistent Left Superior Vena Cava

Figure 1. Left subclavian central line courses in a left paramediastinal location.

Figure 2. Axial CT image of the chest shows a vessel coursing lateral to the aortic arch consistent with a persistent left superior vena cava.

A 19 year old man with acute lymphocytic leukemia was admitted to the ICU with septic shock. Due to areas of cellulitis on the right side of the chest and neck and femoral venous thrombi, a left subclavian central access was attempted. The chest x-ray obtained after line placement is shown below (Figure 1). Blood gas done from the line was consistent with venous blood and venous tranduction was seen. A CT of the chest (Figure 2) confirmed the diagnosis of persistent left superior vena cava (PLSVC).

A persistent left superior vena cava is the most common congenital thoracic venous anomaly, seen in 0.3-0.5% of the population (1). Incidence is increased in patients with congenital heart disease to 5%. In most patients a right sided SVC is also present; hence the term SVC duplication has also been used. Embryologically a PLSVC is formed when the left anterior cardinal vein is not obliterated during fetal development to form the ‘Ligament of Marshall’. It usually drains in to the coronary sinus.

Diagnosis is usually made incidentally on CT scan, echocardiography or,like in our case, after a left sided central access. Practically, its presence may complicate left sided central access including Swan Ganz Catheter placement, implantable cardioverter defibrillator (ICD) placement and during cardiac surgery including during administration of retrograde cardioplegia or cardiac transplant.

Emad Hammode MD¹, Khaled Hamed MD¹, Mohammad Hudeeb MD¹, Veronica Arteaga MD²

¹Department of Internal Medicine

²Department of Thoracic Imaging

University of Arizona Medical Canter

Tucson, AZ

Reference

1. Povoski SP, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol. 2011;9:173. [CrossRef] [PubMed]

Reference as: Hammode E, Hamed K, Hudeeb M, Arteaga V. Medical image of the week: persistent left superior vena cava. Southwest J Pulm Crit Care. 2014;9(4):242-3. doi: http://dx.doi.org/10.13175/swjpcc132-14 PDF

Medical Image of the Week: Partial Anomalous Pulmonary Venous Return

Figure 1. Chest radiograph status post left internal jugular central line placement with arrow pointing to tip of catheter.

   

Figure 2. Axial (Panel A) and coronal (Panel B) views of contrast CT chest showing anomalous pulmonary venous return (yellow arrow). Middle Panel: Video of selected axial sections. Lower Panel: Video of selected coronal sections.

A 69 year old woman presented with septic shock secondary to a urinary tract infection. A chest radiograph (Figure 1) done after uneventful placement of a left internal jugular central line showed  aberrant position of the catheter.

Review of a past contrast-enhanced CT chest (Figure 2) revealed an anomalous pulmonary venous return with a pulmonary vein draining to the brachiocephalic vein.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital defect which results in a left-to-right shunt. The prevalence was 0.1% in one retrospective study of 45,538 contrast-enhanced chest CT scans (1). Diagnosis can be made with echocardiography, angiography, right heart catheterization, or computed tomography. PAPVR is traditionally associated with atrial septal defects, and patients are often asymptomatic. Clinical manifestations occur when there is significant shunting and include syncope, right heart failure, and pulmonary hypertension (2).

Candy Wong MD¹; Tammer Elaini MD²; Naser  Mahmoud MD¹, and Josh Malo MD¹

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

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Ho M, Bhalla S, Bierhals A,Gutierrez F. MDCT of partial anomalous pulmonary venous return (PAPVR) in adults. J Thorac Imaging. 2009;24(2):89-95. [CrossRef] [PubMed]
2. Kivisto S, Hanninen H, Holmstrom M. Partial anomalous pulmonary venous return and atrial septal defect in adult patients detected with 128-slice multidetector computed tomography. J Cardiothorac Surg. 2011;6:126. [CrossRef] [PubMed]

Reference as: Wong C, Elaini T, Mahmoud N, Malo J. Medical image of the week: partial anomalous pulmonary venous return. Southwest J Pulm Crit Care. 2014;9(4):219-20. doi: http://dx.doi.org/10.13175/swjpcc129-14 PDF

September 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 57-year-old non-smoking woman presented to her physician as an outpatient with complaints of worsening cough, fever, chills, and shortness of breath. The patient’s past medical history includes systemic lupus erythematosus diagnosed 18 years earlier, for which the patient has been variably treated with corticosteroids, hydroxychloroquine, and azathioprine. Additional past medical and surgical history includes migraines, mood disorder, diabetes mellitus treated with metformin, hysterectomy for endometriosis, and iron-deficient anemia. The patient was also diagnosed with small lymphocytic lymphoma 3 years earlier following a right breast biopsy when an abnormal opacity was discovered incidentally at routine screening breast imaging. She has not been treated for this neoplasm as no B symptoms have been reported.

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

Figure 1. Panel A: Initial frontal chest x-ray. Panel B: Initial lateral chest x-ray.

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

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows linear and curvilinear opacities suggesting cystic lung disease
4. The chest radiograph shows mild streaky central opacities, possibly reflecting airway thickening
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. September 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(3):161-76. doi: http://dx.doi.org/10.13175/swjpcc117-14 PDF 

Medical Image of the Week: Coccidioidomycosis

Figure 1. Preoperative x-ray (Panel A) demonstrating a right upper lobe cavitary lesion. X-ray (Panel B) status post lobectomy.

Figure 2. Coronal (Panel A) and axial (Panel B) images from a chest CT further demonstrating a right upper lobe cavitary lesion.

Figure 3. The 200x magnification H&E image (Panel A) demonstrates one of the numerous granulomas seen in the lung specimen. A low magnification (40x) (Panel B) H&E image showing the granulomatous infection, prominent at the left, surrounded by a wall made up of collagen.

Figure 4. Two images, both at 400x magnification, are of GMS stained tissue.  Panel A shows the numerous branching hyphae of the lesion.  Panel B shows a granuloma with a central Coccidioides spherule, marked by the red arrow.

A 41-year-old Hispanic man with a history of uncontrolled type 2 diabetes and coccidioidomycosis, presented to the emergency department with a two year history of hemoptysis and recent onset lower chest pain. Patient was found to have a right upper lobe cavitary lesion on x-ray (Figure 1). Due to concern for pulmonary and pericardial tuberculosis the patient was placed on isolation, and QuantiFERON Gold testing, Coccidioides antibodies and computed tomography of the chest were ordered. At this time the patient revealed that he had taken only 30 days of treatment for his coccidioidomycosis 2 years ago due to his understanding this was the complete course. The CT (Figure 2) demonstrated an irregular, spiculated, and thin-walled right apical cavitary lesion with satellite nodules. QuantiFERON Gold testing and Coccidioides testing were both positive. Surgical resection was performed due to ongoing hemoptysis. The surgical specimen demonstrated hyphae (Figure 4A), a rare spherule (Figure 4B) and caseating granulomas (Figure 3) consistent with coccidioidomycosis. Acid-fast stains were negative. Indications for surgery in coccidioidomycosis are continued or progressing symptoms following 3 months of treatment, complications (such as rupture, pneumothorax or effusion), and large size of abscess (1,2).

Kareem Hassan BA, Spencer Paulson MD, Carlos Tafich Rios MD

Departments of Medicine and Pathology

University of Arizona 

Tucson, AZ

References

1. Jaroszewski DE, Halabi WJ, Blair JE, et al. Surgery for pulmonary coccidioidomycosis: a 10-year experience. Ann Thorac Surg. 2009; 88:1765-72. [CrossRef] [PubMed]
2. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis. 2005;41: 1217-23. [CrossRef] [PubMed]

Reference as: Hassan K, Paulson S, Rios CT. Medical image of the week: coccidioidomycosis. Southwest J Pulm Crit Care. 2014;9(2):128-9 . doi: http://dx.doi.org/10.13175/swjpcc106-14 PDF

Medical Image of the Week: Pneumatocele

Figure 1. Portable AP film showing a large cystic lesion in the left lower lobe in addition to small bilateral pleural effusions and adjacent consolidation.

Figure 2. Axial enhanced CT scan section showing a large cystic space with an air-fluid level with adjacent consolidated atelectasis. No perceptible wall is seen.

A 50-year-old man presented with polymicrobial pneumonia which included Proteus mirabilis, Enterobacter cloacea and MRSA pathogens. A large cystic lesion with an air-fluid level was found on chest imaging in a region of pneumonia (Figure 1). There was associated mass effect onto the adjacent lung. No perceptible wall was noted which would be more associated with a cyst rather than a cavity or abscess. Directed aspiration of this lesion resulted in decompression without further complication. Minimal sterile fluid was recovered. Therefore the proposed diagnosis was a pneumatocele within the setting of infection. Pneumatoceles may be challenging at times to distinguish from a cavity particularly when surrounded by airspace disease however merit consideration in the differential diagnosis particularly in the absence of findings of a thick irregular wall.

The exact mechanism causing development of a pneumatocele is not known, but believed to develop due to a check valve type bronchiole or bronchiolar obstruction (1). Pneumatoceles most commonly undergo spontaneous remission within weeks to months without any known long term implications. Complications occur rarely and include pneumothorax, tension pneumatocele, and secondary infection of a pneumatocele. Usual treatment is directed towards the underlying pneumonia with appropriate antibiotics. In rare cases percutaneous drainage may be necessary and is ideally performed with a small bore catheter to minimize trauma. The role of positive pressure ventilation in development of a pneumatocele is unclear.

Bhupinder Natt, MD and Veronica Arteaga, MD

Divisions of Pulmonary and Thoracic Imaging

University of Arizona College of Medicine

Tucson, AZ

Reference

1. Lysy J, Werczberger A, Globus M, Chowers I. Pneumatocele formation in a patient with Proteus mirabilis pneumonia. Postgrad Med J. 1985;61(713):255-7. [CrossRef] [PubMed]

Reference as: Natt B, Arteaga V. Medical image of the week: pneumatocele. Southwest J Pulm Crit Care. 2014;9(2):126-7. doi: http://dx.doi.org/10.13175/swjpcc102-14 PDF

Medical Image of the Week: Idiopathic Pulmonary Artery Hypertension

Figure 1. EKG showing sinus rhythm, right bundle branch block and peaked ('pulmonary') p waves (arrow).

Figure 2. Two view chest X-ray showing right ventricular hypertrophy (arrows, note filling of the retrosternal space by an enlarged right ventricle in the lateral view) and enlarged central pulmonary arteries (arrowhead).

 

  Figure 3. Axial CT angiogram of the chest below the carina showing dilated pulmonary artery (diameter of pulmonary artery greater than aorta, arrow).

 

Figure 4. Panel A: Parasternal short axis view shows septal bowing to the left, a severely dilated right ventricle and a D-shaped left ventricle. Panel B: Four chamber view shows right atrial and ventricular dilatation.

A 39-year-old woman presented to the clinic with a history of progressive shortness of breath of 6-month duration associated with bilateral lower extremity edema, fatigue, lightheadedness, palpitations and occasional substernal chest pain. Her past medical history was unremarkable other than mild anemia. On physical exam her respiratory rate was 20 breaths per minute and O2 saturation 94% on room air by pulse oximetry. There was jugular venous distention at 12 cm, 2+ bilateral lower extremity edema, a 5/6 systolic murmur over the left sternal border with a sternal heave. Labwork was unremarkable except for an elevated BNP 657 (normal value < 100 pg/mL).

EKG (Figure 1) showed sinus rhythm with right bundle branch block. A 2-view chest X-ray (Figure 2) showed an enlarged right ventricle as well as dilated pulmonary arteries with no parenchymal infiltrates. CT angiography confirmed CXR findings (Figure 3) and was negative for pulmonary embolism. A 2D echocardiogram revealed a preserved left ventricle ejection fraction with right ventricular pressure of 80 mmHg + CVP, severe tricuspid regurgitation, decreased right ventricular function (as assessed by a Tricuspid annular plane systolic excursion of 10 mm) and flattened septum, suggestive of right ventricular overload (Figure 4). A right heart catheterization was performed revealing pulmonary pressures of 105/45 mmHg with a mean of 63 mmHg, a wedge pressure of 11 mmHg, a pulmonary vascular resistance of 13.19 Wood units and a cardiac output of 3.94 L/min.

The patient was admitted to the intensive care unit to start treatment with intravenous treprostinil and was eventually discharged home with subcutaneous treprostrinil.

Pulmonary arterial hypertension (PAH) is a disease of the pulmonary circulation characterized by a progressive elevation in pulmonary vascular resistance that leads to right ventricular failure and premature death. It is defined as a mean pulmonary artery pressure at rest of 25 mmHg or higher (1). Idiopathic (group 1) PAH requires the exclusion of parenchymal pathology or venous thromboembolic disease as well as a mean wedge pressure less than 15 mmHg. The initial symptoms of PH are the result of an inability to adequately increase cardiac output during exercise which eventually will progress to signs and symptoms of right ventricular failure such as lower extremity edema, syncope/presyncope and chest pain (2,3). Early recognition is of paramount importance to institute adequate treatment.

Roberto J. Bernardo, MD and Carlos Tafich Rios, MD

Internal Medicine Residency, Department of Medicine

University of Arizona, Tucson, AZ

References 

1. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College. Circulation. 2009. 119:2250-94. [CrossRef] [PubMed] 
2. Runo JR, Loyd JE. Primary pulmonary hypertension. Lancet. 2003. 361:1533-44. [CrossRef] [PubMed]
3. Peacock AJ. Primary pulmonary hypertension. Thorax. 1999;54:1107-18. [CrossRef] [PubMed]

Reference as: Bernardo RJ, Rios CT. Medical image of the week: idiopathic pulmonary artery hypertension. Southwest J Pulm Crit Care. 2014;9(2):101-3. doi: http://dx.doi.org/10.13175/swjpcc101-14   PDF

July 2014 Imaging Case of the Month

Michael B. Gotway, MD

Prasad M. Panse, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 71-year-old Caucasian man presented for venous thromboembolism prophylaxis for a scheduled total right knee arthroplasty. His prior medical history was remarkable for anemia requiring transfusion of 4 units of blood 3 years prior to presentation, hypertension, prostatic hypertrophy, seasonal allergies, and glucose intolerance.

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

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

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

1. The chest radiograph shows a circumscribed left lung mass
2. The chest radiograph shows a mediastinal mass
3. The chest radiograph shows bilateral symmetric linear and reticular opacities
4. The chest radiograph shows multifocal, bilateral consolidation
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB, Panse PM. July 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(1):15-24. doi: http://dx.doi.org/10.13175/swjpcc089-14 PDF

Medical Image of the Week: Constrictive Pericarditis

Figure 1. A computerized tomography of the chest revealed cardiomegaly, bilateral pleural effusions and pericardial calcification noted diffusely with focal regions of pericardial thickening greater than 4 mm.

A 62-year-old woman, with a past medical history significant for oxygen dependent COPD, paroxysmal atrial fibrillation, and obstructive sleep apnea, presented to the hospital with hypoxemic respiratory failure requiring intubation and mechanical ventilation. A computerized tomography of the chest revealed cardiomegaly, bilateral pleural effusions, and pericardial calcification that was noted diffusely with focal regions of pericardial thickening greater than 4 mm. A cardiac catheterization revealed elevated right-sided pressure; markedly elevated left ventricular end diastolic pressure; equalization of LV-RV diastolic pressures; and sharp Y descent on the right atrial pressure waveform; which is all suggestive of constrictive physiology.  The patient was medically optimized and diuresed and eventually underwent a successful pericardiectomy.

Mohammed Alzoubaidi MD, John Bloom MD, Jarrod Mosier MD, Linda Snyder MD

Department of Pulmonary and Critical Care Medicine, University of Arizona,

Tucson, AZ

Reference as: Alzoubaidi M, Bloom J, Mosier J, Snyder L. Medical image of the week: constrictive pericaditis. Southwest J Pulm Crit Care. 2014;8(5):280. doi: http://dx.doi.org/10.13175/swjpcc042-14 PDF

May 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ 

Clinical History: A 66-year-old woman presented with complaints of cough worsening over the previous several months. Her prior medical history was largely otherwise unremarkable. Frontal chest radiography (Figure 1) was performed for evaluation.  

Figure 1. Panel A: Frontal chest radiograph. Panel B: Right anterior oblique image. Panel C: Left anterior oblique image.

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 shows a solitary pulmonary nodule
2. The chest radiograph shows multifocal airway thickening and bronchiectasis
3. The chest radiograph shows multifocal, bilateral cavitary nodules and consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities within diminished lung volumes, suggesting fibrosis
5. The chest radiograph shows multiple small nodules, suggesting a miliary pattern

Reference as: Gotway MB. May 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(5):266-74. doi: http://dx.doi.org/10.13175/swjpcc059-14 PDF

Medical Image of the Week: Fat Embolism Syndrome

A 33-year-old man presented to the emergency department with shortness of breath and hemoptysis. He was discharged two days prior after hospitalization for a motor vehicle accident, in which he suffered a fracture of the shaft of the right femur. He had undergone open reduction and internal fixation of the fracture four days prior to this admission. He had diffuse parenchymal disease on his admission chest x-ray. A CT scan of the chest demonstrated multilobar ground glass opacities (Figure 1).

Figure 1. Thoracic CT scan showing ground glass opacities.

Bronchoscopy demonstrated progressively bloody BAL aliquots in two different lobes, consistent with diffuse alveolar hemorrhage (DAH). His workup for other etiologies was negative, and he was given a diagnosis of DAH secondary to fat embolism syndrome.

Joshua Malo, MD and Kenneth S. Knox, MD

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

University of Arizona, Tucson, AZ

Reference as: Malo J, Knox KS. Medical image of the week: fat embolism syndrome. Southwest J Pulm Crit Care. 2014;8(4):246. doi: http://dx.doi.org/10.13175/swjpcc041-14 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

February 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 presented with a history of weight loss and dysphagia for about 2 weeks duration. There was a possible history of asthma accompanied by ongoing shortness of breath first noticed nearly 2 years ago. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

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

1. The chest radiograph shows a mass
2. The chest radiograph shows hilar and mediastinal lymph node enlargement
3. The chest radiograph shows multifocal consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities suggesting fibrosis
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. February 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(2):88-95. doi: http://dx.doi.org/10.13175/swjpcc010-14 PDF

Medical Image of the Week: Unilateral Diaphragm Paralysis

Figure 1. CT scans showing unilateral diaphragm paralysis and atelectasis of right lower lobe (arrow).

An 85 year old woman with a history of COPD presented to the emergency department (ED) with shortness of breath and cyanosis of her fingers. Her symptoms have been waxing and waning since she recovered from pneumonia a year ago. A week prior to admission, she visited an outpatient clinic for worsening cough, which was treated with levofloxacin, however her shortness of breath and cyanosis persisted. O₂ saturation with 4 L oxygen was 85% and CT chest without contrast showed unilateral diaphragmatic paralysis with basilar atelectasis (Figure 1). She has no history of cardiac surgery, poliomyelitis or cervical spondylosis. Also, no cervical or lung mass was found on CT scan. Her diaphragmatic paralysis is most likely secondary to phrenic nerve injury.

Unilateral diaphragmatic paralysis is usually asymptomatic and does not require treatment in most of cases. However, patients with underlying lung disease can present with shortness of breath and cyanosis because of increased ventilatory demands on physical activity or superimposed pulmonary disease. Occasionally, patients with unilateral diaphragmatic paralysis can develop acute respiratory failure due to exacerbation of obstructive lung disease or respiratory infection, and require ventilatory support (1). Early and careful management of underlying lung disease is pivotal in these patients to prevent respiratory decompensation.

Seongseok Yun, MD PhD; Kahroba Jahan, MD; Natali Hua, DPM; Ibrahim Taweel, MD; Ismail Tabash, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

Reference

Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med. 2009;30(3):315-20.  [CrossRef] [PubMed] 

Reference as: Yun S, Jahan K, Hua N, Taweel I, Tabash I. Medical image of the week: unilateral diaphragm paralysis. Southwest J Pulm Crit Care. 2014;8(1):68-9. doi: http://dx.doi.org/10.13175/swjpcc178-13 PDF