Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
September 2016 Imaging Case of the Month
Michael B. Gotway, MD
Department of Radiology
Mayo Clinic Arizona
Scottsdale, Arizona USA
Imaging Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
Learning Objectives:
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.
Current Approval Period: January 1, 2015-December 31, 2016
Clinical History: A 64-year-old woman presents with a several month history of slowly worsening shortness of breath and dry cough, with worsening exercise limitation. Laboratory data, include white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 93%.
Frontal and lateral chest radiographs (Figure 1) were performed. Previous frontal and lateral chest radiographs, performed 7 years prior to presentation, are shown for comparison.
Figure 1. Frontal (A) and lateral (B) chest radiography. Frontal (C) and lateral (D) chest radiography performed 7 years prior are shown for comparison.
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)
Cite as: Gotway MB. September 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(3):114-22. doi: http://dx.doi.org/10.13175/swjpcc088-16 PDF
Medical Image of the Week: Empyema Necessitans
Figure 1. Panel A: chest radiograph on admission showed mass like lesion centered at the right upper lobe. Panel B: Coronal CT cut showing loculated fluid collection demonstrating peripheral rim enhancement. There is extension of pleural fluid into the soft tissues of the adjacent right chest wall (white arrow).
Figure 2. Panel A: chest radiograph after VATS decortication and antibiotic course shows resolution. Panel B: axial CT cut after completion of therapy shows complete resolution.
A previously healthy 46-year-woman was evaluated for two week history of right shoulder pain, associated pleuritic chest pain and dyspnea.
Chest radiograph showed right apical mass (Figure 1A). Imaging showed loculated fluid collection with extension into the soft tissues of the adjacent right chest wall suggestive of empyema necessitans (Figure 1B).
Chest Tube placement was done along with broad spectrum antibiotics. Blood and pleural fluid cultures showed methicillin-resistant Staphylococcus aureus (MRSA). Due to persistence of loculation despite antibiotics, she underwent a video-assisted-thoracoscopic surgery (VATS) for decortication and further drainage of the effusion.
Symptoms and radiologic findings improved and she was discharged with intravenous antibiotics to complete a six week course. Chest imaging at six week period showed complete resolution (Figure 2).
Empyema necessitans, defined by the extension of an empyema through the parietal pleura, into surrounding tissue is becoming rare with the routine drainage of empyema and antibiotics use. Common causative pathogens include Mycobacterium tuberculosis, Actinomyces israelii, Streptococcus pneumoniae, and Staphylococcus aureus (1). Surgical treatments for thoracic empyema include chest tube drainage, debridement via VATS, decortication, open window thoracostomy, and thoracoplasty (2).
Kai Rou Tey MD1, Bhupinder Natt MD2
1Department of Internal Medicine - South Campus and 2Department of Pulmonary, Critical Care, Allergy and Sleep
University of Arizona College of Medicine
Tucson, AZ USA
References
- Kono SA, Nauser TD. Contemporary empyema necessitatis. Am J Med. 2007;120(4):303-5. [CrossRef] [PubMed]
- Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg. 2007;32(3):422-30. [CrossRef] [PubMed]
Cite as: Tey KR, Natt B. Medical image of the week: empyema necessitans. Southwest J Pulm Crit Care. 2015;11(6):271-2. doi: http://dx.doi.org/10.13175/swjpcc139-15 PDF