Medical Image of the Week: Refractory Dyspnea

A 61 year old man with an extensive smoking history and emphysema was referred for evaluation of dyspnea refractory to standard therapy. He was diagnosed with a pulmonary embolism 5 months prior to presentation and has been on warfarin since that time. Review of the patient’s CT scan performed prior to the visit demonstrated dilated main, right, and left pulmonary arteries (Figure 1).  Also visualized was an eccentrically located thrombus with areas of calcification and central recanalization. Echocardiography confirmed the presence of elevated pulmonary pressures consistent with a diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH).  Medical therapy and a referral for pulmonary artery endarterectomy are being considered.

Figure 1. Chest CT scan showing dilated main, right, and left pulmonary arteries.  Also visualized was an eccentrically located thrombus (arrows) with areas of calcification and central recanalization

Josh Malo, MD; Nathaniel Reyes, MD; Linda Snyder MD; and Franz Rischard, DO

Division of Pulmonary, Critical Care, Allergy and Sleep Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Malo J, Reyes N, Rischard F. Medical image of the week: refractory dyspnea. Southwest J Pulm Crit Care 2012;5:308. PDF

Medical Image of the Week: Tooth Impaction and Extraction

Figure 1: PA (Panel A)and lateral (Panel B) view chest x-ray revealing foreign body likely in right main bronchus.

A 66-year-old gentleman with a history Friedreich’s ataxia underwent a dental extraction procedure just prior to 4 weeks of traveling abroad.  He was seen in emergency room for increasing weakness, cough and low grade fevers.  His chest x-ray revealed a foreign body in the right main bronchus (Figure 1).  He underwent bronchoscopy with forceps and basket removal of partially impacted teeth from the bronchus intermedius (Figure 2).

Figure 2: Partially impacted tooth in bronchus intermedius (Panel A); granulation tissue at the site of impacted foreign body (Panel B); and tooth after successful removal (Panel C).

Tauseef Afaq, MD and Carmen Luraschi-Monjagatta, MD

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

Department of Medicine

University of Arizona

Tucson, AZ

Reference as: Afaq T and Luraschi-Monjagatta C. Medical image of the week: tooth impaction and extraction. Southwest J Pulm Crit Care 2012;5:302. PDF

Medical Image of the Week: EBUS

  

 Image 1.      

 Image 2.

This patient with a history of smoking was referred from an outside pulmonary clinic for a CT chest showing two enlarged right paratracheal nodes.  The larger structure (Image 1) was found to have a hypoechoic appearance under endobronchial ultrasound, which is atypical of a lymph node.  Upon needle aspiration, the structure collapsed and serous fluid was collected.  The smaller lymph node (Image 2) showed the normal hyperechoic presentation and yielded normal lymphatic tissue when sampled.

Wendy Hsu, MD and James Knepler, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona 

Reference as: Hsu W, Knepler J. Medical image of the week: EBUS. Southwest J Pulm Crit Care 2012;5:300. PDF

Medical Image of the Week: Bronchial Clot

This patient was admitted from oncology clinic for ten days of hemoptysis on Coumadin.  Her laboratory data on admission showed a platelet count of 14,000/μL and an INR of 4.5.  She was found on bronchoscopy with her right mainstem completely occluded by a clot.  A cryoprobe was used and the clot was removed in one piece as seen above in a 4 x 4 container.  The clot was notable to have the cast of the right mainstem bronchial rings as well as impressions of the right upper, right middle, and right lower lobe bronchus.  The entire length of the clot was approximately four centimeters. 

Wendy Hsu, MD and Yuval Raz, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Reference as: Hsu W, Raz Y. Medical image of the week: bronchial clot. Southwest J Pulm Crit Care 2012;5:296. PDF

December 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 40-year-old man presented with persistent left chest and flank pain one year following emergent spine surgery for a traumatic burst fracture of L2 associated with left diaphragmatic injury. 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?

1. The chest radiograph shows left lower lobe mass-like consolidation
2. The chest radiograph shows diffuse interstitial thickening
3. The chest radiograph shows a large left pleural effusion
4. The chest radiograph shows a left-sided mediastinal mass
5. The chest radiograph shows a left hydropneumothorax

Reference as: Gotway MB. December 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:286-91. PDF

November 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 61-year-old non-smoking man presented with a history of dyspnea on exertion, fatigue, and worsening lower extremity edema. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography

Which of the following statements regarding the chest radiograph is most accurate?

1. The frontal chest radiograph is normal
2. The frontal chest radiograph shows a diffuse linear, interstitial pattern
3. The frontal chest radiograph shows multilobar consolidation
4. The frontal chest radiograph shows numerous thin-walled cysts
5. The  frontal chest radiograph shows numerous small nodules consistent with a “miliary” pattern

Reference as: Gotway MB. November 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:242-52. PDF

October 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 65-year-old non-smoking woman presented with a history of cough, exertional dyspnea, and occasional wheezing. Frontal chest radiography (Figure 1) was performed.

Figure 1. Admission chest x-ray.

 Which of the following statements regarding the chest radiograph is most accurate?

1. The frontal chest radiograph is normal
2. The frontal chest radiograph is non-specifically abnormal
3. The frontal chest radiograph shows numerous small nodules, consistent with a “miliary” pattern
4. The frontal chest radiograph shows significant right lung volume loss, suggesting endobronchial obstruction
5. The frontal chest radiograph shows diffuse fibrotic lung disease

Reference as: Gotway MB. October 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:186-92. PDF

September 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 35-year-old non-smoking man presented with a history of slowly progressive shortness of breath preceded by cough and wheezing, previously presumptively diagnosed with asthma. He had a previous history of ulcerative colitis and a +PPD for which he received 6 month INH therapy. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Panel A: Frontal chest radiography. Panel B: Lateral chest radiography.

Which of the following statements regarding the chest radiograph is accurate?

1. The radiograph shows a diffuse interstitial abnormality
2. The radiograph appears normal
3. The radiograph shows cystic lung disease
4. The radiograph a mediastinal contour abnormality
5. The radiograph shows abnormal lung volumes

Reference as: Gotway MB. September 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:126-34. (Click here for a PDF version)

August 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona 

Clinical History: A 48-year-old non-smoking man presented with a history of slowly progressive shortness of breath and recent onset of a headache. Frontal chest radiography (Figure 1) was performed. 

Figure 1: Frontal chest radiography shows normal cardiomediastinal contours with bilateral peri- and infrahilar predominant ground-glass opacity with a background of linear and reticular abnormalities.

Which of the differential diagnostic considerations listed below is the most likely consideration for the chest radiographic abnormality?

1. Pneumococcal pneumonia
2. Lung carcinoma
3. Idiopathic pulmonary fibrosis
4. Pulmonary alveolar proteinosis
5. Miliary tuberculosis

Reference as: Gotway MB. August 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;5:74-81. (Click here for a PDF version of the case of the month)

July 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 24-year-old non-smoking man presents to the emergency room with hemoptysis, cough, fever, and chest pain. Frontal and lateral chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography shows opacity in the medial left lung base. No clear evidence of air bronchograms is evident, no pleural abnormality is seen, and no lymphadenopathy is present.

Which of the differential diagnostic considerations listed below is the most likely consideration for the appearance of the lesion on the chest radiograph?

1. Bronchogenic carcinoma
2. A congenital pulmonary lesion
3. A mediastinal germ cell neoplasm
4. A Morgagni diaphragmatic hernia
5. Pneumocystis jiroveci pneumonia

Reference as: Gotway MB. July 2012 imaging case of the month. Soutwest J Pulm Crit Care 2012;5:24-32. (click here for a PDF version of the case) 

June 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 46 -year-old man presents to the emergency room with hemoptysis. Frontal and lateral chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal and lateral chest radiography shows a lobulated, circumscribed lesion within the left hilum. The right hilum appears normal, no lung consolidation is present, and no pleural abnormalities are seen. There is no evidence of mediastinal lymph node enlargement. There is relative lucency involving the left lung, particularly the left upper lobe, compared with the right side.

Which of the differential diagnostic considerations listed below is the least likely consideration for the appearance of the lesion on the chest radiograph?

1. Bronchogenic carcinoma
2. Adenoid cystic carcinoma
3. Carcinoid tumor
4. Sarcoidosis
5. Allergic bronchopulmonary aspergillosis

 Reference as: Gotway MB. June 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:214-21. (click here for a PDF version of the manuscript)

May 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 71-year-old man with a 20-pack-year history of smoking presented with complaints of cough. A chest radiograph (Figure 1) was performed.

Figure 1: Frontal and lateral chest radiography shows a medially located mass projected over the thoracic aorta on the frontal projection (A), residing posteriorly over the thoracic spine on the lateral projection (B). The lesion does not show visible calcification, and is non-specific in appearance.

Which of the differential diagnostic considerations listed below is the least likely consideration for the appearance of the lesion on the chest radiograph?

1. Primary pulmonary malignancy
2. A mass arising from the pleura
3. Pulmonary lymphoma
4. Arteriovenous malformation
5. Hamartoma

Reference as: Gotway MB. May 2012 imaging case of the month. Southwest J Pulm Crit Care 2012:4:155-62. (Click here for a PDF version of the case)

April 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 31-year-old previously healthy, immunocompetent, non-smoking female developed cough and was initially treated with broad spectrum antibiotics without improvement. Approximately 48 hours later, the patient presented to her physician with progressive shortness of breath and fever to 103°F. A chest radiograph was performed (Figure 1).

Figure 1: Frontal chest radiograph shows extensive bilateral pulmonary opacities predominantly in the lower lobes with preserved lung volumes, normal mediastinal width, and no definite pleural effusion.

The differential diagnostic considerations for the appearance on the chest radiograph include which of the following?

1. Hydrostatic pulmonary edema
2. Acute hypersensitivity pneumonitis
3. Community-acquired pneumonia
4. Opportunistic pulmonary infection
5. All of the above

Reference as: Gotway MB. April 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:102-10. (Click here for a PDF version)

March 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 64-year-old woman presents with weight loss and an intermittent history of cough. Skin tuberculin testing was indeterminate, so a chest radiograph (Figure 1) was performed.

Figure 1:  Frontal (A) and lateral (B) chest radiographs show previous median sternotomy and mild cardiomegaly. Poorly defined, mildly hyperattenuating opacities are present in the apices bilaterally. No evidence of architectural distortion or cavitation is present. A calcified left mediastinal lymph node is present, consistent with prior granulomatous inflammation.

Does this chest radiograph show evidence of current or prior granulomatous infection?

1. True
2. False
3. Unknown

Reference as: Gotway MB. March 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:80-7. (Click here for a PDF version of the case)

February 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Clinical History

A 70-year-old woman with no significant past medical history presented with progressive shortness of breath. A chest radiograph (Figure 1A) was obtained. Figure 1B is a frontal chest radiograph obtained 2 years earlier, presented for comparison.

Figure 1A: Frontal chest radiograph. Figure 1B: Frontal chest radiograph obtained 2 years prior to Figure 1A.

What radiological sign is present?

1. The “silhouette sign”
2. “Golden’s S” sign
3. The “dense hilum” sign
4. The “cervicothoracic” sign
5. The “scimitar” sign

Reference as: Gotway MB. February 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:33-9. (Click here for a PDF version of the case)

January 2012 Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Clinical History

A 69-year-old woman with no significant past medical history presented with progressive shortness of breath. A chest radiograph (Figure 1) was obtained.

Figure 1. Frontal chest radiograph.

How would you describe the findings on the chest radiograph (Figure 1)?

1. Multifocal consolidation
2. Blunting of the costophrenic angles suggesting pleural effusion
3. Multifocal reticulonodular opacities
4. Bilateral cavitary lung consolidation
5. Miliary nodular opacities

Reference as: Gotway MB. January 2012 case of the month. Southwest J Pulm Crit Care 2012;4:12-18. (Click here for a PDF version)

December 2011 Case of the Month

Clinical History

A 19-year-old woman presents with complaints of cough, with a history of recurrent left pneumonias and abnormalities noted in the left lung on outside facility prior imaging. A frontal and lateral chest radiographic examination (Figures 1A and B) was performed. A chest radiograph (Figure 1C) obtained over one year previously is shown for comparison.

Figure 1.

What is the main finding on the current chest radiograph (Figures 1A and B)? How would you describe the finding?

1. A left upper lobe mass is present
2. A wide mediastinum is present
3. Partial collapse of the left upper lobe is present
4. An extrapulmonary lesion is projected over the left upper thorax
5. A left pleural effusion is present

Reference as: Gotway MB. December 2011 case of the month. Southwest J Pulm Crit Care 2012;4:5-11. (Click here for a PDF version of the manuscript)

November 2011 Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Reference as: Gotway MB. November 2011 Case of the month. Southwest J Pulm Crit Care 2011;3: 154-8. (Click here for PDF version of manuscript)

Clinical History

A 47-year-old woman presents with complaints of hemoptysis. The hemoptysis was witnessed and was massive, resulting in anemia. A frontal and lateral chest radiograph (Figures 1A and B) was performed.

Figure 1: Frontal and lateral chest radiograph

What is the main finding on the chest radiograph? How would you describe the finding?

1. A solitary pulmonary nodule
2. An anterior mediastinal mass
3. Basal predominant linear and reticular abnormalities suggesting fibrotic lung disease
4. An intracavitary mass superimposed on a background of interstitial abnormality
5. Bilateral pleural effusions and thickening

October 2011 Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Reference as: Gotway MB. October 2011 Case of the month. Southwest J Pulm Crit Care 2011;3:145-9. (Click here for a PDF version of the manuscript)

Clinical History

A 67-year-old man with a history of squamous cell carcinoma of the throat, melanoma, and anemia presented with vague complaints of chest pain. A frontal chest radiograph (Figure 1) was performed.

What is the main finding on the chest radiograph? How would you describe the finding?  (Click on the answer to proceed)

1. A solitary pulmonary nodule
2. Diffuse linear and reticular abnormalities suggesting interstitial lung disease
3. A posterior mediastinal mass
4. Multiple cavitary nodules
5. Bilateral pleural effusions and thickening

September 2011 Case of the Month

Michael B. Gotway, M.D.
Associate Editor, Imaging

Reference as: Gotway MB. September 2011 case of the month. Southwest J Pulm Crit Care 2011;3:58-63. Click here for PDF version

Clinical History

A 44-year-old man presents for chest radiography for pre-operative screening prior to surgical repair of a meniscal tear in his right knee. An abnormality was noted on this study. 

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

What abnormality is seen on the chest X-ray? (Depending on your computer settings, you may need to enlarge the chest x-ray with your browser to identify the abnormality.)

1. Right lower lobe consolidation
2. Left lower lobe consolidation
3. Right lower lobe nodule
4. Left upper lobe nodule
5. Left lower lobe nodule