Medical Image of the Week: White Cell Count 347

Tauseef Afaq Siddiqi, MD¹

Sarah G. McGinn, MD²

Yuval Raz, MD¹

¹ Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, AZ, USA

² Department of Pathology, University of Arizona, Tucson, AZ, USA

A 77-year-old gentleman with a history of hypertension developed worsening weakness of a month duration.  His blood work at an outside facility revealed severe leukocytosis. He was transferred to University of Arizona Medical Center for leukapheresis.  His initial lab data revealed WBC count of 347.2X1000/microL (Normal 3.4-10.4X1000/microL) with 90% blasts.  His pulse oximetry was 92% on 4 L/min oxygen, although his arterial blood gas showed a pO2 of 46 (Normal 70-95 mm Hg) due to hyperleukocytosis and enhanced metabolic activity of malignant cells. His electrolyte panel showed pseudohypokalemia with potassium level of 2.4 (Normal 3.5-5.1 mMol/L).

Figure 1. Chest X-Ray showing hilar prominence and vascular fullness (interstitial and alveolar infiltrates).

Figure 2. Peripheral Blood shows increased white count with numerous blasts and promonocytes.

Figure 3. Bone Marrow Aspirate showing numerous blasts composed of a mixture of monoblasts with moderate gray blue cytoplasm and fine chromatin, and promonocytes with fine chromatin and kidney bean shaped nuclei.

Figure 4. Panel A: Bone Marrow Clot is hyerpcellular at 99% (40x magnification). Panel B: high power view of clot shows sheets of blasts (400x).

Reference as: Siddiqi TA, McGinn SG, Raz, Y. Medical image of the week: white cell count 347. Southwest J Pulm Crit Care. 2013;6(4):181-3. PDF

Medical Image of the Week: Duplicate Superior Vena Cava

Figure 1. AP chest X-ray demonstrating duplicate superior vena cava (SVC) with central lines in both the right and left superior vena cava (arrows at catheter tips). The chest x-ray shows the characteristic left-sided course of the catheter passing through a persistent left SVC (straight arrow).

Figure 2. Contrast enhanced CT of chest revealing left -sided SVC (arrow).

A persistent left SVC is the most common thoracic venous anomaly and usually opens into the right atrium via the coronary sinus.  A central line inserted into the left SVC may be mistaken for placement in other sites such as the subclavian or carotid artery, the mediastinum, the pericardium or pleural space. A duplicate SVC may cause difficulty in introducing central venous catheters or pulmonary artery catheters because of the narrow opening of the coronary sinus to reach the right atrium. In addition, a duplicate SVC is associated with important cardiac conditions such as atrial septal defects and ventricular arrhythmias.

Dena L’Heureux MD, Josh Malo MD and Linda Snyder MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona

Tucson, AZ

Reference as: L'Heureux D, Malo J, Snyder L. Medical image of the week: duplicate superior vena cava. Southwest J Pulm Crit Care. 2013;6(4):178-9. PDF

April 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

A 38-year old man presented to the Emergency Department with complaints of chest pain, shortness of breath, and fever. A frontal chest radiograph (Figure 1A) was performed; a comparison chest radiograph (Figure 1B) is presented as well.

Figure 1. Panel A: Frontal chest radiography. Panel B: A comparison frontal chest radiograph performed one year earlier.

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

1. The chest radiograph shows bilateral linear and reticular abnormalities
2. The chest radiograph appears normal and unchanged from previous
3. The chest radiograph shows multiple, bilateral poorly defined nodular opacities
4. The chest radiograph shows multifocal pleural abnormalities
5. The chest radiograph shows mediastinal widening

Reference as: Gotway MB. April 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(4):171-7. PDF

Medical Image of the Week: Septic Emboli

Figure 1. Photograph showing septic emboli to distal digits.

A 34 year old woman was admitted for a vasculitis workup after presenting with painful fingers, chest pain, and diffuse joint pain. Her blood cultures grew Staphyloccccus aureus and she was diagnosed with mitral and aortic valve endocarditis.  She had widespread joint involvement as well as a thoracic epidural abscess.

Jarrod Mosier, MD and Nathaniel Reyes, MD

Departments of Medicine and Emergency Medicine

University of Arizona

Tucson, Arizona

Reference as: Mosier J, Reyes N. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2013;6(4):170. PDF

Medical Image of the Week: Iatrogenic Pneumothorax

Figure 1: AP Chest X Ray showing an unfortunate placement of a feeding tube (yellow tracing) as it passes through the left mainstem bronchus and loops into the left pleural space causing a moderate size pneumothorax (arrows).

Aarthi Ganesh, MD; Ryan Nahapetian, MD; Prathima Guruguri, MD, and Carmen Luraschi-Monjagatta, MD

Department of Medicine

University of Arizona, South Campus

Tucson, Arizona

Reference as: Ganesh A, Nahapetian R, Guruguri P, Luraschi-Monjagatta C. Medical image of the week: iatrogenic pneumothorax. Southwest J Pulm Crit Care. 2013;6(3):150. PDF

Medical Image of the Week: Extensive Small Cell Lung Cancer with Cardiac Invasion

A 73 year old woman was seen with a lung mass and acute onset of ataxia. MRI of the brain was notable for multifocal infarcts (Figure 1). Echocardiography (ECHO) was obtained to identify cardiac source of emboli and was notable for freely mobile mass tethered to the lateral left atrial wall, crossing the mitral valve into the left atrium (Figure 2). A contrast enhanced CT scan of the chest was obtained which confirmed the presence of a large right upper lobe mass with extension to the right pulmonary vein, left atrium and into the left ventricle (Figures 3 and 4). The biopsy confirmed small cell lung cancer.

Figure 1. Axial MRI brain showing multifocal embolic infarcts.

Figure 2. Transthoracic ECHO 4-chamber view showing a mobile mass originating within the left atrium, across the mitral valve, and into the left ventricle.

Figure 3. Axial CT of the chest showing tumor extension into the right pulmonary vein (arrow).

Figure 4. Coronal CT of the chest showing large right apical mass extending into the left atrium and across the mitral valve into the left ventricle (arrow).

Ryan Nahapetian MD, MPH.

Internal Medicine Residency.

University of Arizona at South Campus.

Carmen Luraschi-Monjagatta MD.

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

Arizona Respiratory Center

University of Arizona

Tucson, Arizona.

Reference as: Nahapetian R, Luraschi-Monjagatta C. Medical image of the week: extensive small cell lung cancer with cardiac invasion. Southwest J Pulm Crit Care. 2013;6(3):143-4. PDF

Medical Image of the Week: DAH

 

Figure 1. Portable CXR (A) and CT (B) showing diffuse infiltrates of unclear etiology.

Figure 2. Progressively bloodier lavage indicative of pulmonary hemorrhage syndrome.

A 59 year old female was admitted to the ICU with hypoxemic respiratory failure and a clinical picture of ARDS (Figure 1), requiring intubation and mechanical ventilation. She underwent bone marrow and renal transplantation several years prior for multiple myeloma and myeloma kidney, respectively. She had been restarted on lenalidomide one month prior to presentation.  She was also taking tacrolimus, mycophenolate, prophylactic antimicrobials, warfarin for deep venous thrombosis, and aspirin for coronary artery disease. Emergent bronchoscopy with bronchoalveolar lavage revealed progressively bloodier specimens (Figure 2) consistent with diffuse alveolar hemorrhage (DAH). Further work-up was negative for vasculitis. Her lenalidomide, anticoagulation, and trimethoprim/sulfamethoxazole was stopped. She was started on high dose steroids and improved over 2 weeks.

Sage P. Whitmore, MD; Candy Wong, MD; James L. Knepler, MD and Carmen Luraschi-Monjagatta, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Whitmore SP, Wong C, Knepler JL, Luraschi-Monjagatta C. Medical image of the week: DAH. Southwest J Pulm Crit Care 2013;6(3):129. PDF

Medical Image of the Week: Trousseau’s Sign

Figure 1. Metacarpophalangeal joint flexion, extension of the distal interphalangeal and proximal interphalangeal joints and finger adduction (Trousseau’s sign) during blood pressure measurement.

A 22 year old woman was admitted for numbness and tingling of her hands, feet and face 72 hours after total thyroidectomy for a nonfunctional goiter. Initial ionized calcium was 3.2 mg/dL and magnesium 1.2 mg/dL. The patient received 1 ampule of calcium gluconate (90 mg calcium) and 2 mg MgSO4 intravenously.  The next day a rapid response was called.  The patient was lethargic, and said she felt very ill, although she could not be more specific.  Her ionized calcium was 4.3 mg/dL. She demonstrated Trousseau's sign when her blood pressure was measured with an arm cuff (Figure 1). She also had a positive Chvostek's sign.  She did not have stridor or papilledema. She received another ampule of calcium gluconate and 2 mg MgSO4 intravenously and was transferred to the ICU, where she had a 60 sec duration generalized seizure.  A calcium gluconate infusion was started, that delivered 990 mg calcium as calcium gluconate over 20 hours.  Oral calcium and vitamin D supplements were started.  PTH levels confirmed hypoparathyroidism, likely secondary to a surgical mishap at the time of thyroidectomy. 

Emad Wissa MD and Robert A. Raschke MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

Reference as: Wissa E, Raschke RA. Medical image of the week: Trousseau's sign. Southwest J Pulm Crit Care. 2013;6(3):128. PDF

March 2013 Imaging Case of the Month

Michael B. Gotway, MD*

Sudheer Penupolu, MD^‡

Jasminder Mand, MD^†

*Department of Radiology, Mayo Clinic, Arizona

^‡Fellow, Pulmonary Medicine, Mayo Clinic Arizona

^†Pulmonary and Critical Care Medicine, Maricopa Medical Center

Clinical History: A 54-year old Hispanic woman with no significant past medical history presented with complaints of cough and worsening dyspnea. She was in her usual state of health until 4-5 weeks prior to presentation when she started noticing gradually worsening dyspnea on exertion. She reported a dry cough initially which subsequently became productive of whitish, mucoid sputum. The patient denied chest pain, sore throat, sick contacts, or recent travel history. A chest x-ray was performed (Figure 1).

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 bilateral linear and reticular abnormalities
2. The chest radiograph shows nodular interstitial thickening
3. The chest radiograph shows multiple, bilateral circumscribed nodules
4. The chest radiograph shows mediastinal and hilar lymph node enlargement
5. The chest radiograph shows mediastinal widening

Reference as: Gotway MB, Penupolu S, Mand J. March 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(3):112-24. PDF

Medical Image of the Week: Squamous Cell Carcinoma Presenting as an Endobronchial Mass

Figure 1. CT axial cut showing large endobronchial mass (arrow) at the junction of the right upper lobe bronchus and bronchus intermedius.

Figure 2. Endobronchial lesion with view from trachea before (Panel A) and after (Panel B) removal by APC.

A 65 year old woman with previously diagnosed emphysema presented with two weeks of worsening dyspnea on exertion. CT scan of the chest showed a 14mm x 12mm irregular endobronchial lesion (arrow) occluding the bronchus intermedius. Right-sided compensatory “ball-valve” emphysematous changes are noted.  Right posterior atelectasis is also seen.  Endobronchial biopsy revealed squamous cell carcinoma. The patient later underwent palliative argon plasma coagulation (APC) therapy with removal of the tumor (Figure 2) with re-expansion of the right middle lobe.

Sage P. Whitmore, MD; James L. Knepler, Jr. MD and Linda Snyder, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Whitmore SP, Knepler JL Jr, Snyder L. Medical image of the week: squamous cell carcinoma presenting as an endobronchial mass. Southwest J Pulm Crit Care 2013;6(2):85-6. PDF

Medical Image of the Week: Sarcoidosis

Figure 1.  Stage 2 radiographic sarcoidosis with lymphadenopathy (arrows) on CXR (A), micronodular and macronodular infiltrates with beading along the fissure and bronchovascular bundles are more easily seen  on CT (B), multiple lung granulomas of various sizes and stages of maturity on transbronchial biopsy (C).

A 42 year old African-American man from Indianapolis presented with cough and skin lesions.  ACE level was elevated at 86 μg/L.  Spirometry was normal except for a diffusing capacity 52% of predicted.  Imaging was suggestive of sarcoidosis versus granulomatous infection.  Bronchoscopy with bronchoalveolar lavage cytospin revealed a lymphocytic alveolitis (27% lymphocytes) with a CD4:CD8 ratio of 6.2:1 by flow cytometry.  Biopsy showed classic noncaseating granulomas and no organisms supporting the diagnosis of sarcoidosis.  The patient’s symptoms and radiographic findings improved with 20 mg prednisone every other day for 3 months duration.

Kenneth S. Knox, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Knox KS. Medical image of the week: sarcoidosis. Southwest J Pulm Crit Care 2013;6(2):84. PDF

Medical Image of the Week: MRI of Wernicke’s Encephalopathy

Figure 1:  Thalamic enhancement (arrows)

A 61 year old male presented to the ED with altered mental status after being found down at home with several beer cans around him.  He was noted to have horizontal nystagmus on hospital day 2 and a MRI was performed.  MRI showed bilateral thalamic enhancement (Figure 1, arrows) on flair imaging consistent with Wernicke’s encephalopathy.  His thiamine dose was increased with improvement in his mental status.

Nathaniel Reyes, MD and Jarrod Mosier, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, AZ

Reference as: Reyes N, Mosier J. Medical image of the week: MRI of Wernicke's encephalopathy. Southwest J Pulm Crit Care. 2013;6(2):83. PDF

Medical Image of the Week: BAL Findings in Lipoid Pneumonia

 

Figure 1: Oil red O stain shows red-stained cytoplasm of several lipid-laden alveolar macrophages

A 66 year old woman presented with a two year history of recurrent pneumonias requiring multiple hospitalizations for treatment. A chest CT revealed bilateral multifocal opacities. The patient admitted regular use of a petroleum based product in her nose at night and severe gastroesophageal reflux disease. A bronchoalveolar lavage (BAL) was performed in the right lower lobe.  The BAL revealed significant Oil red O staining of alveolar macrophages (approximately 20% in Figure 1) consistent with exogenous lipid, suggesting recurrent microaspiration.

Aarthi Ganesh, MD; Rebecca Millius, MD and Linda Snyder, MD

Departments of Medicine and Pathology

University of Arizona

Tucson, Arizona

Reference as: Ganesh A, Millius R, Snyder L. Medical image of the week: findings in lipoid pneumonia. Southwest J Pulm Crit Care 2013;6(2):82. PDF

February 2013 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor Imaging

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 50-year-old previously healthy woman presented with complaints of intermittent back pain. The patient’s physical examination was unremarkable. Conservative treatment for these complaints was unsuccessful and thoracic spine radiography was performed, which showed abnormal lung findings, prompting frontal chest radiography (Figure 1).

 Figure 1. Frontal chest radiography.

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

1. The chest radiograph shows multiple, bilateral cavitary nodules
2. The chest radiograph shows nodular interstitial thickening
3. The chest radiograph shows multiple, bilateral circumscribed nodules
4. The chest radiograph shows mediastinal and hilar lymph node enlargement
5. The chest radiograph shows multifocal nodular pulmonary consolidation

Reference as: Gotway MB. February 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(2):75-81. PDF

Medical Image of the Week: Amyloidosis

A 60-year-old man with multiple pulmonary calcified nodules and masses was found to have nodular pulmonary light chain amyloidosis with a G kappa light chain in serum. He underwent stem cell transplant in 2003. In 2009, he was found to have pulmonary hypertension. Despite therapy, pulmonary hypertension and amyloidosis progressed.

Figure 1: Axial CT scan of the chest, lung and mediastinal windows, showing multiple calcified pulmonary nodules and masses secondary to Amyloidosis

Steven Knoper, MD; Carmen Luraschi-Monjagatta, MD and Aarthi Ganesh, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Refernce as: Knoper S, Luraschi-Monjagatta C, Ganesh A. Medical image of the week: amyloidosis. Southwest J Pulm Crit Care 2013;6(1):52. PDF

Medical Image of the week: Pulmonary Artery Endarterectomy

Figure 1. Organized thrombus with fresh clot removed during pulmonary thromboendarterectomy.

A 34 year-old male was admitted after an episode of syncope.  An echocardiogram revealed moderate enlargement of the RA and RV and an estimated systolic PA pressure of 85 mm Hg.  A perfusion scan showed segmental perfusion defects in the RUL, RML and LLL. He underwent pulmonary thromboendarterectomy with removal of chronic and partially organized thrombus from all lobar and segmental vessels of the right lung, lingula and left lower lobe.  Organized thrombus with some fresh clot is shown.

Nathaniel Reyes, MD and Linda Snyder, MD

Division of Pulmonary, Critical Care, Allergy and Sleep Medicine

Arizona Respiratory Center

University of Arizona

Reference as: Reyes N, Snyder L. Medical image of the week: pulmonary artery endarterectomy. Southwest J Pulm Crit Care 2013;6(1):37. PDF

Medical Image of the Week: Anomalous Pulmonary Venous Circulation

Figure 1. Thoracic CT scan showing the tip of the central line deviating beyond the expected margin of the aortic wall (arrow).

A 51 year old woman was admitted for treatment of acute kidney injury. A dialysis catheter and central line were inserted with ultrasound guidance. Thoracic CT scan (Figure 1) showed the tip of the left central line deviated laterally beyond the expected margin of the aortic wall (arrow). Blood gases were measured showing a partial pressure of oxygen of 154 mm Hg. Arterial line transducer was connected and tracing was consistent with venous system pressures.  A CT angiogram revealed the left internal jugular catheter was within the left superior pulmonary vein which was anomalously draining to the left brachiocephalic vein. This explained the arterial-like oxygenation and venous pressure tracing on arterial transducer. The central line was removed without the need of surgical intervention.

Hiram Rivas-Perez MD and Maria Lucarelli MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

Ohio State University

Columbus, Ohio

Reference as: Rivas-Perez H, Lucarelli M. Medical image of the week: anomalous pulmonary venous circulation. Southwest J Pulm Crit Care 2013;6(1):36. PDF

Medical Image of the Week: Hypertriglyceridemia-induced Pancreatitis

Figure 1. Panel A. Abdominal CT scan showing pancreatitis with edema and indistinct pancreatic borders (arrows). Panel B. Patient’s milky serum sample from elevated triglycerides. 

A 38 year old man presented with diffuse abdominal pain and was found to have pancreatitis on abdominal CT image (Figure 1, Panel A). His triglyceride level was 4573 mg/dL and his serum red top tube was visibly lipemic (Figure 1, Panel B).  He underwent one cycle of plasmapheresis and his triglyceride level decreased to below 500mg/dL.

Nathaniel Reyes, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, AZ

Reference as: Reyes N, Carr G. Medical image of the week: hypertriglyceridemia-induced pancreatitis. Southwest J Pulm Crit Care 2013;6(1):22. PDF

January 2013 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 previously healthy man presented with complaints of cough with blood-streaked sputum. 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?

1. The chest radiograph shows focal consolidation
2. The chest radiograph shows a loculated left pleural effusion
3. The chest radiograph shows pulmonary cavities
4. The chest radiograph shows tubular opacities suggesting arteriovenous malformations
5. The chest radiograph shows a left diaphragmatic hernia

Reference as: Gotway MB. January 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(1):15-21. PDF

Medical Image of the Week: Metastatic Colon Cancer to the Pleura

Figure 1. Pleuroscopy showing visceral (star) and parietal pleura (arrow) adenocarcinoma lesions.

A 55 year old man presented with recurrent exudative effusion of unexplained etiology. After non-diagnostic thoracentesis, pleuroscopy was performed.  Visceral (star) and parietal pleura (arrow) lesions were found (Figure 1).  Biopsies were performed and showed adenocarcinoma consistent with colon cancer on immunohistochemical staining.  Subsequent colonoscopy confirmed an asymptomatic colon cancer.

James L. Knepler, Jr. MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona 

Tucson, Arizona

Reference as: Knepler JL. Medical image of the week: metastatic colon cancer to the pleura. Southwest J Pulm Crit Care 2013(1);6:4. PDF