Medical Image of the Week: Duodenal Obstruction Secondary to Superior Mesenteric Artery Syndrome

Figure 1. Massive dilation of the gastric body with extension into the pelvis.

Figure 2. CTA demonstrating an acute aortomesenteric angle with the duodenum compressed.

Figure 3. Contrast MRI with impingement of the third part of the duodenum by the superior mesenteric artery and abdominal aorta.

The patient was a 46 year-old female admitted for accelerated hypertension.  Several days into her hospital stay she reported new complaints of progressive abdominal pain, vomiting, and constipation.  An abdominal radiograph confirmed severely dilated bowel and a subsequent CT scan of the abdomen was unable to identify a cause for bowel obstruction.  Endoscopy was performed with successful entrance of the first part of the duodenum.  MRI of the abdomen with contrast was ultimately able to delineate an obstruction of the third part of the duodenum between the superior mesenteric artery and the aorta.

Superior mesenteric artery syndrome is a rare but recognized cause for duodenal obstruction.  Patients may present with intermittent or progressive epigastric pain, nausea with bilious vomiting, and early satiety.  Medical management is largely conservative with gastric suctioning and pain management, with definitive treatment being surgical correction of the aortomesenteric angle.

Seth Assar, MD; Natasha Sharda, MD; Varun Takyar, MD; Bujji Ainapurapu, MD

Department of Medicine at South Campus

University of Arizona

Tucson, Arizona

References

1. Hines J, Gore R, Ballantyne G. Superior mesenteric artery syndrome. Diagnostic criteria and therapeutic approaches. Am J Surg. 1984;148:630–2. [CrossRef]
2. Felton BM, White JM, Racine MA. An uncommon case of abdominal pain: superior mesenteric artery syndrome. West J Emerg Med. 2012;13(6):501-2. [PubMed] 
3. Baltazar U, Dunn J, Floresguerra C, Schmidt L, Browder W. Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction. South Med J. 2000;93(6):606-8. [PubMed] 

Reference as: Assar S, Sharda N, Takyar V, Ainapurapu B. Medical image of the week: duodenal obstruction secondary to superior mesenteric artery syndrome. Southwest J Pulm Crit Care. 2013:7(2):84-6. doi: http://dx.doi.org/10.13175/swjpcc100-13 PDF 

August 2013 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 gradually worsening shortness of breath and dry cough over the previous six months, unresponsive to presumptive antibiotic therapy with levofloxacin first, followed by azithromycin. 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 chest radiograph shows basal predominant fibrotic lung disease
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multifocal bronchiectasis
4. The chest radiograph shows multiple nodules
5. The chest radiograph shows upper lobe peripheral consolidation and reticulation

Reference as: Gotway MB. August 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(2):75-83. doi: http://dx.doi.org/10.13175/swjpcc102-13  PDF

Medical Image of the Week: Tracheal Stenosis

Figure 1. Pulmonary function tests showing a flat inspiratory loop.

Figure 2.  When viewed from vocal cords, tracheal stenosis seen distally (arrow).

Figure 3. Tracheal stenosis seen on bronchoscopy (arrow).

Figure 4. Area of tracheal stenosis after balloon dilation.

A 43-year-old woman was seen in clinic for dyspnea on exertion that began several months ago.  Prior workup included a computed tomography of the chest with mild narrowing noted in the upper trachea.  Pulmonary function tests (Figure 1) showed a flat inspiratory loop with a normal expiratory loop, which suggests a variable extrathoracic obstruction.  On bronchoscopy, a tracheal stenosis was seen just past the vocal cords (Figure 2, Figure 3).  Balloon dilation (Figure 4) of the stenosis returned the area to normal caliber.

Wendy Hsu, MD and James Knepler, MD

Division of Pulmonary and Critical Care

University of Arizona

Tucson, AZ

Reference as: Hsu W, Knepler J. Medical image of the week: tracheal stenosis. Southwest J Pulm Crit Care. 2013:7(1):53-4. doi: http://dx.doi.org/10.13175/swjpcc099-13 PDF

Medical Image of the Week: Dual Primary Lung Cancers

Figure 1A. Chest x-ray showing mass-like consolidation of the right upper lobe.

Figure 1B. Thoracic CT showing abrupt cutoff of the apical and posterior segments of the right upper lobe bronchus and encasement of the anterior segment.

Figure 1C. Endobronchial mass with obstruction of the right upper lobe bronchus.

Figure 1D. H&E stain of right upper lobe mass consistent with small cell lung cancer.

Figure 1E. Positive CD56 staining of the right upper lobe mass.

Figure 1F. Positive chromogranin staining of the right upper lobe mass.

Figure 2A. Thoracic CT showing second lesion (red arrow) at the right lower lobe lateral segment bifurcation.

Figure 2B. Endobronchial mass at the lateral segment of the right lower lobe.

Figure 2C. H&E stain of right lower lobe mass consistent with squamous cell carcinoma.

A 73 year old man was admitted to the hospital with complaints of right upper quadrant pain and was found to have consolidation in the right upper lobe (Figure 1A).  He was started on antibiotics but failed to have any improvement. A chest CT scan showed a mass-like consolidation with possible mass at the right upper lobe bronchus (Figure 1B). Pulmonary was consulted for bronchoscopy which revealed an endobronchial lesion at the right upper lobe takeoff (Figure 1C) as well as a second endobronchial lesion at the right lower lobe (Figures 2A and 2B). Pathology of the right upper lobe lesion was consistent with small cell carcinoma (Figures 1D-F) while histology for the right lower lobe lesion showed squamous cell carcinoma (Figure 2C). CD56 and chromogranin are important stains used to diagnose small cell lung cancer (1).  Data is scarce regarding “synchronous” primary tumors.  Though not applicable to our patient, it is estimated that the incidence of dual primary lung cancers is around 16 percent in a patient whose first tumor was surgically resected (2).  Our patient opted for hospice care in light of multiple metastases to the brain and abdomen.

Candy Wong, MD; Nathaniel Reyes, MD; Andrea McGonigle, MD; Tan Nguyen, MD; Margaret Rennals, MD; Wei Shen, MD

Department of Pathology and Department of Medicine

University of Arizona and Southern Arizona VA Health Care System

Tucson, AZ

References

1. Kontogianni K, Nicholson AG, Butcher D, Sheppard MN. CD56: a useful tool for the diagnosis of small cell lung carcinomas on biopsies with extensive crush artefact. J Clin Pathol. 2005;58(9):978-80. [CrossRef] [PubMed]
2. Johnson BE. Second lung cancers in patients after treatment for an initial lung cancer. J Natl Cancer Inst. 1998;90(18):1335-45. [CrossRef] [PubMed]

Reference as: Wong C, Reyes N, McGonigle A, Nguyen T, Rennals M, Shen W. Medical image of the week: dual primary lung cancers. Southwest J Pulm Crit Care. 2013;7(1):46-9. doi: http://dx.doi.org/10.13175/swjpcc094-13 PDF

Medical Image of the Week: Dynamic Collapse of the Trachea

Figures 1A (Inspiratory) and 1B (Expiratory). CTs showing greater than 50% reduction of the anterior-posterior diameter of the trachea (double-headed arrow in Panel A compared to single-headed arrow in Panel B) during expiration consistent with dynamic airway collapse.

A 61 year old man with a history of chronic obstructive pulmonary disease (COPD) requiring multiple intubations over the past 2 years as well as obstructive sleep apnea (OSA) presented with acute dyspnea, cough and difficulty expectorating sputum over the last 24 hours.  His physical exam was notable for expiratory and inspiratory wheezing.  ABG revealed a pH of 7.24, P_aCO₂ of 71, P_aO₂ of 103, and HCO₃ of 29 mMol consistent with an acute on chronic respiratory acidosis. In the Emergency Department, the patient was given multiple bronchodilators and eventually placed on BiPAP with gradual improvement. CT of the chest revealed the caliber of the trachea was narrowed greater than 50% during expiration (Figure 1B) consistent with dynamic airway collapse of tracheobronchomalacia. This often overlooked condition may be related to past intubations or COPD with chronic bronchitis and is often misdiagnosed as COPD or treatment resistant asthma. Stents are often entertained in these patients but are fraught with complications and when used a removable stent is chosen.

Prathima Guruguri MD, Varun Takyar MD, Janet Campion MD, Stephen Klotz MD, and Philip Factor DO

University of Arizona

Tucson,  AZ

Reference as: Guruguri P, Takyar V, Campion J, Klotz S, Factor P. Medical image of the week: collapse of the trachea. Southwest J Pulm Crit Care. 2013;7(1):40. doi: http://dx.doi.org/10.13175/swjpcc090-13 PDF

Medical Image of the Week: Septic Emboli from Elbow Abscess

Figure 1. Panel A: Multiple thick wall cavities. Panel B: pneumothorax (arrows).

A 45 year old man with past medical history of rheumatoid arthritis and intravenous drug use presented with a several week history of progressive right elbow pain. He underwent incision and drainage with an operative diagnosis of septic arthritis.  He developed postoperative respiratory failure requiring prolonged mechanical ventilation.  Wound and blood cultures grew methacillin-resistant Staphylococcus aureus.  CT Chest revealed multiple thick walled cavities (A) from septic emboli as well as rupture of a pneumatocele causing a pneumothorax (B, arrows) necessitating chest tube insertion.

John F. Rosell, MD, Janet Campion, MD and Philip Factor, DO

Departments of Medicine and Emergency Medicine

University of Arizona

Tucson, AZ

Reference as: Rosell JF, Campion J, Factor P. Medical image of the week: septic emboli from elbow abscess. Southwest J Pulm Crit Care. 2013;7(1):27. doi: http://dx.doi.org/10.13175/swjpcc088-13 PDF

Medical Image of the Week: Massive Cerebral Infarction

 

Figure 1. Movie of head CT scan.

 

Figure 2. Movie of head MRI.

A 77 year old man with a history of chronic heart failure was admitted to the hospital complaining of left sided hemiparesis for about an hour. He was oriented but had slurred speech and was unable to move his left arm or leg. His pulse was irregular and ECG showed atrial fibrillation. A CT scan of the head (Figure 1) was interpreted as relatively unremarkable. Magnetic resonance imaging (MRI) of the head (Figure 2) showed massive right brain infarction. These studies illustrate the higher sensitivity of MRI in comparison to CT in the detection of stroke, especially early after the onset on symptoms (1).

Nijamudin Samani, MD; Yong-Jie Yin, MD; Sanjaya Karki, MD; and Jing-Xiao Zhang, MD

Department of Emergency and Critical Care

Second Hospital of Jilin University

Norman Bethune College of Medicine

Changchun, China

Reference

1. Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369(9558):293-8. [CrossRef] [PubMed]

Reference as: Samani N, Yin YJ, Karki S, Zhang JX. Medical image of the week: massive cerebral infarction. Soutwest J Pulm Crit Care. 2013;7(1):25-6. doi: http://dx.doi.org/10.13175/swjpcc084-13 PDF

July 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 64-year-old woman with a history of multiple sclerosis (wheelchair-bound), neurogenic bladder, and a number of other chronic medical conditions, presented with complaints of non-radiating neck pain without tingling or numbness. The patient also reported mild subjective fever and occasional nausea, but denied shortness of breath. Frontal and lateral chest radiography (Figure 1) was performed.

      Figure 1. Frontal (Panel A) and lateral (Panel B) chest x-ray.                 

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

1. The chest radiograph shows bibasilar consolidation
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multiple nodules
4. The chest radiograph shows no abnormalities
5. The chest radiograph shows symmetrical bilateral pleural effusions

Reference as: Gotway MB. July 2013 imaging case of the month. Southwest J Pulm Crit Care. 20130.;7(1):17-24. doi: http://dx.doi.org/10.13175/swjpcc087-13 PDF

Medical Image of the Week: Purpura Fulminans

Figure 1: Purpura fulminans, a cutaneous manifestation of disseminated intravascular coagulation, due to Group A streptococcal septic shock (A), which improved with antibiotics, resuscitation, IVIG infusion, and topical nitroglycerin (B).

Jarrod Mosier, MD and John Bloom, MD

Emergency Medicine-Critical Care Program

Division of Pulmonary and Critical Care

University of Arizona

Tucson, Arizona

Reference as: Mosier J, Bloom J. Medical image of the week: purpura fulminans. Southwest J Pulm Crit Care. 2013;6(6):305.  doi: http://dx.doi.org/10.13175/swjpcc082-13 PDF

Medical Image of the Week: Metastatic Melanoma with Hemorrhage

Figure 1. Axial image of CT Chest with contrast showing pulmonary metastatic masses and alveolar opacities consistent with pulmonary hemorrhage.

Figure 2. Coronal image of CT Chest with contrast showing innumerable pulmonary nodules and masses along with ground-glass alveolar opacities representing alveolar hemorrhage.

A 62 year-old gentleman presented with right leg swelling due to an extensive DVT in the right femoral vein.  He was found to have a right groin mass attributed to metastatic malignant melanoma.  Chest X-ray and CT revealed multiple bilateral pulmonary nodules.  He was started on warfarin 3mg daily for acute DVT and referred to Oncology.  2 weeks later he developed hemoptysis and was found to be hypoxemic.  He was admitted to our MICU.  His INR upon admission was 8.2 and hemoglobin 6.4.  CT Chest showed innumerable bilateral pulmonary nodules and ground-glass alveolar opacities with thickening and nodularity of intra-lobular septa adjacent to the nodules.  Warfarin was held and packed RBC and FFP transfusions were given with progressive improvement in hemoptysis and pulmonary status.

Tauseef Afaq Siddiqi, MD; Abdulmajid Eddib, MD; Phillip Factor, DO; and Steven Knoper, MD

Department of Medicine

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ 85724, USA

Reference as: Siddiqi TA, Eddib A, Factor P, Knoper S. Medical image of the week: metastatic melanoma with hemorrhage. Southwest J Pulm Crit Care. 2013;6(6):287-8. http://dx.doi.org/10.13175/swjpcc079-13 PDF

Medical Image of the Week: Tracheoesophageal fistula

Figure 1. Bronchoscopy showing tracheoesophageal fistula (arrow) with Dobhoff tube (arrowhead).

A 51 year old woman with a history of tracheal and bronchial stents for airway impingment from small cell carcinoma was intubated for respiratory failure. After prolonged intubation, she underwent tracheostomy to transition into hospice. The tracheal stent was removed during the procedure due to its location.  A tracheoesophageal fistula was demonstrated by visualization of her feeding tube on bronchoscopy performed the next day.  The patient underwent palliative ablation of the tracheal tumor and died several days later in hospice.

Candy Wong, MD; Josh Malo, MD; James Knepler, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Wong C, Malo J, Knepler J. Medical image of the week: tracheoesophageal fistula. Southwest J Pulm Crit Care. 2013;6(6):277. PDF

Medical Image of the Week: CREST plus ILD

Figure 1. Illustrations of CREST syndrome (see below).

A 60 year old female with a history of fibromyalgia presented with dyspnea and skin changes, predominantly on the hands.  Physical exam and imaging showed classic findings of limited cutaneous systemic sclerosis (scleroderma) CREST syndrome.  Calcinosis cutis (Figure 1A), Raynaud’s (not shown but endorsed by the patient), Esophageal dysmotility (Figure 1B, dilated esophagus), Sclerodactyly (Figure 1C), and Teleganectasias (Figure 1D) were all present.  Ground glass opacities were seen predominantly in the bilateral lower lung zones, associated with increased reticular markings (Figure 2A), and traction bronchiectasis (Figure 2B). 

Figure 2. Representative images from the patient’s CT scan showing pulmonary involvement.

Pulmonary involvement is noted in the majority of scleroderma patients.  Interstitial lung disease (ILD) is common and often portends a poor prognosis.

Isabel Oliva, MD and Ken Knox, MD

Division of Thoracic Imaging and Pulmonary & Critical Care Medicine

Interstitial Lung Disease Program

Reference as: Oliva I, Knox K. Medical image of the week: CREST plus ILD. Southwest J Pulm Crit Care. 2013;6(6):275-6. PDF 

June 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 42-year-old woman complained of cough and intermittent wheezing with shortness of breath. Her previous medical history was unremarkable. Frontal and lateral (Figures 1A and B) chest radiography was performed.

Figure 1. Frontal (Panel A) and lateral (Panel B) chest x-ray.

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

1. The chest radiograph shows no abnormalities
2. The chest radiograph shows bilateral, basal reticulation suggesting fibrotic lung disease
3. The chest radiograph shows medial left lower lobe opacities
4. The chest radiograph shows large lung volumes associated with faint cystic change
5. The chest radiograph shows numerous small nodules suggesting a miliary pattern 

Reference as: Gotway MB. June 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;6(6):263-71. PDF

Medical Image of the Week: Expiratory Imaging Accentuates Mosaic Attenuation

A 66 year old female presented with cough, fever and marked shortness of breath.   Infectious work up was found to be negative.  An inspiratory high resolution thoracic CT (HRCT) image (A) shows faint groundglass and mosaic lung attenuation with subtle centrilobular ill-defined nodules.  However, an image obtained on expiration (B) shows more obvious mosaic attenuation which suggesting air-trapping. Due to progressive dyspnea, a lung biopsy was performed and revealed a bronchiolocentric cellular interstitial pneumonia with non-caseating granuloma consistent with subacute hypersensitivity pneumonitis.

Veronica A. Arteaga, MD and Kenneth S. Knox, MD

Divisions of Thoracic Imaging and Pulmonary/Critical Care Medicine

University of Arizona

Tucson, Arizona

Reference as: Arteaga VA, Knox KS. Medical image of the week: expiratory imaging accentuates mosaic attenuation. Southwest J Pulm Crit Care. 2013;6(5):245. PDF

Medical Image of the Week: Osler-Weber-Rendu Syndrome

A 44 year-old woman with Osler-Weber-Rendu syndrome (commonly known as Hereditary Hemorrhagic Telangiectasia [HHT]) presented with hemoptysis. Her past history was notable for hemoptysis treated with hemostatic coil placement in multiple areas of arteriovenous (AV) malformations.  Her last episode of hemoptysis was 15 years prior to this admission and she had not been seen by a physician for almost 2 years.  Her CT Chest revealed multiple previous hemostatic coils and new AV malformations.

Figure 1. Chest X-Ray: Multiple hemostatic metallic coils throughout both lungs.

Figure 2. Axial images of CT Chest: Metallic foreign bodies are seen within the lungs. Several areas are enhancing and somewhat serpentine, possibly representing small residual or new areas of arteriovenous abnormality with dilated veins (arrows).

Tauseef Afaq Siddiqi MD, Toral Parikh MD and Phillip Factor DO

Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ 85724, United States

Reference as: Siddiqi TA, Parikh T, Factor P. Medical image of the week: Osler-Weber-Rendu syndrome. Southwest J Pulm Crit Care. 2013;6(5):241-2. PDF

Medical Image of the Week: Hepatocellular Carcinoma with Pulmonary Metastasis

A 58-year-old man with a history of hepatitis-C, liver cirrhosis and hepatocellular carcinoma treated with sorafenib and chemoembolization was admitted with septic shock due to spontaneous bacterial peritonitis with concomitant hemorrhage and acute renal failure.  The patient did not respond to broad-spectrum antibiotics, aggressive care with multiple vasopressors and ventilatory support and died shortly after admission.  An autopsy was performed revealing hepatocellular carcinoma with extensive intra-abdominal and thoracic metastasis.

Figure 1. Axial CT image of upper abdomen revealing cirrhotic liver with a large mass in left hepatic lobe (star) and massive ascites.

Figure 2. Cross-section of liver showing green-yellow hepatocellular carcinoma in left hepatic lobe (star).

Figure 3. Cross-section of lung showing numerous green-yellow metastatic lesions in pulmonary parenchyma and hilar nodes.

Figure 4.  Hematoxylin and eosin (40x [Panel A] and 100x [Panel B]) stained lung demonstrating micro-tumor emboli (arrows) of hepatocellular carcinoma.

Tauseef Afaq Siddiqi MD¹, Sachin Chaudhary MD¹,Nicholas Hernandez MD², Christopher Geffre MD² and Richard Sobonya MD²

¹ Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ 85724, United States

² Department of Pathology, The University of Arizona, Tucson, AZ 85724, United States.

Reference as: Siddiqi TA, Chaudhary S, Hernandez N, Geffre C and Sobonya R. Medical image of the week: hepatocellular carcinoma with pulmonary metastasis. Southwest J Pulm Crit Care. 2013;6(5):234-6. PDF

Medical Image of the Week: Eisenmenger Syndrome and Hemoptysis

A 26 year-old female with Eisenmenger syndrome presented with hemoptysis. An echocardiogram showed an enlarged right ventricle and two large mid-muscular ventricular septal defects (VSD) with right to left shunting (Figures 1 and 2).

Figure 1. Apical four-chamber view of the heart as seen on a transthoracic echocardiogram demonstrating an enlarged right ventricle (RV) and two large mid muscular ventricular septal defects (*).  RA - right atrium, LA - left atrium, LV - left ventricle.

Figure 2.  Apical four-chamber view on a transthoracic echocardiogram.  Color Doppler jets (blue color) demonstrate right-to-left shunt through the two mid-muscular ventricular septal defects seen in Figure 1.

A contrast enhanced CT of the chest showed an enlarged pulmonary artery, no evidence of pulmonary embolism and the VSDs (Figure 3 and 4).

Figure 3. Contrast enhanced CT of chest demonstrating markedly enlarged main pulmonary artery (arrow), approximately twice the size of the ascending aorta (straight arrow).

Figure 4. Contrast enhanced CT of chest showing ventricular septal defects (arrows).

Eisenmenger syndrome is a condition in which increased pulmonary blood flow secondary to a left to right intracardiac shunt leads to irreversible pulmonary vascular obstructive disease.  The resultant high pulmonary vascular resistance causes reversal and right to left intracardiac shunt.  Hemoptysis is a common complication of Eisenmenger syndrome and has been reported as the cause of death in 11-29% of patients. It can be caused by pulmonary artery thrombosis, pulmonary embolism, rupture of aortopulmonary collaterals, pulmonary artery dissection and hemorrhage due to an aneurysm or thin-walled arterioles, infectious sources or a bleeding diathesis.  Treatment of hemoptysis in patients with Eisenmenger syndrome is challenging because they are at increased risk for bleeding and thrombotic complications. Hemoptysis in patients with Eisenmenger syndrome is often self-limited; however, it can be severe and life threatening. It is estimated that nearly 90% of patients with congenital heart disease survive into adulthood therefore adult pulmonologists may encounter this clinical scenario.  Our patient’s hemoptysis resolved spontaneously and she remains clinically stable.

Jamie Nicole Colombo DO*, Linda Snyder MD^¶, and Daniela Lax MD^§

Department of Pediatrics*, Division of Pediatric Cardiology^§

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

University of Arizona

Reference as: Colombo JN, Snyder L, Lax D. Medical image of the week: Eisenmenger syndrome and hemoptysis. Southwest J Pulm Crit Care. 2013;6(5):231-3. PDF

May 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 21-year-old woman presented with complaints of cough. Frontal and lateral chest radiography (Figures 1A & B) was performed. A detail comparison chest radiograph from several years prior (Figure 1C) is presented as well.

 

Figure 1. Frontal (A) and lateral (B) chest radiography at presentation and a radiograph from several years earlier (C).

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

1. The chest radiograph predominantly shows bilateral linear and reticular abnormalities
2. The chest radiograph shows a combination of nodules, masses and thin-walled cysts
3. The chest radiograph shows multifocal consolidation with air bronchograms
4. The chest radiograph shows multifocal pleural abnormalities
5. The chest radiograph shows mediastinal widening & hilar lymphadenopathy

Reference as: Gotway MB. May 2013 imaging case of the month. Southwest J Pulm Crit Care.2013;6(5):218-30. PDF 

Medical Image of the Week: Right Neck Mass with Thoracic Extension

Figure 1. Coronal MRI image showing cavitary lesion (1.9 cm, yellow arrow) in the right lower lobe and multiple enlarged mediastinal and hilar lymph nodes with the largest lymph node measuri 2 x 2.5 cm.

Figure 2. Coronal MRI image of neck showing ill-defined infiltrative mass (2.8 x 4.1 x 6.4 cm, yellow star) in the right lateral neck posterior to the sternocleidomastoid muscle and jugular vein.

Figure 3. Right upper lobe endobronchial lesion (yellow arrow).  Biopsy showed Coccidioides spherules.

Figure 4. Hematoxylin and eosin (upper panel) and Gomori's methenamine silver stain stains of 4R lymph node showing Coccidioides spherule.

A 28-year-old female with a history of chronic pancreatitis s/p total pancreatectomy and auto-islet cell transplantation developed a progressively enlarging right neck mass of 4 weeks duration. Coccidioides IgM antibodies were negative and IgG antibodies were positive by immunoassay (EIA), with titers 1:4 by complement fixation (CF).  Fine needle aspiration with subsequent excisional biopsy of the right neck mass was performed and showed reactive lymphoid hyperplasia without fungal elements.  Bronchoscopy with right upper lobe endobronchial biopsy and 4R lymph node endobronchial ultrasound-fine needle aspiration revealed granulomatous inflammation and Coccidioides spherules on Gomori's methenamine silver stain.  Fungal cultures from the right neck mass fine needle aspiration, endobronchial biopsy, and 4R lymph node grew Coccidioides after three weeks of culture.

Tauseef Afaq Siddiqi, MD¹

Candy Wong, MD¹

Robert Ricciotti, MD²

Afshin Sam, MD¹

¹ Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine 

² Department of Pathology

University of Arizona

Tucson, AZ 85724

Reference as: Siddiqi TA, Wong C, Ricciotti R, Sam A. Medical image of the week: right neck mass with thoracic extension. Southwest J Pulm Crit Care. 2013;6(5):196-8. PDF

Medical Image of the Week: Ascending Cholangitis from Biliary Obstruction

Figure 1 – Sagittal view of the gallbladder on ultrasound showing gallstone (red arrow).

Figure 2 – Cholangiogram showing multiple filling defects in the gallbladder (red arrowheads) and diffuse dilatation of the common bile duct to 16mm with no contrast flow into the duodenum (arrow), suggestive of distal obstruction.

A 79 year old man with a history of quadriplegia presented to an outside hospital in septic shock.  He was found to have an elevated total bilirubin of 10 mg/dL, direct bilirubin of 7 mg/dL, alkaline phosphatase of 405 U/L, and lipase of 370 U/L.  Imaging showed cholelithiasis with likely intra- and extrahepatic biliary duct dilatation.  The patient underwent placement of a biliary drain with clinical improvement.  Additional imaging was requested prior to endoscopic retrograde cholangiopancreatography (ERCP), but magnetic resonance cholangiopancreatography (MRCP) was unavailable due to metallic implants.  Interventional radiology performed a cholangiogram using the biliary drain which confirmed biliary obstruction.  ERCP was then performed, with significant biliary sludge found and two stents placed.

Candy Wong, MD¹, Preethi William, MD² and Gordon Carr, MD¹

¹Division of Pulmonary and Critical Care Medicine

²Department of Medicine

University of Arizona

Tucson, Arizona

Reference as: Wong C, William P, Carr G. Medical image of the week: ascending cholangitis from biliary obstruction. Southwest J Pulm Crit Care. 2013;6(4):187-8. PDF