Medical Image of the Week: Undulating Arterial Waveform

Figure 1. Arterial line and oxygen saturation tracings demonstrating variability with inspiration, a sign of volume responsiveness.

Volume responsiveness assessed by variation in arterial line tracing demonstrating either stroke volume variation, systolic pressure variation, or pulse pressure variation has been shown to be far superior to traditional static indicators of preload responsiveness as they consider cardiopulmonary interactions (1). Additionally, variability in the O2 sat tracing has also been shown to be a reliable indicator of volume responsiveness (2).  

Jarrod M. Mosier, MD and John W. Bloom, MD

Emergency Medicine-Critical Care Program

Division of Pulmonary and Critical Care

University of Arizona

Tucson, Arizona

References

1. Marik PE, Baram M. Noninvasive hemodynamic monitoring in the intensive care unit. Crit Care Clin. 2007;23(3):383-400. [CrossRef] [PubMed]
2. Feissel M, Teboul JL, Merlani P, Badie J, Faller JP, Bendjelid K. Plethysmographic dynamic indices predict fluid responsiveness in septic ventilated patients. Intensive Care Med. 2007;33(6):993-9. [CrossRef] [PubMed] 

Reference as: Mosier JM, Bloom JW. Medical image of the week: undulating arterial waveform. Southwest J Pulm Crit Care. 2013;7(5):315. doi: http://dx.doi.org/10.13175/swjpcc153-13 PDF

Medical Image of the Week: Aortic Tear

Figure 1.  Portable chest x-ray demonstrating widened mediastinum with an apical cap, consistent with aortic rupture.

A 56-year old man presented as a trauma victim with the chief complaint of severe back pain. He was hemodynamically acceptable on arrival, but arrested shortly after this portable film was obtained (Figure 1). Emergency Department (ED) thoracotomy revealed a 3 cm longitudinal tear of the thoracic aorta and he exsanguinated in the ED.

Jarrod M. Mosier, MD

Department of Medicine and Emergency Medicine

Emergency Medicine-Critical Care Program

University of Arizona

Tucson, Arizona

Reference as: Mosier JM. Medical image of the week: aortic tear. Southwest J Pulm Crit Care. 2013;7(5): . doi: http://dx.doi.org/10.13175/swjpcc152-13 PDF

Medical Image of the Week: Migration of Fractured PICC Line

Figure 1. Chest radiograph showing catheter fragment coiled within the main pulmonary artery with the tips extending to the peripheral pulmonary vasculature (arrow).

A 29 year old man had a peripherally inserted central catheter (PICC, 60 cm, 4 Fr, single lumen Groshong), placed at a rural hospital via right brachial vein approach for long term antibiotic therapy for an infected diabetic foot. Two days later, nursing staff noticed difficulty in flushing the PICC line. A chest X-ray was obtained which showed fracture of a portion of the PICC line with migration to the pulmonary vasculature (Figure 1). The broken catheter was successfully removed in a two-step process using a 6 x10 mm EN Snare® from the left pulmonary artery. The patient, however remained asymptomatic and without any arrhythmias on the telemonitor. Intravascular migration and subsequent malposition of PICC lines are usually due to their pinch off, small size, as well as changes in intrathoracic pressure and body position (1).

Santhosh G. John MD, Paola Devis MD

University of Arizona

Tucson, AZ

Reference

1. Zhang Y, Jiang H, Wei L, Yu H. Persistent hiccup Caused by peripherally inserted central catheter migration. J Anesth. 2011;25(4):625-6. [CrossRef] [PubMed]

Reference as: John SG, Devis P. Medical image of the week: migration of fractured PICC line. Southwest J Pulm Crit Care. 2013;7(5): . doi: http://dx.doi.org/10.13175/swjpcc151-13 PDF

Medical Image of the Week: Empyema

Figure 1. Admission thoracic CT showing a low density collection in the right lung likely from necrosis (*).

Figure 2. Selected views from the thoracic CT obtained 1 week after admission. Panel A: Architectural distortion (white circle) suggests necrotizing pneumonia. Note fluid within the bronchus intermedius (*). Panel B: Defect in visceral pleura (arrow) with decompression of parenchymal necrosis into the pleural space.  Note enhancement and thickening of both pleural layers. Panel C: Defect in parietal pleura (black arrow) with fluid extending into the extrapleural space. Pericardial effusion (*), new left pleural effusion and left parietal pleura enhancement (white arrow) suggests spread of infection. Incidental hiatal hernia (+).

A 71 year-old man with chronic obstructive pulmonary disease (COPD) presents to the emergency department complaining of dyspnea after recent admission for pneumonia. Chest CT shows a low density collection in the right lung suggesting necrosis (Figure 1). A CT obtained 1 week after admission (Figure 2) shows progression to empyema.

Management of empyema can be difficult. If the fluid cannot be removed with a therapeutic thoracentesis, a chest tube should be inserted and consideration be given to the intrapleural instillation of fibrinolytics (1). If the loculated effusion persists, the patient should be subjected to video-assisted thoracoscopic surgery. If the lung cannot be expanded with this procedure, a full thoracotomy with decortication should be performed. The definitive procedure should be performed within fourteen days.

Jason R. Young MD and David L. August, MD

Department of Radiology

Maricopa Integrated Health System

Phoenix, AZ

Reference

1. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006;3(1):75-80. [CrossRef] [PubMed]

Reference as: Young JR, August DL. Medical image of the week: empyema. Southwest J Pulm Crit Care. 2013;7(5):300-1. http://dx.doi.org/10.13175/swjpcc143-13 PDF

November 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 67-year-old man complained of intermittent shortness of breath. A few crackles were audible in the patient’s lung bases bilaterally. 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 basal predominant linear opacities suggesting fibrosis
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multifocal ground-glass opacity and cavitary consolidation
4. The chest radiograph shows multifocal ground-glass opacity and consolidation associated with linear and reticular abnormalities
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. November 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(5):291-9. doi: http://dx.doi.org/10.13175/swjpcc149-13 PDF

Medical Image of the Week: Massive Esophagus

Figure 1. Chest x-ray taken 10 years prior to admission showing mild thickening of the right paratracheal stripe (arrow).

Figure 2. Admission chest x-ray showing a mass with mixed density silhouetting the right pulmonary artery and right paraspinal stripe.

Figure 3. Coronal view of the thoracic CT scan showing the mass is a massive esophagus.

A 34 year-old male inmate presents with chest pain 10 years prior to admission. His prior chest x-ray shows only mild thickening of the right paraspinal stripe (Figure 1). Chest x-ray on admission 10 years later shows a large right mixed density paramediastinal mass silhouetting the right pulmonary artery and right paratracheal stripe (Figure 2). This was confirmed to be a massive esophagus on thoracic CT scan (Figure 3). The patient was eventually diagnosed with achalasia.

A number of disorders can present with a massive esophagus including achalasia, esophagectomy with colonic interposition, scleroderma, esophageal carcinoma with stricture, and esophagitis with stricture (1). Diagnostic imaging findings using fluroscopy, CT and X-ray can help differentiate these disorders.  A massive esophagus due to achalasia is smooth walled with symmetric tapering to a "bird-beak" deformity and a chest x-ray may initially be normal.  Colonic interposition is evident by colonic haustra.  A dilated esophagus due to scleroderma is normal above aortic arch (striated muscle) but atonic below the aortic arch (smooth muscle).  On an upper GI series there is dilated jejunum with thin, crowded folds that are pathognomonic (Hidebound sign) for scleroderma.  Esophageal carcinoma shows a fixed irregularity with disruption of normal mucosal pattern.  Esophagitis has fine nodularity with an ulcerated mucosa on fluroscopy.

Jason R. Young MD, David L. August MD

Department of Radiology

Maricopa Integrated Health System

Phoenix, AZ

Reference

1. Cole TJ, Turner MA. Manifestations of gastrointestinal disease on chest radiographs. Radiographics. 1993;13(5):1013-34. [PubMed] 

Reference as: Young JR, August DL. Medical image of the week: massive esophagus. Southwest J Pulm Crit Care. 2013;7(4):265-6. doi: http://dx.doi.org/10.13175/swjpcc142-13 PDF

Medical Image of the Week: Coccidioidomycosis Pneumothorax

Figure 1. Right-sided pneumothorax (A) with subsequent placement of pigtail catheter and re-expansion of right lung (B).  CT shows bilateral multifocal airspace consolidation with nodules and cavitary interstitial disease (C).

Figure 2. PAP stain (A) and GMS stain (B) demonstrating Coccidioidomycosis from BAL (magnification, 400x).

A 36-year-old man with AIDS and disseminated coccidioidomycosis presented with severe right chest pain, shortness of breath, and a right-sided pneumothorax on CXR. A pigtail catheter was placed with near resolution of the pneumothorax. A bronchoscopy with bronchoalveolar lavage revealed spherules on cytology as well as coccidioidomycosis on culture. No other pathogens were identified. The pigtail catheter was removed three days later with resolution of the pneumothorax.

Rupture of subpleural coccidioidomycosis cavity into the pleural space resulting in pyopneumothorax and/or bronchopleural fistula is rare with reported rates of 1.4 – 2.6% for cavitary lesions (1).  Despite antiretroviral therapy and an undetectable viral load, disease was unresponsive to fluconazole.  Therapy was subsequently initiated with amphotericin B lipid complex, which resulted in significant improvement of his disease.

Ishna Poojary MD,  Christopher Geffre MD PhD,  Tirdad Zangeneh DO MA and Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

1. Tiu CT, Cook J, Pineros DF, Rankin LF, Lin YS, Ghitan M, Brichkov I, Shaw JP, Chapnick EK. Pneumothorax in a young man in Brooklyn, New York. Clin Inf Dis. 2011;53(12);1296-7. [CrossRef] [PubMed] 

Reference as: Poojary I, Geffre C, Zangeneh T, Campion J. Medical image of the week: coccidioidomycosis pneumothorax. Southwest J Pulm Crit Care. 2013;7(4):251-2. doi: http://dx.doi.org/10.13175/swjpcc140-13 PDF

Medical Image of the Week: Pneumatosis Intestinalis Secondary to Massive Acute Blood Loss

Figure 1. Coronal view of a non-contrast CT scan demonstrating pneumatosis intestinalis of the distal small bowel, ascending colon, and superior mesenteric vein (arrows).

Figure 2. Transverse cross-section of severe pneumatosis secondary to acute blood loss intestinal ischemia (arrows).

The patient was a 32 year-old male with a past medical history significant for end stage liver disease secondary to severe alcoholism who was found with an altered mental status.  In the emergency department, the patient divulged he had been throwing up blood clots in the preceding days.  Shortly into his presentation he began throwing up voluminous bright red blood.  Initial hemoglobin concentration was 2.8 mg/dL.  CT scan of the abdomen revealed pneumatosis within the ascending colon, small bowel, and mesenteric veins.  Despite massive transfusion efforts and two episodes of successful cardiac resuscitation the patient expired.

Seth Assar, MD; Herman Solorzano; Ishna Poojari, MD; Maria del Carmen Luraschi Monjagatta, MD

The University of Arizona College of Medicine at South Campus, Tucson, Arizona

References

1. Pieterse AS, Leong AS, Rowland R. The mucosal changes and pathogenesis of pneumatosis cystoides intestinalis. Hum Pathol. 1983;16(7):683-8. [CrossRef]
2. Heng Y, Schuffler MD, Haggitt RC, Rohrmann CA. Pneumatosis intestinalis: a review. Am J Gastroenterol. 1995;90(10):1747.[PubMed] 

Reference as: Assar S, Solorzano H, Poojari I, Monjagatta MCL. Medical image of the week: pneumatosis intestinalis secondary to massive acute blood loss. Southwest J Pulm Crit Care. 2013;7(4): . doi: http://dx.doi.org/10.13175/swjpcc135-13 PDF

Medical Image of the Week: Kartagener Syndrome

Figure 1. Chest x-ray showing right-sided aortic knob, heart and stomach bubble (arrows).

Figure 2. Abdominal CT scan showing right-sided stomach bubble (white arrow) and left-sided liver (yellow arrow).

Figure 3. Representative thoracic CT lung windows showing bronchiectasis with bronchi larger than blood vessels with thickened bronchial walls (arrows).

A 52 year old woman was admitted for dyspnea and fatigue. Kartagener syndrome had been diagnosed at age 3 with situs inversus totalis (Figures 1 and 2). She has bronchiectasis (Figure 3) with chronic Pseudomonas colonization, chronic sinusitis, and nasal polyposis.

Kartagener syndrome is a type of primary cilia dyskinesia or immotile-cilia syndrome. When primary ciliary dyskinesia is combined with situs inversus it is known as Kartagener syndrome (KS) after the Swiss internist who recognized the association of situs inversus, bronchiectasis and sinusitis (1). It is popular in case presentations especially with the chest x-ray or CT scans deliberated presented inverted.

KS is an autosomal recessive disorder of the ciliary axoneme with incomplete penetrance and extensive heterogeneity (2). The typical ciliary axoneme consists of 2 central microtubules surrounded by 9 microtubular doublets. Patients with primary ciliary dyskinesia exhibit a wide range of defects in ciliary ultrastructure and motility, which ultimately impairs ciliary beating and mucociliary clearance. The most common defect is a reduction in the number of dynein arms, which decreases the ciliary beat frequency.

Treatment is similar to other forms of bronchiectasis and sinusitis. There is no definitive curative therapy.

Nam H. Chan MD, Robert W. Viggiano MD and Lewis J. Wesselius MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

References

1. Kartagener M. Zur pathogenese der bronchiectasien. I Mitteilung:bronchiectasien bei situs viscerum inversus. Betr Klin Tuberk. 1933;83:498-501.
2. Bent JP III, Willis EB. Kartagener syndrome. Medscape. Available at: http://emedicine.medscape.com/article/299299-overview (accessed 10/2/13).

Reference as: Chan NH, Viggiano RW, Wesselius LJ. Medical image of the week: Kartagener syndrome. Southwest J Pulm Crit Care. 2013;7(4):239-40. doi: http://dx.doi.org/10.13175/swjpcc137-13 PDF

October 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ 

Clinical History

A 67-year-old man with a history of hypertension and chronic lymphocytic leukemia (CLL), the latter diagnosed 10 years earlier, in remission until recently, presented with complaints of weight loss, not eating much, lethargy, and shortness of breath. His CLL had recurred and he was treated with rituximab, and bendamustine (a nitrogen mustard alkylating agent) and intravenous immunoglobulin. Frontal chest radiography (Figure 1) was performed.

Figure 1. Initial chest radiograph.

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

1. The chest radiograph shows basal predominant linear opacities suggesting fibrosis
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multifocal ground-glass opacity and cavitary consolidation
4. The chest radiograph shows multifocal ground-glass opacity and consolidation associated with linear and reticular abnormalities
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. October 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(4):223-31. doi: http://dx.doi.org/10.13175/swjpcc133-13 PDF

TEST

TEST

Medical Image of the Week: Cytomegalovirus Pneumonia

Figure 1. CT Chest, coronal cut showing left lower lobe consolidation.

Figure 2.  Pap stain highlights an enlarged cytomegalovirus-infected pneumocyte containing a single, dark intranuclear inclusion (arrow) with surrounding halo, giving the cell a characteristic “owl’s eye” appearance. Background cells consist of predominantly of macrophages and red blood cells (100x).

Figure 3. CMV-infected pneumocyte demonstrating an enlarged nucleus with a single dense intranuclear inclusion. The cytoplasm contains smaller basophilic inclusions with vacuolization and cytoplasmic projections (Pap stain, 100x).

A 29 year-old female with a history of systemic lupus erythematosus presented with a seven-day history of fever, dyspnea and a non-productive cough. She underwent renal transplantation four weeks prior to admission and was maintained on mycophenolate, tacrolimus, prednisone and prophylactic fluconazole, trimethoprim/sulfamethoxazole and valgangcyclovir. A CT chest was performed (Figure 1) and revealed left lower lobe consolidation. A BAL was performed in the left lower lobe and the cell count revealed 50% lymphocytes, 13% neutrophils and 37% macrophages. The BAL Papanicolaou stain showed enlarged cytomegalovirus-infected pneumocytes with the characteristic “owl’s eye” appearance (Figures 2 and 3). CMV quantitative PCR from serum resulted 648,615 IU/m.  The BAL culture grew CMV. The patient was started on treatment with valgangcyclovir with clinical improvement.

While often thought of as a “pneumonitis” with diffuse infiltrates, CMV can cause a lobar pneumonia in up to 30% of patients.  Prophylaxis is effective, but cases can occur despite a preemptive strategy.

Nathaniel Reyes MD^*, Julianna J. Weiel MSII⁺, Erika R. Bracamonte MD⁺, Linda Snyder MD^*
Department of Medicine, Division of Pulmonary and Critical Care Medicine*
Department of Pathology⁺

University of Arizona

Tucson, Arizona

Reference

Kang E, Patz E, Miller NL. Cytomegalovirus pneumonia in transplant patients: CT findings. J Comput Assisted Tomogr. 1998:20:295-9. [CrossRef]

Reference as: Reyes N, Weiel JJ, Bracamonte ER, Snyder L. Medical image of the week: cytomegalovirus pneumonia. Southwest J Pulm Crit Care. 2013;7(4):221-2. doi: http://dx.doi.org/10.13175/swjpcc131-13 PDF

Medical Image of the Week: Uvula Hematoma Secondary to Endotracheal Intubation

Figure 1: Uvula with elongation and hematoma of the tip, in the anterior and superior position.

A 53 year old male with no significant past medical history admitted for acute cholecystitis, underwent an uneventful laparoscopic cholecystectomy. Per anesthesia report, intubation was difficult.  A few hours after extubation, he complained of dyspnea and a choking sensation. Examination showed a hematoma of the uvula with elongation and abnormal position of the uvula anterior to the soft palate. The patient was given a dose of intravenous steroids and anti-histamine with resolution of his symptoms over time.

Bhupinder Natt MD, Carmen Luraschi Monjagatta MD, Rene Franco MD, John Sandoval-Gonzalez MD.

Departments of Internal Medicine and Family Medicine

University of Arizona Health Network, South Campus

University of Arizona

Tucson, Arizona

Reference as: Natt B, Luraschi-Monjagatta C, Franco R, Sandoval-Gonzalez J. Medical image of the week: uvula hematoma secondary to endotracheal intubation. Southwest J Pulm Crit Care. 2013:7(3):204. doi: http://dx.doi.org/10.13175/swjpcc127-13 PDF

Medical Image of the Week: Accessory Cardiac Bronchus

Figure 1. Axial (Panel A) and Coronal (Panel B) CT Chest demonstrate an accessory cardiac bronchus that can be seen in the axial and coronal views (arrows) arising from the bronchus intermedius.

A 77-year-old man with a 120 pack-year smoking history was found to have incidental rudimentary bronchus arising from the medial wall of the bronchus intermedius on thoracic CT obtained for lung nodule evaluation.

A congenital tracheobronchial anomaly called a cardiac bronchus was first described in 1946 by Brock and is thought to develop in the 6^th week of gestation. The incidence of a cardiac bronchus is reported as 0.07 – 0.5% and is most commonly seen arising directly opposite the right upper lobe orifice.  The average diameter is 8.7 mm and the average length is 12mm advancing in a caudal direction towards the pericardium. Cardiac bronchi are lined by normal bronchial mucosa and have cartilage, which distinguish them from acquired diverticula. Most end abruptly but some do develop small bronchioles and bronchiolar parenchymal tissue. Accessory cardiac bronchi are usually asymptomatic and discovered incidentally as in this case, but can be associated with cough, hemoptysis, and recurrent infections. Pulmonologists should be aware of this congenital accessory bronchus in order to properly evaluate patients during diagnostic bronchoscopy.

Bhupinder Natt MD, Veronica Arteaga MD, Janet Campion MD

University of Arizona Medical Center, Tucson AZ.

Reference

Desir A, Ghaye B. Congenital anomalities of intrathoracic airways. Radiologic Clinics of North America. 2009; 47(2); 203-225. [CrossRef] [PubMed]

Reference as: Natt B, Arteaga V, Campion J. Medical image of the week: accessory cardiac bronchus. Southwest J Pulm Crit Care. 2013:7(3):193. doi: http://dx.doi.org/10.13175/swjpcc126-13 PDF

Medical Image of the Week: Solitary Fibrous Tumor

 

 

      

 Figure 1. Pleural based Right Lung mass shown on CXR (A), CT scan (B), and MRI (C).  MRI confirms lack of significant invasion to surrounding structures.

Figure 2.  Bisection of specimen (A) reveals a pale, tan-brown 9.5 x 10.2 x 4.5 cm mass suspended from surrounding normal lung by two pedicles, without gross evidence of invasion of surrounding lung tissue. H & E staining of a representative section of lung mass (B) reveals a dense infiltrate of spindly, fibroblast-like mesenchymal cells with bland nuclear features in the background of a dense collagenous stroma. When labeled with anti-CD34 antibody (C), a marker of fibroblasts and endothelial cells, diffuse cytoplasmic and membranous positivity is seen. Though not shown, staining for Bcl-2 and pankeratin were also performed, and were diffusely positive and negative, respectively. These immunohistochemical findings and a storiform or “pattern-less” pattern is characteristic of typical benign solitary fibrous tumors.

A 68 year old female with a history of resected lung cancer and new onset joint pain and swelling presented for evaluation.  Imaging revealed a right intrapleural mass and resection confirmed solitary fibrous tumor (SFT) of the pleura (benign).  The patient experienced resolution of her joint pain, which was due to pulmonary hypertrophic osteoarthropathy, shortly after resection.  Although not present in our patient, tumor induced hypoglycemia (Doege-Potter syndrome) can also be seen in SFTs.  Solitary fibrous tumors are uncommon neoplasms of mesenchymal tissue, and can originate from either visceral or parietal pleural surfaces.  Though they can grow to large size before clinical detection, the majority are benign, and can be treated with en bloc surgical resection.

Jessica Baumann, MD¹; James L Knepler, MD²; Richard Sobonya, MD¹ and Samuel Kim, MD³

Departments of Pathology¹, Medicine², and Surgery³

University of Arizona Thoracic Oncology Program

Tucson, Arizona

Reference

Cardillo G, Lococo F, Carleo F, Martelli M. Solitary fibrous tumors of the pleura. Curr Opin Pulm Med. 2012;18(4):339-46. [CrossRef] [PubMed]

Reference as: Baumann J, Knepler JL, Sobonya R, Kim S. Medical image of the week: solitary fibrous tumor. Southwest J Pulm Crit Care. 2013;7(3):179-80. doi: http://dx.doi.org/10.13175/swjpcc120-13 PDF 

Medical Image of the Week: Acute Epiglottitis

Figure 1. Lateral (Panel A) and AP (Panel B) views of the neck demonstrate a patent airway, but epiglottis and its associated folds are quite thickened suggesting the patient has developing epiglottitis. The lateral view demonstrates a ‘thumbprint’ sign with an enlarged epiglottis (T).

A 24 year old man without a significant past medical history presented with a 3 day history of sore throat, fever and less than 24 hour history of pain with breathing and swallowing secretions. He was intubated using fiberoptic nasopharyngoscopy in the emergency department due to stridor with a 6.0 mm endotracheal tube until successfully extubated five days later. Initially he was treated with broad spectrum antibiotics and methylprednisolone 40 mg intravenously every 12 hours. A CT scan of the neck did not show an epiglottic abscess.

Acute epiglottitis in adults appears to have a rising incidence with an associated mortality of 7% that is related to Haemophilus influenzae type b, as well as other miscellaneous pathogens, mechanical injury or smoke inhalation. Risk factors associated with obstruction are drooling, rapid onset of symptoms, evidence of abscess formation and a history of diabetes mellitus. Epiglottic abscess is infrequent sequelae of acute epiglottis. Use of steroids in severe cases is common, but there is no evidence of benefit.

Chirag Desai MD, Mohammad Dalabih MD, Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

Berger G, Landau T, Berger S, Finkelstein Y, Bernheim J, Ophir D. The rising incidence of adult acute epiglottitis and epiglottic abscess. Am J Otolaryngol. 2003; 24(6);374-83. [CrossRef] [PubMed] 

Reference as: Desai C, Dlabih M, Campion J. Medical image of the week: acute epiglottitis. Southwest J Pulm Crit Care. 2013;7(3):161. doi: http://dx.doi.org/10.13175/swjpcc119-13 PDF

September 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 61-year-old man presented with a 6-month history of easy fatigability and worsening shortness of breath. The patient noted that his difficulty breathing improved somewhat when lying flat. 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 multiple nodules
4. The chest radiograph shows tubular opacities in the lower lobes bilaterally
5. The chest radiograph shows upper lobe peripheral consolidation and reticulation

Reference as: Gotway MB. September 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(3):151-60. doi: http://dx.doi.org/10.13175/swjpcc118-13 PDF

Medical Image of the Week: Fontan Procedure

Figure 1. Thoracic CT scan showing Fontan anatomy, with the superior vena cava (SVC) connected to the pulmonary arteries (yellow arrow) and a single atrium and ventricle (red arrow).

Figure 2. SVC venography shows SVC connected to the pulmonary artery.

A 25-year-old man with a history of transposition of the great vessels (L-TGA) was admitted for persistent hemoptysis. He had a history of a double inlet left ventricle, pulmonary hypertension and was postoperative for a Fontan procedure completed at age of 2. No anatomical source for the hemoptysis was found.  A thoracic CT showed the Fontan anatomy: SVC connected to the pulmonary artery as per the Glenn connection (IVC drained to right pulmonary artery through the Fontan pathway) and a single ventricle and atrium (Figure 1). SVC venography showed the SVC connected to the pulmonary artery (Figure 2). The hemoptysis resolved after started sidenafil and bosentan for pulmonary hypertension.

Mohammed Alzoubaidi MD, Carmen Luraschi Monjagatta MD, Maria Tumanik DO, Naomi Jean Young MD

University of Arizona

Department of Pulmonary and Critical Care Medicine

Internal Medicine, South Campus.

Family Medicine, South Campus

Tucson, AZ

Reference as: Alzoubaidi M, Monjagatta CL, Tumanik M, Young NJ. Medical image of the week: Fontan procedure. Southwest J Pulm Crit Care. 2013;7(2):112-3. doi: http://dx.doi.org/10.13175/swjpcc114-13 PDF

Medical Image of the Week: Lepidic Growth

 

Figure 1. Two different tumors showing lepidic growth along the alveolar interstitium with preserved alveolar architecture.

Lepidic growth is most often seen in adenocarcinoma in situ (Figure A, 40x magnification).  Adenocarcinoma in situ is formerly known as bronchoalveolar cell carcinoma (BAC).  A similar growth pattern in a morphologically very different tumor (mucinous adenocarcinoma) is shown for comparison (Figure B, 400x).  Mucinous adenocarcinoma growing on alveolar septae nearly always is invasive, so the entity of mucinous adencioarcinoma in situ practically doesn't exist, further differentiating this entity from BAC.

Ken Knox, MD and Richard Sobonya, MD

Departments of Medicine and Pathology

University of Arizona

Tucson, Arizona

Reference as: Knox KS, Sobonya RE. Medical image of the week: lepidic growth. Southwest J Pulm Crit Care. 2013;7(2):109. doi: http://dx.doi.org/10.13175/swjpcc111-13 PDF

Medical Image of the Week: Right Main Bronchus Obstruction in a Young Man

Figure 1. Panel A: chest x-ray at presentation. Panel B: CT scan at presentation.

Figure 2. Panel A: Mass encroaching the carina. Panel B: Near total occlusion of the right main bronchus.

Figure 3. Tissue removed during bronchoscopy.

Figure 4. Post-procedure image.

The patient is a 22 year old man with long standing history of recurrent laryngeal papillomatosis since childhood.

He was referred to the hospital by his ENT surgeon and pulmonology was consulted for evaluation of pneumonia and lung mass. Initial chest x-ray (Figure 1A) demonstrated a white out of the right lung. A CT scan (Figure 1B) obtained showed a pedunculated mass in the right main stem and extensive post obstructive pneumonia. At bronchoscopy, a near total occlusion of the right main stem bronchus was seen with extension in to the trachea (Figure 2). Piecemeal excision of the mass was done using multiple snare passes (Figure 3). The right main stem was subsequently cleared and the distal airway found patent with no endobronchial lesions (Figure 4). The mass continued to obstruct the right upper lobe take off completely.

Pathology was consistent with squamous papilloma with dysplasia. Further work up revealed no metastatic disease and the patient is undergoing evaluation for treatment strategies.

Laryngeal papillomatosis is a human papilloma virus (HPV) associated disease that may progress to malignancy, not only of the larynx but anywhere in the aero-digestive tract.

Bhupinder Natt MD, Nauman Hamid MD, and James Knepler MD  

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

University of Arizona

Tucson, Arizona.

Reference as: Natt B, Hamid N, Knepler J. Medical image of the week: right main bronchus obstruction in a young man. Southwest J Pulm Crit Care. 2013;7(2):100-2. doi: http://dx.doi.org/10.13175/swjpcc107-13 PDF