Medical Image of the Week: Leptomeningeal Carcinomatosis

Figure 1. PET/CT scan showing metabolic activity in the mid 3^rd of the left breast without significant adenopathy (arrows).

Figure 2. Panel A: Brain MRI T1 pre contrast image shows normal signal intensity in cerebrum, brain stem and cerebellum with no evidence of acute infarction. Panels B and C: Post contrast images show diffuse leptomeningeal enhancement involving bilateral cerebellar folia and around the surface of brainstem (arrows).

A 65 year old woman with a history of breast cancer presented to the emergency department (ED) with dizziness and disequilibrium, which started a week prior to admission. A year ago, she was diagnosed with locally advanced lobular carcinoma confined to the left breast (Figure 1). She underwent mastectomy followed by chemoradiation including taxol, sunitinib, cyclophosphamide and doxorubicin with remarkable response, and achieved complete remission. In the ED, her neurologic status deteriorated rapidly, she developed tonic-clonic seizures and became unresponsive to verbal and painful stimuli. CT of the head showed no evidence of acute intracranial abnormality or metastatic lesion, however, a brain MRI brain showed contrast enhancement and increased fluid attenuated inversion recovery (FLAIR) signal of the leptomeninges in cranial nerves III, V, VII and VIII as well as cerebellar surface, suggesting meningeal carcinomatosis (Figure 2B and 2C). A lumbar puncture demonstrated malignant cells in the cerebospinal fluid confirming the diagnosis of leptomeningeal carcinomatosis. Palliative radiation therapy with thiotepa was planned, however, her family opted for comfort care only and the patient passed away 6^th day of hospital stay.

Leptomeningeal carcinomatosis (LC) is a devastating complication of systemic cancer that can occur in patients with solid or hematologic malignancies. LC has been described in 5% to 10% of patients with solid tumors, more frequently breast adenocarcinoma, lung adenocarcinoma and melanoma (1,2). LC may be the first manifestation of cancer in 5% to 11% of patients and maybe the sole site of relapse in patients successfully treated for cancer (2). Treatment of LC is currently palliative for most patients, with an expected median survival of less than 6 months (1,2)

Roberto Bernardo MD, Seongseok Yun MD PhD, Ateefa Chaudhury MD, Keri Maher DO, and Tauseef Siddiqi MD

Department of Medicine, University of Arizona, Tucson, AZ

References

1. Bruna J, González L, Miró J, Velasco R, Gil M, Tortosa A. Leptomeningeal carcinomatosis: prognostic implications of clinical and cerebrospinal fluid features. Cancer. 2009;115(2):381–9. [CrossRef] [PubMed] 
2. Kesari S, Batchelor TT. Leptomeningeal metastases. Neurol Clin. 2003:21(1): 25-66. [CrossRef] [PubMed]

Referece as: Bernardo R, Yun S, Chaudhury A, Maher K, Siddiqi T. Medical image of the week: leptomeningeal carcinomatosis. Southwest J Pulm Crit Care. 2014;8(3):190-1. doi: http://dx.doi.org/10.13175/swjpcc028-14 PDF

Medical Image of the Week: Bilateral Pneumothorax, Pneumomediastinum, and Massive Subcutaneous Emphysema

Figure 1.  Computed tomography of the thorax showing subcutaneous air dispersed in the adipose tissue, separating the fascia of the pectoralis major, and the delineation of its fibers (top arrow), pneumothorax compressing the lung (middle arrow), and pneumomediastinum compressing the trachea (bottom arrow).

An 80 year old man with chronic obstructive pulmonary disease (COPD) presented to the emergency department with respiratory distress and poor oxygen saturation. Physical exam revealed an obese male in respiratory distress with poor air entry bilaterally and scattered wheezing. His chest, neck, tongue, and lips were swollen. The patient was intubated for respiratory failure, felt to be due to angioedema. His oxygen saturation immediately improved, however the patient developed progressive swelling throughout his body including his eyelids, fingers and toes. Diffuse crepitus was felt on palpation. Chest radiography and computed tomography (CT) of the chest revealed large bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema (Figure 1). Bilateral chest tubes were inserted with re-expansion of both lungs. Over the next several days his respiratory parameters improved, with full re-expansion of the lungs and reabsorption of the pneumomediastinum and subcutaneous emphysema. The patient was extubated successfully and was discharged in good health.

Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema (SCE) are complications that may occur individually or rarely concomitantly, as in our case, during COPD exacerbations (the exact occurrence rate has not been described in the literature) (1-3). Bilateral spontaneous pneumthorax occurs in 1.9% of all spontaneous pneumothorax (4). The diagnosis is made with physical exam and appropriate imaging. Depending on the tension physiology, these conditions may lead to rapid respiratory failure and decreased cardiac output, especially when complicated by pulmonary barotrauma during mechanical ventilation (5,6).  In severe cases, SCE may involve respiratory compromise by compressing the trachea.

The early diagnosis with meticulous physical exam and relevant testing is essential, in order to immediately initiate appropriate management, and hence avoid the life-threatening complications associated with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema.

Zavier Ahmed MD, Manpreet Singh MD, Ricardo Lopez, MD

Icahn School of Medicine at Mount Sinai

Queens Hospital Center

82-68 164th Street

Queens, NY

References

1. Williams-Johnson J, Williams EW, Hart N, Maycock C, Bullock K, Ramphal P. Simultaneous spontaneous bilateral pneumothoraces in an asthmatic. West Indian Med J. 2008;57(5):508-10.[PubMed] 
2. Karakaya Z, Demir S, Sagay SS, Karakaya O, Ozdinc S. Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema: rare and fatal complications of asthma. Case Rep Emerg Med. 2012; 242579. [PubMed] 
3. Limthongkul S, Wongthim S, Udompanich V, Charoenlap P, Nuchprayoon C. Spontaneous pneumothorax in chronic obstructive pulmonary disease. J Med Assoc Thai. 1992;75(4):204-12. [PubMed] 
4. Athanassiadi K, Kalavrouziotis G, Loutsidis A, Hatzimichalis A, Bellenis I, Exarchos N. Treatment of spontaneous pneumothorax: ten-year experience. World J Surg, 1998;22: 803–6. [CrossRef] [PubMed] 
5. Hashim T, Chaudry AH, Ahmad K, Imhoff J, Khouzam R. Pneumomediastinum from a severe asthma attack. JAAPA. 2013;26(7):29-32. [CrossRef] [PubMed] 
6. Sakamoto A, Kogou Y, Matsumoto N, Nakazato M. Massive subcutaneous emphysema and pneumomediastinum following endotracheal intubation. Intern Med. 2013;52(15):1759. [CrossRef] [PubMed]

Reference as: Ahmed Z, Singh M, Lopez R. Medical image of the week: bilateral pneumothorax, pneumomediastinum, and massive subcutaneous emphysema. Southwest J Pulm Crit Care. 2014;8(3):181-2. doi: http://dx.doi.org/10.13175/swjpcc020-14 PDF

Medical Image of the Week: Esophageal-Pleural Fistula

Figure 1. Esophagram showing fistulous tract formation from the distal esophagus just proximal to the gastroesophageal junction, with possible communication with the pleural space.

Figure 2. CT scan of the chest showed empyema with LLL pneumonia and air in the mediastinum.

Figure 3. Three- dimensional CT scan of the chest showed fistulous tract close to the gastroesophageal junction.

A 51 year old woman with rheumatoid arthritis, diabetes mellitus and gastroesophageal reflux disease had a transoral incisionless fundoplication for a hiatal hernia 6 months before admission. She presented with left lower lobe pneumonia and empyema. The esophagram showed a fistulous tract communicating with the pleural space (Figure 1). CT scan of the chest also showed air in the mediastinum (Figure 2) as well a fistulous tract in the three dimensional reconstruction (Figure 3). Esophagogastroduodenoscopy (EGD) showed an esophageal defect 5 cm above the gastroesophageal junction. An esophageal stent was placed with success.

Mohammed Alzoubaidi MD, Carmen Luraschi Monjagatta MD

Department of Pulmonary and Critical Care Medicine.

University of Arizona

Tucson, AZ

Referenc as: Alzoubaidi M, Luraschi-Monjagatta C. Medical image of the week: esophageal-pleural fistula. Southwest J Pulm Criti Care. 2014;8(3):179-80. doi: http://dx.doi.org/10.13175/swjpcc019-14 PDF

March 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man with a history of severe asthmatic bronchitis presented with a 6 week history of intermittent fever, productive cough, shortness of breath, and decreased appetite. Four weeks earlier the patient was presumptively treated with amoxicillin for presumed community-acquired pneumonia, with some improvement, but his symptoms recurred 10 days following completion of his course of therapy. The patient also thought he was diagnosed with a COPD exacerbation during this time period and was treated with a short course of corticosteroids without improvement.

The patient was seen by his pulmonologist who noted decreased breath sounds over the right thorax, and referred the patient to the emergency room.

In the emergency room, a leukocytosis (white blood cell count = 17.4 x 10⁹ / L with neutrophilia) was noted. Broad-spectrum antibiotic coverage was re-instituted and 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? (Click on the correct answer to move to the next panel)

1. The chest radiograph homogeneous complete right lung consolidation
2. The chest radiograph shows a right-sided mediastinal mass
3. The chest radiograph shows homogeneous right lung opacity suggesting right lung collapse
4. The chest radiograph shows homogeneous right lung opacity suggesting a large right pleural effusion
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. March 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014:8(3):161-9. doi: http://dx.doi.org/10.13175/swjpcc015-14 PDF

Medical Image of the Week: Massive Spontaneous Intra-Abdominal Bleeding

Figure 1. CT scan of the abdomen and pelvis showing diffuse intra-abdominal bleeding.

A 67 year-old female with RA, on anti-TNF and steroids, was admitted to the ICU with severe shock, likely hemorrhagic. She was on Coumadin for atrial fibrillation. She was found to have severe coagulopathy and diffuse spontaneous abdominal bleeding (Figure 1). She also developed left popliteal artery thrombosis, with compartment syndrome requiring surgical intervention. DIC was the final diagnosis.

Mohammed Alzoubaidi MD, Carmen Luraschi-Monjagatta MD, Sridhar Reddy MD, Robert McAtee MD.

Departments of Pulmonary and Critical Care, Internal Medicine and Emergency Medicine

South Campus

Tucson, Arizona

Reference as: Alzoubaidi M, Luraschi-Monjagatta C, Reddy S, McAtee R. Medical image of the week: massive spontaneous intra-abdominal bleeding. Southwest J Pulm Crit Care. 2014;8(2):135. doi: http://dx.doi.org/10.13175/swjpcc018-14 PDF 

Medical Image of the Week: Pancreatic Abscess

Figure 1. CT scan of the abdomen showing fluid collections (arrows).

Figure 2. Ultrasound of the abdomen showing a distended pancreatic duct, which communicates to an inferior fluid collection, likely a pseudo-cyst.

Figure 3. Coronal CT of the abdomen and pelvis showing pelvic abscess (arrow). 

A 55 year old woman, with a history of alcohol abuse and necrotizing pancreatitis, was readmitted for worsening abdominal pain and acute respiratory failure. A CT scan of the abdomen and pelvis showed an atrophic pancreas and multiple fluid collections. Along the inferior surface of the pancreas, there is a fluid collection with an evolving loculated rim, which is asymmetric, the larger component measure 2.9 cm x 4.7 cm (Figure 1, large arrow). Anterior to the body of the pancreas, there is an additional 2.2 cm x 2.4 cm with evolving loculated rim (Figure 1, short arrow), both compatible with a pseudocyst.  Ultrasound of the abdomen showed a distended pancreatic duct that communicates to the smaller fluid collection (Figure 2).  Coronal CT of the abdomen and pelvis showed a 12.4 cm pelvic abscess (Figure 3). CT guided drainage of the pelvic abscess was performed with positive culture of the fluid for E. coli. She developed secondary peritonitis and had a successful exploratory laparotomy.

Carmen Luraschi-Monjagatta MD, Mohammed Alzoubaidi MD, and Elizabeth Ulliman MD

Department of Pulmonary, Allergy, Sleep and Critical Care.

Internal Medicine, South Campus.

University of Arizona

Tucson, Arizona

Reference as: Lurachi-Monjagatta C, Alzoubaidi M, Ullman E. Medical image of the week: pancreatic abscess. Southwest J Pulm Crit Care. 2014;8(2):126-7. doi: http://dx.doi.org/10.13175/swjpcc017-14 PDF

Medical Image of the Week: Increased Liver Attenuation

Figure 1. Coronal (A) and axial (B) CT scan without contrast demonstrating diffuse increase in hepatic density.

An 86-year old man had a non-contrast thoracic CT for evaluation of a chest x-ray abnormality. Incidentally, the CT scan showed diffuse increase in liver density with Hounsfield units of 105. The normal unenhanced attenuation value is between 55-65 Hounsfield units in a normal liver on CT scan without contrast (1).   Hepatic attenuation is reflected in Hounsfield values and depends on combinations of factors including the presence or absence (as well as phase) of IV contrast administration.

The patient had no known underlying liver disease and liver function studies were within normal limits.  Figure 1 shows coronal and axial views of the CT scan of the patient.

There are several intrinsic liver pathologies leading to diffuse changes in liver attenuation including (2):

• Deposits of certain metals seen in hemochromatosis, hemosiderosis, and Wilson’s disease.
• Glycogen storage disease(es)
• Medications/drugs including amiodarone and gold therapy (3-7).
• Previous Thorotrast administration – Thorotrast is a contrast agent used between 1930-1950 and was found to be carcinogenic and can cause hepatic angiosarcoma, cholangiocarcinoma, and hepatocellular carcinoma. It is retained in the reticulo-endothelial system for long periods of time (8).

After reviewing the patient’s case he had been on chronic amiodarone therapy and had not had exposures or clinical history related to any of the other above causes of increased hepatic density. Based on imaging and history it is suspected that patient’s diffuse increase in liver density is secondary to iodine infiltration from chronic amiodarone usage.

Allen Thomas MD, Sandra Till DO, and Jeremy Patterson RT

Phoenix VA Medical Center

References

1. Boll DT, Merkle EM. Diffuse liver disease: strategies for hepatic CT and MR imaging. Radiographics. 2009;29:1591-614. [CrossRef] [PubMed]
2. Weerakkody Y. Hepatic attenuation on CT. Radiopaedia. Available at: http://radiopaedia.org/articles/hepatic-attenuation-on-ct (accessed 2/6/14).
3. Markos J, Veronese ME, Nicholson MR, McLean S, Shevland JE. Value of hepatic computerized tomographic scanning during amiodarone therapy. Am J Cardiol. 1985;56(1):89-92. [CrossRef] [PubMed]
4. Nicholson AA, Caplin JL, Steventon DM. Measurement of tissue-bound amiodarone and its metabolites by computed tomography. Clin Radiol. 1994;49(1):14-8. [CrossRef] [PubMed]
5. De Maria M, De Simone G, Laconi A, Mercadante G, Pavone P, Rossi P. Gold storage in the liver; appearance on CT scans. Radiology. 1986;159(2):355-6. [PubMed] 
6. Goldman IS, Winkler ML, Raper SE, Barker ME, Keung E, Goldberg HI, Boyer TD. Increased hepatic density and phospolipidosis due to amiodarone. AJR Am J Roentgenol. 1985;144(3):541-6. [CrossRef] [PubMed] 
7. Kojima S, Kojima S, Ueno H, Takeya M, Ogawa H. Increased density of the liver and amiodarone-associated phospholipidosis. Cardiol Res Pract. 2009;2009:598940. [CrossRef] [PubMed]
8. Weber E, Laarbaui F, Michel L, Donckier J. Abdominal pain: do not forget Thorotrast! Postgrad Med J. 1995;71(836):367-8. [CrossRef] [PubMed] 

Reference as: Thomas AR, Till S, Patterson J. Medical image of the week: increased liver attenuation. Southwest J Pulm Crit Care. 2014;8(2):105-7. doi: http://dx.doi.org/10.13175/swjpcc011-14 PDF

Medical Image of the Week: Neurogenic Pulmonary Edema

Figure 1. CT scan showing intraparenchymal hemorrhage in the left frontal lobe, scattered subdural, subarachnoid and intraventricular hemorrhage with 1.1 cm of left to right midline shift.

Figure 2. Chest X-ray showing central vascular congestion with bilateral pulmonary edema throughout the lung fields

A 79 year old woman with a history of diabetes, hypertension and subarachnoid hemorrhage presented to the emergency department (ED) with altered mental status. The patient had a fall one day prior to admission, and hit her head on the ground. There was no loss of consciousness or seizure activity at that moment, however, she was found unresponsive in the bathroom the next day with brownish vomitus in the mouth and on her face. CT of the head without contrast showed a large intraparenchymal hemorrhage on the left frontal lobe with subdural hemorrhage on the right frontal and temporal lobe. Also, intraventricular blood with 1.1 cm left to right midline shift was observed (Figure 1). Although she had no history of left heart failure or pulmonary disease, physical exam showed coarse lung sound and chest X-ray showed acute change with prominence central vasculature with fluffy central airspace opacities, which were consistent with neurogenic pulmonary edema secondary to intracranial hemorrhage (Figure 2). An external ventricular drain was placed by neurosurgery and patient was intubated for airway protection, however she passed away the next day after her family decided comfort care.

The most common cause of neurogenic pulmonary edema is central nervous system injury including cerebral hemorrhage, head trauma and epileptic seizure (1). It usually develops several hours after an insult, although cases of immediate or delayed onset have been reported. The most common symptoms and signs include dyspnea, hemoptysis, tachypnea, tachycardia, which are not secondary to heart or lung parenchymal disease. Aspiration pneumonia is common presentation of patients with altered mental status, and it is hard to differentiate neurogenic pulmonary edema from aspiration pneumonia, however neurogenic pulmonary edema tends to develop and resolve more rapidly with no signs of infection such as fever and focal infiltration (2). The prognosis of neurogenic pulmonary edema mainly depends on the neurologic pathology rather than pulmonary edema itself, and the mainstream of treatment is supportive care, although medications including β-agonists, dobutamine or chlorpromazine can be tried.

Seongseok Yun, MD PhD; Tuan Phan, MD; Natasha Sharda, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

References

1. Neurogenic pulmonary oedema. Lancet. 1985;1(8443):1430-1. [PubMed]
2. Colice GL, Matthay MA, Bass E, Matthay RA. Neurogenic pulmonary edema. Am Rev Respir Dis. 1984;130(5):941-8. [PubMed] 

Reference as: Yun S, Phan T, Sharda N. Medical image of the week: neurogenic pulmonary edema. Southwest J Pulm Crit Care. 2014;8(1): . doi: http://dx.doi.org/10.13175/swjpcc004-14 PDF

February 2014 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 a history of weight loss and dysphagia for about 2 weeks duration. There was a possible history of asthma accompanied by ongoing shortness of breath first noticed nearly 2 years ago. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Choose the correct answer to move to the next panel)

1. The chest radiograph shows a mass
2. The chest radiograph shows hilar and mediastinal lymph node enlargement
3. The chest radiograph shows multifocal consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities suggesting fibrosis
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. February 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(2):88-95. doi: http://dx.doi.org/10.13175/swjpcc010-14 PDF

Medical Image of the Week: Unilateral Diaphragm Paralysis

Figure 1. CT scans showing unilateral diaphragm paralysis and atelectasis of right lower lobe (arrow).

An 85 year old woman with a history of COPD presented to the emergency department (ED) with shortness of breath and cyanosis of her fingers. Her symptoms have been waxing and waning since she recovered from pneumonia a year ago. A week prior to admission, she visited an outpatient clinic for worsening cough, which was treated with levofloxacin, however her shortness of breath and cyanosis persisted. O₂ saturation with 4 L oxygen was 85% and CT chest without contrast showed unilateral diaphragmatic paralysis with basilar atelectasis (Figure 1). She has no history of cardiac surgery, poliomyelitis or cervical spondylosis. Also, no cervical or lung mass was found on CT scan. Her diaphragmatic paralysis is most likely secondary to phrenic nerve injury.

Unilateral diaphragmatic paralysis is usually asymptomatic and does not require treatment in most of cases. However, patients with underlying lung disease can present with shortness of breath and cyanosis because of increased ventilatory demands on physical activity or superimposed pulmonary disease. Occasionally, patients with unilateral diaphragmatic paralysis can develop acute respiratory failure due to exacerbation of obstructive lung disease or respiratory infection, and require ventilatory support (1). Early and careful management of underlying lung disease is pivotal in these patients to prevent respiratory decompensation.

Seongseok Yun, MD PhD; Kahroba Jahan, MD; Natali Hua, DPM; Ibrahim Taweel, MD; Ismail Tabash, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

Reference

Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med. 2009;30(3):315-20.  [CrossRef] [PubMed] 

Reference as: Yun S, Jahan K, Hua N, Taweel I, Tabash I. Medical image of the week: unilateral diaphragm paralysis. Southwest J Pulm Crit Care. 2014;8(1):68-9. doi: http://dx.doi.org/10.13175/swjpcc178-13 PDF

Medical Image of the Week: Finger in Glove

Figure 1. PA (Panel A) and lateral (Panel B) chest x-ray showing finger in glove (arrow) in the right upper lung with other scattered areas of consolidation.

Figure 2. Repeat chest x-ray about a month later showing generalized clearing.

A 45-year old man with a history of asthma presented with increasing shortness of breath, and cough productive of dark firm plugs, sometimes branching. His chest x-ray (Figure 1) shows finger in glove (arrow) in the right upper lung with other scattered areas of consolidation. His serum IgE was elevated at 750 IU/ml (normal < 380 IU/ml).  His eosinophil count was 12%.   Aspergillus IgE was 6.69 (normal< 0.35). A diagnosis of probable allergic bronchopulmonary aspergillosis (ABPA) was made. He was given oral corticosteroids. Follow up about a month later showed dramatic clinical improvement and a repeat chest x-ray (Figure 2) showed generalized clearing.

The initial chest x-ray shows a “finger in glove” pattern in the right upper lobe (Figure 1, arrow), which is due to mucoid impaction within the larger bronchi (1). The same appearance has also been referred to as the rabbit ear appearance, Mickey Mouse appearance, toothpaste-shaped opacities, Y-shaped opacities, V-shaped opacities and the Churchill sign because it resembles the “V” gesture often associated with Winston Churchill.

ABPA is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, manifesting with poorly controlled asthma, recurrent pulmonary infiltrates and central bronchiectasis (2). Primary therapy consists of oral corticosteroids to control exacerbations, itraconazole as a steroid-sparing agent and optimized asthma therapy. Uncertainties surround the prevention and management of bronchiectasis, chronic pulmonary aspergillosis and aspergilloma as complications, concurrent rhinosinusitis, environmental control and long-term management.

Gerald F. Schwartzberg, MD

Phoenix, AZ

References

1. Weerakkody Y, Jones J. Finger in glove sign. Available at: http://radiopaedia.org/articles/finger-in-glove-sign (accessed 11/22/13).
2. Agarwal R, Chakrabarti A, Shah A, Gupta D, Meis JF, Guleria R, Moss R, Denning DW; ABPA complicating asthma ISHAM working group. Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy. 2013;43(8):850-73. [CrossRef] [PubMed]

Reference as: Schwartzberg GF. Medical image of the week: finger in glove. Southwest J Pulm Crit Care. 2014:8(1):64-5. doi: http://dx.doi.org/10.13175/swjpcc169-13 PDF

Medical Image of the Week: Oligemic Lung Field

A Sinister Sign of Acute Pulmonary Embolism? 

Figure 1. Panel A: The chest x-ray showed decreased vascular markings in the right lung field (oligemic right lung field) and reduced prominence of right pulmonary artery.  There is also a small opacity in right lower lung field possibly a pulmonary infarct. Panel B: A Coronal section of the computed tomographic pulmonary angiography showing a large thrombus in the right pulmonary artery (white arrow). Panel C: A 12-lead EKG shows sinus tachycardia, right bundle branch block, deep S wave in lead I (black arrow), deep q wave (orange arrow) and inverted T-wave (green arrow) in lead III. Panel D: A computed tomographic pulmonary angiography showing an enlarged right ventricle (blue arrow) compressing the left ventricle (red arrow).

A 67 year-old woman presented with pleuritic, non-radiating chest pain of sudden onset. She was anxious, diaphoretic, and tachycardic.

The chest radiograph (Figure 1A) showed decreased vascular markings in the entire right lung field (oligemic right lung field) and reduced prominence of the right pulmonary artery.  A small opacity in right lower lung field was suspicious for a pulmonary infarct. A follow-up computed tomographic pulmonary angiography (CTA) showed a large embolus in right pulmonary artery and a smaller embolus in the subsegmental left pulmonary artery (Figure 1B). Twelve-lead electrocardiogram (EKG) findings were notable for a new onset right bundle branch pattern, deep S wave in lead I, with a q-wave and inverted T-wave in Lead III (Figure 1C). A 2-Dimentional echocardiogram showed a massively dilated and hypokinetic right ventricle. The CTA also revealed that the massively distended right ventricle with a deviated interventricular septum was compressing the left ventricle (Figure 1D). Venous duplex study of lower extremities showed an acute thrombosis of the right popliteal vein. 

The patient showed marked clinical improvement after the infusion of tissue plasminogen activator (tPA) and heparin. A chest x-ray obtained 2 days later showed resolution of right sided oligemia. On Day 6, the right bundle branch block had resolved.

Radiographic findings in acute pulmonary embolism (PE) are uncommon. The Westermark sign (oligemia), Hampton hump and prominent central pulmonary artery are infrequently seen in acute PE. Westermark sign of an entire side lung field is rare, sinister sign of a large burden pulmonary embolism.  If identified early, this sign can be invaluable in early recognition and management.

Suman B. Thapamagar MBBS, Ramya Mallareddy MD, Ilya Lantsberg MD

Easton Hospital, Drexel University, Department of Internal Medicine, 250 S. 21st Street, Easton, PA 18042

Reference

1. Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363(3):266-74. [CrossRef] [PubMed]

Reference as: Thapamagar SB, Mallareddy R, Lantsberg I. Medical image of the week: oligemic lung field. Southwest J Pulm Crit Care. 2014:8(1):48-9. doi: http://dx.doi.org/10.13175/swjpcc163-13 PDF

Medical Image of the Week: Pneumomediastinum

Figure 1.  Chest x-ray (CXR) shows subtle evidence of pneumomediastinum with air outlining left cardiac border and trachea (arrows).

 

Figure 2. Chest computerized tomography (CT) showing pneumomediastinum (Panel A) extending into lower neck (Panel B) without evidence of pneumothorax.

A 65 year old man presented with mild increase in shortness of breath. He had a past medical history of diabetes mellitus, hypertension, and severe malnutrition with percutaneous endoscopic gastrostomy (PEG) placement after a colectomy and end ileostomy for sigmoid volvulus. CXR (Figure 1) suggested a pneumomediastinum with subsequent chest CT (Figure 2) confirming moderate sized pneumomediastinum. He had a chronic cough from chronic obstructive pulmonary disease (COPD) as well as aspiration and chest CT also demonstrated emphysema with small blebs. He denied any significant chest pain. He was followed conservatively with imaging and discharged in stable condition.

Pneumomediastinum can be caused by trauma, esophageal rupture after vomiting (Boerhaave’s syndrome) and can be a spontaneous event if no obvious precipitating cause is identified (1). Valsalva maneuvers such as cough, sneeze, vomiting and childbirth, can all cause pneumomediastinum. Risk factors include asthma, COPD, interstitial lung disease and inhalational recreational drug use. Hamman's sign (a crunching sound in time with the heartbeat) can occasionally be heard.  More commonly, subcutaneous emphysema is felt on exam (crepitus). Complications can include single or bilateral pneumothorax, tension pneumothorax and pleural effusion. CXR often does not identify mediastinal air and CT imaging is highly sensitive and confirmatory. Conservative management is recommended with close clinical follow up for possible complications.

Rene Franco, Jr MD, Mohammad Dalabih MD, Janet Campion MD

University of Arizona Medical Center, Tucson AZ

Reference

1. Newcomb AE, Clarke CP. Spontaneous Pneumomediastinum. Chest. 2005;128:3298-3302. [CrossRef] [PubMed] 

Reference as: Franco R Jr, Dalabih M, Campion J. Medical image of the week: pneumomediastinum. Southwest J Pulm Crit Care. 2014:8(1):46-7. doi: http://dx.doi.org/10.13175/swjpcc160-13 PDF

January 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 77-year-old man presented for an executive health physical. His past medical history was significant for coronary artery disease, renal stones, gout, and a left nephrectomy for clear cell renal carcinoma 17 years earlier. Chest radiography (Figure 1) was performed. Prior chest radiographs from the previous year (Figure 2) and 7 years earlier (Figure 3) are shown for comparison.

 

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

 

 Figure 2. Frontal (A) and lateral (B) chest radiography performed one year prior to presentation. 

Figure 3. Frontal chest radiography performed 7 years prior to presentation.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to move to next panel)

1. The chest radiograph shows a mass
2. The chest radiograph shows an unusual cardiac configuration
3. The chest radiograph shows basal predominant linear opacities suggesting fibrosis
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. January 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(1):27-40. doi: http://dx.doi.org/10.13175/swjpcc002-14 PDF

Medical Image of the Week: Central Pontine Myelinolysis

Figure 1. MRI axial T2 Image showing central pontine lesion consistent with osmotic demyelination. 

Figure 2. MRI axial (Panel A) and sagittal (Panel B) flair Images showing a hyperintensity located centrally within the pons with some sparing of the periphery measuring 1.6 by 1.3 cm.

A 38-year-old woman with history of alcohol abuse was admitted with generalized weakness, dehydration, alcoholic hepatitis, hyponatremia (serum sodium 116 mM/L), and cachexia (BMI 19 kg/m2).  She developed hypoxemic respiratory failure after intravenous fluid resuscitation and required intubation and mechanical ventilation.  Neurological exam revealed motor weakness, hyporeflexia, ataxia, and unsustained clonus.  Neurology consultation was obtained and MRI revealed hyperintensity in the pons consistent with osmotic demyelination syndrome (1).  Review of her records revealed her sodium level increased by 8 mM/L in first 6 hours of presentation, and then a slow increase of 4-6 mM/L daily to the normal range. She received nutritional support and aggressive physical therapy, and was discharged to skilled nursing facility after six weeks of hospitalization.

Tauseef Afaq Siddiqi, MD; Yeeck Sim, MD; Thi Nguyen, MD; Afshin Sam, MD

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

Department of Medicine

University of Arizona

Tucson, AZ

Reference

Kumar S, Fowler M, Gonzalez-Toledo E, Jaffe SL. Central pontine myelinolysis, an update. Neurol Res. 2006;28(3):360-6. [CrossRef] [PubMed] 

Reference as: Siddiqi TA, Sim Y, Nguyen T, Sam A. Medical image of the week: central pontine myelinolysis. Southwest J Pulm Crit Care. 2013;8(1):18-9. doi: http://dx.doi.org/10.13175/swjpcc159-13 PDF

Medical Image of the Week: Azygous Lobe

Figure 1. Chest X-Ray (A) and thoracic CT scan (B) shows the azygos fissure and the ‘tadpole’ appearance (arrow).  Chest CT (C) shows the lateral course of the azygos vein (arrow) and the accessory lobe.

A 59 year old man underwent chest radiography for evaluation of fever and cough. Imaging showed an accessory azygous lobe.  An azygos lobe is found in 1% of anatomic specimens and forms when the right posterior cardinal vein, one of the precursors of the azygos vein, fails to migrate over the apex of the lung (1). Instead, the vein penetrates the lung carrying along pleural layers that entrap a portion of the right upper lobe. The vein appears to run within the lung, but is actually surrounded by both parietal and visceral pleura. The azygos fissure therefore consists of four layers of pleura, two parietal layers and two visceral layers, which wrap around the vein giving the appearance of a tadpole. Apart from an interesting incidental radiological finding, it is of limited clinical importance except that its presence should be recognized during thoracoscopic procedures. This patient was found to have a cavitary lung lesion which was the cause of his symptoms.

Bhupinder Natt MD, Abdulmagid Eddib MD, Dena H’Leureux MD

Department of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona and the Southern Arizona VA Health Care System

Tucson, AZ 

Reference

Mata J, Cáceres J, Alegret X, Coscojuela P, De Marcos JA. Imaging of the azygos lobe: normal anatomy and variations. AJR Am J Roentgenol. 1991;156(5):931-7. [CrossRef] [PubMed]

Reference as: Natt B, Eddib A, H'Leureux D. Medical image of the week: azygous lobe. Southwest J Pulm Crit Care. 2013;7(6):353-4. doi: http://dx.doi.org/10.13175/swjpcc158-13 PDF

Medical Image of the Week: Hemophagocytic Lymphohistiocytosis (HLH)

Figure 1. Axial (Panel A) and coronal (Panel B) PET-CT Scan Images showing numerous metabolically active pulmonary nodules and mediastinal lymph nodes.

Figure 2. Axial (Panel A) and Sagittal (Panel B) images of the chest CT showing consolidative pulmonary nodules with surrounding ground glass halo and mediastinal lymphadenopathy.

Figure 3. Bone Marrow Biopsy (x1000). Panel A: macrophage engulfing a neutrophil. Panel B: macrophage engulfing erythrocyte debris.

Figure 4. Panel A: Lower power view of the lung biopsy (H&E stain) showing the interface between the neoplastic lymphocytic infiltrate and benign, normal lung. Panel B: high power view showing the neoplastic B-cell lymphoma with sheets of large lymphocytes.

A 41-year-old African American woman with a history of diffuse large B cell lymphoma in remission was admitted to the hospital with severe dyspnea and abdominal pain. Recent imaging revealed extensive pulmonary and liver nodules with significant mediastinal lymphadenopathy (Figures 1 and 2).  She had an extensive outpatient evaluation of these abnormalities including multiple percutaneous and endoscopic biopsies which were nondiagnostic.  She deteriorated clinically and a ferritin level was elevated at 36,284 ng/mL.  Due to the markedly elevated ferritin, a bone marrow biopsy was performed and was normocellular with trilineage hematopoiesis and erythrophagocytosis consistent with hemophagocytic lymphohistiocytosis (HLH, Figure 3).  A VATS guided lung biopsy was performed revealing recurrence of the diffuse large B cell lymphoma (Figure 4).  She started chemotherapy with the E-SHAP (etoposide, methylprednisolone, cytarabine, cisplatin), however, became severely pancytopenic and developed acute respiratory failure, shock and multi-organ failure.  She died despite aggressive care in the intensive care unit.  Patients with HLH often present with sepsis like symptoms and multiorgan failure.  Measurement of serum ferritin level is a critical test in suggesting the diagnosis once infection is excluded.  Early recognition and prompt treatment is essential to preventing fatal outcomes.

Tauseef Afaq Siddiqi, MD¹; Carlos Tafich Rios, MD²; Carlos L Cantu, MD³; James Knepler, MD¹; Linda Snyder, MD¹

¹ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine,

² Department of Medicine,

³ Department of Pathology, The University of Arizona, Tucson, AZ 85724, USA.

References

1. Raschke RA, Garcia-Orr R. Hemophagocytic lymphohistiocytosis: a potentially underrecognized association with systemic inflammatory response syndrome, severe sepsis, and septic shock in adults. Chest. 2011;140(4):933-8. [CrossRef] [PubMed] 
2. Okabe T, Shah G, Mendoza V, Hirani A, Baram M, Marik P. What intensivists need to know about hemophagocytic syndrome: an underrecognized cause of death in adult intensive care units. J Intensive Care Med. 2012;27(1):58-64. [CrossRef] [PubMed]

Reference as: 

Siddiqi TA, Rios CT, Cantu CL, Knepler J, Snyder L. Medical image of the week: hemophagoctyic lymphohistiocytosis (HLH). Southwest J Pulm Crit Care. 2013;7(6):351-2. doi: http://dx.doi.org/10.13175/swjpcc157-13 PDF

Medical Image of the Week: Infective Endocarditis in an IV Drug User

Figure 1. Transthoracic echocardiogram showing a large, irregular, mobile mass attached to the mitral valve annulus (arrows).

A 30 year old man presented with a one week history of fever, chills, body aches, and fatigue, as well as lower extremity and right wrist edema and pain. The patient also had a history of intravenous (IV) drug use. On exam, a previously undocumented 3/6 blowing crescendo murmur was heard at the fifth intercostal space in the midclavicular line. Transthoracic echocardiogram demonstrated a large, irregular, mobile mass, measuring 2.0 x 2.5 cm, attached to the posterior mitral annulus (Figure 1). Cardiothoracic surgery performed a primary repair of the mitral valve.

Abigail S. Hawke, MD

Department of Internal Medicine

University of Arizona

Tucson, Arizona

Arthia Satyanarayan, MS III

University of Arizona College of Medicine

Tucson, Arizona

Reference as: Hawke AS, Satyanarayan A. Medical image of the week: infective endocarditis in an IV drug user. Southwest J Pulm Crit Care. 2013;7(6):348. doi: http://dx.doi.org/10.13175/swjpcc156-13 PDF

December 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 30-year-old man complained of intermittent shortness of breath and recurrent respiratory tract infections. Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiograph.

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

1. The chest radiograph mediastinal lymphadenopathy
2. The chest radiograph shows basal predominant linear opacities suggesting fibrosis
3. The chest radiograph shows large lung volumes with faint, thin-walled cystic lesions bilaterally
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. December 2013 imaging case of the month. Southwest J Pulm Crit Care. 2013;7(6):339-47. doi: http://dx.doi.org/10.13175/swjpcc172-13 PDF

Medical Image of the Week: Maggots

Figure 1. Chronic ulcerated wound with clean base due to the debridement caused by the maggots.

An 80-year old man presented with pruritic exacerbation of his chronic wound. He had venous stasis ulcers chronically to the lower extremities bilaterally, requiring bandages. He presented with pruritis, but no fevers or pain. The bandage was removed which revealed the maggots (Figure 1).

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: maggots. Southwest J Pulm Crit Care. 2013;7(6):338. doi: http://dx.doi.org/10.13175/swjpcc154-13 PDF