Medical Image of the Week: Idiopathic Pulmonary Hemosiderosis

Figure 1. Representative axial high-resolution CT (HRCT) scan sections demonstrating increased attenuation of the lungs due to diffuse groundglass opacification with subpleural and scattered clustered cysts most evident in the upper lung zones.

The patient is a 40 year-old man who was diagnosed with Idiopathic Pulmonary Hemosiderosis (IPH) at the age of three. He has recurrent episodes of hemoptysis several times a year that are controlled with increased doses of prednisone. He is chronically on 10 mg daily which usually control his symptoms. A HRCT scan of the chest shows predominantly upper lung cystic changes both subpleural and clustered with a honeycomb appearance superimposed on a background of diffuse ground glass opacification.

Typical HRCT findings include patchy scattered areas of ground glass opacity and consolidation that usually involve the perihilar and lower aspects of the lungs. However, case reports of rare findings of multiple honeycomb cystic changes have been reported that are thought to be a result of progressive fibrotic changes from hemosiderin deposition in the interstitium (1). These honeycomb cysts may represent sites of more severe and recurrent alveolar hemorrhage in adults with IPH and are probably related to a traction phenomenon secondary to interstitial fibrosis following recurrent episodes of alveolar hemorrhage.

Nathaniel Reyes MD^*, Linda Snyder MD^*, Veronica Arteaga MD⁺
Department of Medicine, Division of Pulmonary and Critical Care Medicine*
Department of Radiology⁺

University of Arizona, Tucson, Arizona

Reference

1. Harte S, McNicholas WT, Donnelly SC, Dodd JD. Honeycomb cysts in idiopathic pulmonary haemosiderosis: high-resolution CT appearances in two adults. Br J Radiol. 2008;81(972):e295-8. [CrossRef] [PubMed] 

Reference as: Reyes N, Snyder L, Arteaga V. Medical image of teh week: idiopathic pulmonary hemosiderosis. Southwest J Pulm Crit Care. 2014;9(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc092-14 PDF

Medical Image of the Week: May-Thurner Syndrome

Figure 1. Figure A: Venogram showing extensive thrombosis of the left common iliac vein. Thrombus appearing as filling defects (arrows). Patient is in prone position. Figure B: Venogram after catheter-directed pharmaco-mechanical thrombectomy and stent placement (2). Inferior vena cava filter in place (1). Patient is in prone position. Figure C: Venogram after catheter-directed pharmaco-mechanical thrombectomy and stent (arrow) placement showing improved venous flow. Patient is in prone position.

A 20-year-old Caucasian female presented with 7-day history of pain and swelling of the left lower extremity. She had no significant past medical history. Her only medication at the time of presentation was oral contraceptive pills. She denied smoking cigarettes. She denied shortness of breath, recent travel, surgery or miscarriage. She did not have any family history of clotting problems. She was hemodynamically stable. Physical examination was significant for swelling of the left lower extremity up to mid-thigh level. Duplex ultrasonography of the extremity showed extensive thrombosis of the left ilio-femoral, common femoral and popliteal veins. A retrievable inferior vena cava filter was placed. Subsequently, she underwent catheter directed thrombolysis and percutaneous mechanical thrombectomy.  Venogram, after the procedure showed resolution of most of the clot burden. It also revealed a band-like stenosis at the location where the right iliac artery is expected to cross the left iliac vein, consistent with May-Thurner syndrome. Endovascular stenting was done. Following the placement of stent venous flow improved significantly. The inferior vena cava filter was removed about a week later. She completed 6 months of anticoagulation with warfarin. Screening for hypercoagulable state, including protein C and S level, antithrombin III level, homocysteine level, anti-phospholipid antibody, factor V Leiden mutation and prothrombin gene mutation was negative.

May-Thurner syndrome is an anatomical variation of the left common iliac vein that increases the risk of deep venous thrombosis of the left lower extremity. It is caused by the compression of the left iliac vein by the right iliac artery against the fifth lumbar vertebra, where it crosses over the vein. Chronic pulsation of the artery against the vein causes vascular thickening. Patients are usually females and commonly present in their second to fourth decades of life. The estimated prevalence is about 22% in the general population. So, it should be suspected when younger females present with extensive, proximal deep venous thrombosis of the left lower extremity. Patients are at increased risk of recurrent thrombosis which can be prevented by correction of the anatomical lesion.

Sathish Krishnan MD, Malav Parikh MD, Dima Dandachi MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

1. Kalu S, Shah P, Natarajan A, Nwankwo N, Mustafa U, Hussain N.. May-Thurner Syndrome: A Case Report and Review of the Literature. Case Rep Vasc Med. 2013; 2013:740182. [CrossRef] [PubMed]
2. Peters M, Syed RK, Katz M, Moscona J, Press C, Nijjar V, Bisharat M, Baldwin D. May-Thurner syndrome: a not so uncommon cause of a common condition. Proc (Bayl Univ Med Cent) ; 25(3):231-3. [PubMed]

Reference as: Krishnan S, Parikh M, Dandachi D. Medical image of the week: May-Thurner syndrome. Southwest J Pulm Crit Care. 2014;9(1):25-26. doi: http://dx.doi.org/10.13175/swjpcc066-14 PDF

July 2014 Imaging Case of the Month

Michael B. Gotway, MD

Prasad M. Panse, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 71-year-old Caucasian man presented for venous thromboembolism prophylaxis for a scheduled total right knee arthroplasty. His prior medical history was remarkable for anemia requiring transfusion of 4 units of blood 3 years prior to presentation, hypertension, prostatic hypertrophy, seasonal allergies, and glucose intolerance.

Frontal and lateral chest radiography (Figure 1) was performed.

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

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

1. The chest radiograph shows a circumscribed left lung mass
2. The chest radiograph shows a mediastinal mass
3. The chest radiograph shows bilateral symmetric linear and reticular opacities
4. The chest radiograph shows multifocal, bilateral consolidation
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB, Panse PM. July 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(1):15-24. doi: http://dx.doi.org/10.13175/swjpcc089-14 PDF

Medical Image Of The Week: Metastatic Testicular Cancer

Figure 1.  Axial image of the abdomen demonstrating multiple hypodense hepatic lesions (orange oval) and a large left adrenal mass (green arrow).

Figure 2. Axial image of the abdomen with innumerable hepatic metastatic lesions and a mass arising from the left adrenal gland resulting in compression of the left kidney (red arrow) and lateral displacement of the spleen (blue arrow).

A 30 year-old man with metastatic embryonal testicular cancer was admitted to the hospital with severe abdominal pain. A contrast enhanced CT of the abdomen demonstrated large metastatic burden throughout the liver and the left adrenal gland (Figures 1 and 2). The mass arising from the left adrenal gland caused significant mass effect. The left kidney was compressed, though without hydronephrosis, and the spleen was displaced laterally. Renal and hepatic functions were preserved. His pain was controlled with opioids and oral steroids with significant improvement.

Michael Debo DO1, Linda Snyder MD2, S. Michelle Rhodes MD3.

1Department of Internal Medicine, Genesys Regional Medical Center; Grand Blanc, MI

2Departments of Medicine, Pulmonary and Critical Care and Palliative Medicine, University of Arizona Medical Center; Tucson, AZ

3Departments of Emergency Medicine, Geriatrics, Palliative and General Medicine, University of Arizona Medical Center; Tucson, AZ

Reference as: Debo M, Snyder L, Rhodes SM. Medical image of the week: metastatic testicular cancer. Southwest J Pulm Crit Care. 2014;8(6):354-5. doi: http://dx.doi.org/10.13175/swjpcc063-14 PDF

Medical Image of the Week: REM Sleep Behavior Disorder in Parkinson Disease

Figure 1. 120 second polysomnogram window showing phasic REM sleep without atonia. Arm and leg movements were seen (black up arrows) and patient was heard moaning and speaking out (black down arrows).

A 55 year old female with a past medical history significant for Parkinson disease status-post implantation of bilateral deep brain stimulators, depression, and restless legs syndrome, who initially presented to the sleep clinic on referral by neurology for evaluation of disordered sleep. Medications included carbidopa-levodopa, escitalopram, gabapentin, lorazepam, ambien, and pramipexole. Her subjective sleep complaints included snoring, restless sleep, difficulty in maintaining sleep, sleep related anxiety, dream enactment behavior, nightmares, and sleep talking. She was sent to the sleep laboratory for evaluation of suspected rapid eye movement behavior disorder (RBD). Overnight polysomnogram did not show evidence for sleep disordered breathing. The sleep study was notable for rapid eye movement (REM) sleep without atonia, visible arm and leg movements, and audible moaning, speaking, and crying out. These findings corroborated the subjective complaints expressed by the patient and her husband. Her medication regimen was altered. Zolpidem and lorazepam were discontinued and she was started on clonazepam. On follow up three months later she reported significant improvement in symptoms and quality of life. She reported near resolution of dream enactment behavior and reduction in restlessness as reported by her husband.

RBD is a sleep disorder characterized by vigorous motor activity that occurs during REM sleep. There is an abnormal loss of normal muscle atonia that usually occurs during REM sleep. REM behavior disorder is commonly seen in individuals with synucelopathies such as Parkinson disease. Lesions within pontomedullary structures are suggested to be the cause of dysfunction of motor control during sleep. REM sleep behavior disorder may actually precede symptoms of parkinsonism by decades, portending the development of overt Parkinson disease in the future (1).

Ryan Nahapetian, MD, MPH and Kenneth S. Knox, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona, Tucson, AZ

Reference

1. Boeve BF. Idiopathic REM sleep behaviour disorder in the development of Parkinson's disease. Lancet Neurol. 2013 May;12(5):469-82. [CrossRef]  [PubMed]

Reference as: Nahapetian RR, Knox KS. Medical image of the week: REM sleep behavior disorder in Parkinson disease. Southwest J Pulm Crit Care. 2014;8(6):347-8. doi: http://dx.doi.org/10.13175/swjpcc062-14 PDF

Medical Image of the Week: Malignant Pericardial Effusion and Cardiac Tamponade

Figure 1. EKG showing sinus tachycardia, low QRS voltage and electric alternans, suggesting pericardial effusion.

Figure 2. Chest X-ray pre- and post-pericardiocentesis. Panel A: Cardiomegaly with water bottle shape shown before procedure. Panel B: resolution after drainage of 1.8 L of pericardial fluid.

Figure 3. Echocardiogram showing massive pericardial effusion (dashed line), floating heart, and collapsed right atrium and ventricle that are consistent with cardiac tamponade.

Figure 4. Intra-pericardial space pressure tracing with maximum pressure measured at 25 mmHg.

A 53 year old woman with history of metastatic breast cancer presented to the emergency department (ED) with worsening shortness of breath for 2 weeks. She was initially diagnosed with grade III breast intraductal carcinoma was estrogen receptor, progesterone receptor, and HER2 negative 5 years earlier. A lumpectomy was performed followed by 4 cycles of chemotherapy with cyclophosphamide and taxol as well as radiation therapy. However, follow-up CT and MRI and subsequent biopsy demonstrated metastatic disease in the left adrenal gland, right ovary, and mediastinal lymph nodes, for which additional chemotherapy was started a month prior to presentation. In the ED, the patient was tachycardic and tachypneic. Vital signs showed BP 112/94 mmHg, HR 118 /min, RR 28 /min, temperature 97.5 °F, and SpO₂ 97 % with room air. EKG showed sinus tachycardia, low QRS voltage with electric alternans (Figure 1), and chest x-ray demonstrated cardiomegaly with a water bottle shaped heart (Figure 2A), suggesting pericardial effusion. Over the hour at ED, patient developed sudden hypotension with BP of 78/44. 1 L of normal saline was administrated immediately, and patient was transferred to cardiac catherization laboratory for emergent pericardiocentesis. Echocardiogram before the procedure demonstrated massive pericardial effusion and a floating heart in the pericardial space (Figure 3). Intra-pericardial pressure was measured at 25 mmHg (Figure 4). A total of 1.8 L of sanguineous fluid was drained. Pericardial fluid cell count with differential and chemistry showed WBC 2444 /μL, RBC 1480000 /μL, lymphocytes 32 /μL , neutrophils 64 /μL, glucose 108 mg/dL, and protein 5.2 g/dL, and cytology analysis with fluid demonstrated adenocarcinoma, confirming the diagnosis of malignant pericardial effusion and cardiac tamponade. Chest x-ray after the procedure showing resolution of the water bottle-shaped heart (Figure 2B). Elective thoracotomy with pericardiectomy was performed the next day, and patient was eventually discharged in stable condition.

Pericardial effusion seen in cancer patients may results from several sources. Constrictive pericarditis with pericardial effusion can arise as a complication of radiation therapy. Uremia and certain medications can induce pericardial effusion as well. Metastatic cardiac involvement may causes pericardial effusion. A previous autopsy study showed 10.7 % of patients with underlying malignancy had metastatic disease in the heart (1). Adenocarcinoma is the most frequently found cell type, and lung cancer, malignant lymphoma and breast cancers are the most common primary tumors metastasizing to the heart. Symptoms of malignant pericardial effusion include shortness of breath, cough, chest pain, and edema. Vaitkus et al. (2) proposed three goals in the management of symptomatic malignant pericardial effusion:1) relief of immediate symptoms, 2) determination of cause, and 3) prevention of recurrence (2). No single modality has been proved to be superior since most patients with malignant pericardial effusion need more than one therapeutic modality. Pericardiocentesis is commonly used for acute symptomatic relief while other chemical or mechanical modalities such as systemic chemotherapy, radiation therapy, intrapericardial sclerosing agents, indwelling pericardial catheter, or thoracotomy with pericardiectomy are options to prevent relapse.

Seongseok Yun, MD PhD; Juhyung Sun, BS; Rorak Hooten, MD; Yasir Khan, MD;Craig Jenkins, MD

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

References

1. Klatt EC, Heitz DR. Cardiac metastases. Cancer. 1990;65(6):1456-9. [CrossRef]
2. Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion. JAMA. 1994;272(1):59-64. [CrossRef] [PubMed] 

Reference as: Yun S, Sun J, Hooten R, Khan Y, Jenkins C. Medical image of the week: malignant pericardial effusion and cardiac tamponade. Southwest J Pulm Crit Care. 2014;8(6):343-6. doi: http://dx.doi.org/10.13175/swjpcc048-14 PDF

Medical Image of the Week: Cheyne-Stokes Respiration on Overnight Polysomnography

Figure 1. 300 second polysomnogram window showing crescendo-decrescendo pattern of Cheyne-Stokes respiration (solid black arrows). Cycle length is approximately 60 seconds in duration (Outlined black arrows).

A 75 year old man with a significant past medical history of atrial fibrillation, hypertension, complete heart block status-post pacemaker implantation, thoracic aortic aneurysm, and ischemic cardiomyopathy, was referred to the sleep laboratory for evaluation for suspected sleep disordered breathing. The patient had subjective complaints of morning headaches, reported apnea, un-refreshing sleep, nocturnal urination, and intermittent snoring. The diagnostic polysomnogram was significant for periodic breathing, Cheyne-Stokes pattern, with a cycle length that ranged from 60-65 seconds (Figure 1). Oxygen saturation nadir was 79% as measured by pulse oximetry. Electrocardiogram showed a persistently paced rhythm.

Cheyne-Stokes respiration is a periodic breathing pattern characterized by crescendo-decrescendo episodes of respiratory effort that are interspersed between periods of apnea. It is typically seen in individuals with systolic heart failure, but can also be seen in those with intracerebral hemorrhage or infarction. The mechanism for Cheyne-Stokes respiration involves increased central controller gain causing increased central nervous system sensitivity to changes in arterial blood gas PCO₂ and PO₂. Increased circulation time results in circulatory delay between gas exchange occurring at the alveolar capillary membrane and the central chemoreceptors in the medulla. The result is instability in respiration (1).

Ryan Nahapetian, MD, MPH and Sairam Parthasarathy, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona, Tucson, AZ

Reference

1. Quaranta AJ, D'Alonzo GE, Krachman SL. Cheyne-Stokes respiration during sleep in congestive heart failure. Chest. 1997;111(2):467-73. [CrossRef] [PubMed]

Reference as: Nahapetian R, Parthsarathy S. Medical image of the week: Cheyne-Stokes respiration on overnight polysomnography. Southwest J Pulm Crit Care. 2014;8(6):328-9. doi: http://dx.doi.org/10.13175/swjpcc055-14 PDF

June 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 63-year-old man with a history of early-stage Parkinson disease and coronary artery disease presented with a painful “lump” in the lower left neck. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (panel A) and lateral (panel B) chest radiograph.

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

1. The chest radiograph shows a mediastinal mass
2. The chest radiograph shows an asymmetric linear, interstitial pattern
3. The chest radiograph shows bilateral symmetric linear and reticular opacities
4. The chest radiograph shows multifocal, bilateral consolidation
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. June 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(6):320-7. doi: http://dx.doi.org/10.13175/swjpcc074-14 PDF

Medical Image of the Week: Parietal Mass

Figure 1. MRI of the head with contrast. Panel A: A 2.2 cm X 2.1 cm enhancing mass within the right precuneus with surrounding vasogenic edema. Panel B: Coronal view.

A 48 year old man presented to the emergency department with a witnessed tonic clonic seizure by family members and 1 week worsening headaches and gait ataxia. Non-contrast CT of the head showed a large right-sided parietal mass. MRI of the head was done to further evaluate the mass (Figure 1). CT chest/abdomen/pelvis showed bilateral pulmonary nodules, mediastinal lymphadenopathy, hepatic lesions, and thickening of the mid-distal esophagus. The patient was evaluated by neurology and started on dexamethasone and levetiracetam. Neurosurgery was consulted and performed a right-sided craniotomy and parietal mass resection. Later, an EGD was performed and biopsies were taken of the esophagus. The patient was found to have metastatic esophageal adenocarcinoma.

Andrew I. Kovoor MD and Sudhir Kumar Tutiki MD

Department of Medicine

University of Arizona

Tucson, Arizona

Reference as: Kovoor AI, Tutiki SK. Medical image of the week: parietal mass. Southwest J Pulm Crit Care. 2014;8(5):290. doi: http://dx.doi.org/10.13175/swjpcc045-14 PDF

Medical Image of the Week: Aspergilloma

Figure 1.  Axial thoracic computed tomography (CT) image showing emphysematous disease throughout with prominent bullous disease in the upper lobes.  Areas of consolidation were concerning for infection.  Large cavitation with particulate matter (arrow) was seen in the left upper lobe. 

A 69-year-old woman, a current smoker, with very severe chronic obstructive pulmonary disease and prior atypical mycobacterium, was found unresponsive by her family and intubated in the field by emergency medical services for respiratory distress.  Her CT thorax showed severe emphysematous disease, apical bullous disease, and a large left upper lobe cavitation with debris (Figure 1).  She was treated with broad-spectrum antibiotics and anti-fungal medications.  Hemoptysis was never seen.  Sputum cultures over a span of two weeks repeatedly showed Aspergillus fumigatus and outside medical records confirmed the patient had a known history of stable aspergilloma not requiring therapy. 

Aspergillomas usually arises in cavitary areas of the lung damaged by previous infections.  The fungus ball is a combination of colonization by Aspergillus hyphae and cellular debris.  Individuals with aspergillomas are usually asymptomatic or have mild symptoms (chronic cough) and do not require treatment unless it begins to invade into the cavity wall.  When bleeding complications arise, surgical resection is curative but in high-risk patients, embolization may be considered as a stabilizing measure. 

Wendy Hsu, MD, Carmen Luraschi-Monjagatta, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

University of Arizona 

Tucson, AZ 

Reference 

Kousha M1, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011;20(121):156-74. [CrossRef] [PubMed]

Reference as: Hsu W, Luraschi-Monjagatta C, Carr G. Medical image of the week: aspergilloma. Southwest J Pulm Crit Care. 2014;8(5):282-3. doi: http://dx.doi.org/10.13175/swjpcc044-14 PDF 

Medical Image of the Week: Bronchus Sui

Figure 1. Panel A: Coronal view of the thoracic CT scan showing the right upper lobe superior subsegment bronchus taking off from the trachea (arrow). Panel B: Bronchoscopy confirming the tracheal origin of the superior subsegment bronchus.

A 65 year-old man presented to the outpatient clinic for evaluation of a chronic cough. The patient underwent CT Chest (Figure 1A) that shows a right upper lobe (RUL) infiltrate with an incidental right-sided tracheal bronchus. The incidence of right-sided tracheal bronchus is 0.1-2% and has different subtypes. This patient has the most common subtype called a displaced tracheal bronchus as the aberrant, superior segment has normal RUL branching, which coexists with normal right-sided anatomy except that the one branch of the upper lobe bronchus is missing. A true “bronchus sui” (pig bronchus) is when the RUL takes off from the trachea and the right main bronchus acts as the bronchus intermedius feeding the right middle and lower lobes. A tracheal bronchus is usually asymptomatic but can be associated with recurrent pneumonia, chronic bronchitis and bronchiectasis. Bronchoscopy (Figure 1B) was performed for the purpose of RUL bronchoalveolar lavage and endobronchial ultrasound of the mediastinal lymphadenopathy. 

Nathaniel Reyes MD, Bhupinder Natt MD, Janet Campion MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, AZ

Reference

Findik S. Tracheal bronchus in the adult population. J Bronchology Interv Pulmonol. 2011;18(2):149-52. [CrossRef] [PubMed] 

Reference as: Reyes N, Natt B, Campion J. Medical image of the week: bronchus sui. Southwest J Pulm Crit Care. 2014;8(5):281. doi: http://dx.doi.org/10.13175/swjpcc043-14 PDF

Medical Image of the Week: Constrictive Pericarditis

Figure 1. A computerized tomography of the chest revealed cardiomegaly, bilateral pleural effusions and pericardial calcification noted diffusely with focal regions of pericardial thickening greater than 4 mm.

A 62-year-old woman, with a past medical history significant for oxygen dependent COPD, paroxysmal atrial fibrillation, and obstructive sleep apnea, presented to the hospital with hypoxemic respiratory failure requiring intubation and mechanical ventilation. A computerized tomography of the chest revealed cardiomegaly, bilateral pleural effusions, and pericardial calcification that was noted diffusely with focal regions of pericardial thickening greater than 4 mm. A cardiac catheterization revealed elevated right-sided pressure; markedly elevated left ventricular end diastolic pressure; equalization of LV-RV diastolic pressures; and sharp Y descent on the right atrial pressure waveform; which is all suggestive of constrictive physiology.  The patient was medically optimized and diuresed and eventually underwent a successful pericardiectomy.

Mohammed Alzoubaidi MD, John Bloom MD, Jarrod Mosier MD, Linda Snyder MD

Department of Pulmonary and Critical Care Medicine, University of Arizona,

Tucson, AZ

Reference as: Alzoubaidi M, Bloom J, Mosier J, Snyder L. Medical image of the week: constrictive pericaditis. Southwest J Pulm Crit Care. 2014;8(5):280. doi: http://dx.doi.org/10.13175/swjpcc042-14 PDF

May 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ 

Clinical History: A 66-year-old woman presented with complaints of cough worsening over the previous several months. Her prior medical history was largely otherwise unremarkable. Frontal chest radiography (Figure 1) was performed for evaluation.  

Figure 1. Panel A: Frontal chest radiograph. Panel B: Right anterior oblique image. Panel C: Left anterior oblique image.

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 shows a solitary pulmonary nodule
2. The chest radiograph shows multifocal airway thickening and bronchiectasis
3. The chest radiograph shows multifocal, bilateral cavitary nodules and consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities within diminished lung volumes, suggesting fibrosis
5. The chest radiograph shows multiple small nodules, suggesting a miliary pattern

Reference as: Gotway MB. May 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(5):266-74. doi: http://dx.doi.org/10.13175/swjpcc059-14 PDF

Medical Image of the Week: Fat Embolism Syndrome

A 33-year-old man presented to the emergency department with shortness of breath and hemoptysis. He was discharged two days prior after hospitalization for a motor vehicle accident, in which he suffered a fracture of the shaft of the right femur. He had undergone open reduction and internal fixation of the fracture four days prior to this admission. He had diffuse parenchymal disease on his admission chest x-ray. A CT scan of the chest demonstrated multilobar ground glass opacities (Figure 1).

Figure 1. Thoracic CT scan showing ground glass opacities.

Bronchoscopy demonstrated progressively bloody BAL aliquots in two different lobes, consistent with diffuse alveolar hemorrhage (DAH). His workup for other etiologies was negative, and he was given a diagnosis of DAH secondary to fat embolism syndrome.

Joshua Malo, MD and Kenneth S. Knox, MD

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

University of Arizona, Tucson, AZ

Reference as: Malo J, Knox KS. Medical image of the week: fat embolism syndrome. Southwest J Pulm Crit Care. 2014;8(4):246. doi: http://dx.doi.org/10.13175/swjpcc041-14 PDF

Medical Image of the Week: Lung Cancer with Vascular Invasion

Figure 1. Panel A: Representative axial view of the thoracic CT scan showing tumor invading the left atrium via the right superior pulmonary vein (arrow). Panel B: Coronal view showing tumor invasion (arrow).

A 73-year-old woman presented to the emergency department with seizures and a subacute history of mild dyspnea on exertion. Her admission chest x-ray demonstrated a large right upper lobe lung mass, and MRI of the brain demonstrated multiple bilateral enhancing lesions concerning for a cardiac embolic source. Representative axial (Figure 1A) and coronal (Figure 1B) images from her chest CT scan demonstrate tumor invading the left atrium via the right superior pulmonary vein (arrow). The tumor was confirmed to be small cell carcinoma of the lung.

Joshua Malo, MD and Franz Rischard, DO

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

University of Arizona, Tucson, AZ 

Reference as: Malo J, Rischard F. Medical image of the week: lung cancer with vascular invasion. Southwest J Pulm Crit Care. 2014;8(4):235. doi: http://dx.doi.org/10.13175/swjpcc040-14 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1. Acute aortic dissection presenting with the following radiographic signs: rightward deviation of the trachea (red arrow); left apical pleural capping (blue arrow); aortic “double-calcium” sign (between white arrows); depression of the left bronchus (purple arrow); pleural effusion (green arrow); widened mediastinum and loss of the aorto-pulmonary window (not labeled).

The patient was a 75 year old woman with a past medical history of uncontrolled hypertension and recent type-A aortic dissection post graft repair. She presented with a sudden onset of sharp mid-back pain which awoke her from sleep. In the emergency room a chest x-ray revealed numerous features consistent with a de novo type B aortic dissection which was ultimately confirmed by magnetic resonance angiography of the chest and abdomen. This dissection extended from the left subclavian artery to the right renal artery. There was no evidence of end-organ mal-perfusion and the patient was medically managed by way of blood pressure control.

Seth Assar, MD; Thien Vo, MD; Jarrod Mosier, MD

The University of Arizona College of Medicine, Tucson, Arizona

Reference

Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007;6(1):64-7. [CrossRef]

Reference as: Assar S, Vo T, Mosier J. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2014;8(4):234. doi: http://dx.doi.org/10.13175/swjpcc039-14 PDF

Medical Image of the Week: Pulmonary Arteriovenous Fistula

Figure 1. Panel A: Micro-bubbles appear in the right atrium (RA) and right ventricle (RV) with delayed appearance in the left atrium (LA) and left ventricle (LV). Panels B and C: The density of the micro-bubbles were same in the left and the right cardiac chambers even after 10 cardiac cycles. Panel D: When the injection was stopped, there were micro-bubbles in the left cardiac chambers, but none in the right cardiac chambers.

A 60 year-old man with hepatic cirrhosis, was referred for chest pain, shortness of breath, and progressive cyanosis and an echocardiographic evaluation. PaO2 was 64 mm Hg on room air, but only 74 mm Hg on 100% oxygen.  Chest X-ray and pulmonary function testing were normal. A contrast echocardiography using agitated saline (bubble study) was performed. A delayed appearance of a substantial amount of micro-bubbles in the left atrium greater than three cardiac cycles after appearance in the right atrium and ventricle was suggestive of pulmonary arteriovenous fistula (Figure 1A). The delayed appearance and a large amount of micro-bubbles in the left atrium preclude the intracardiac shunting result of a patent foramen ovale (PFO) or atrial septal defect (ASD). Interestingly, the density of micro-bubbles were same in the left and the right cardiac chambers even after 10 cardiac cycles (Figure 1B and 1C). When the injection was stopped, there were micro-bubbles in the left cardiac chambers, but none in the right cardiac chambers (Figure 1D). Although pulmonary angiography remains the gold standard method for definitive diagnosis of the pulmonary arteriovenous malformations, contrast echocardiography can suggest arteriovenous fistula in the setting of unexplained hypoxemia before angiography, especially in hospitals without on-site angiography facilities.

Manisha Bajracharya MD, Madhu Gupta MD, Liping Chen MD PhD

Department of Gynecology and the Cardiovascular Disease Center, Norman Bethune College of Medicine, Jilin University, Changchun, China

Reference

Nanthakumar K, Graham AT, Robinson TI, Grande P, Pugash RA, Clarke JA, Hutchison SJ, Mandzia JL, Hyland RH, Faughnan ME. Contrast echocardiography for detection of pulmonary arteriovenous malformations. Am Heart J. 2001;141(2):243-6. [CrossRef] [PubMed]

Reference as: Bajracharya M, Gupta M, Chen L. Medical image of the week: pulmonary arteriovenous fistula. Southwest J Pulm Crit Care. 2014;8(4): . doi: http://dx.doi.org/10.13175/swjpcc035-14 PDF

April 2014 Imaging Case of the Month

Eric A. Jensen, MD

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ 

Clinical History: A 34-year-old woman presented with complaints of abdominal fullness. The patient described a history of several pneumonias, successfully treated with antibiotics. Liver function testing showed a mild transaminitis. Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiograph. 

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

1. The chest radiograph shows multifocal coarse linear opacities suggesting bronchiectasis
2. The chest radiograph shows multifocal ground-glass opacity and consolidation
3. The chest radiograph shows multifocal, somewhat basal predominant linear opacities within diminished lung volumes, suggesting fibrosis
4. The chest radiograph shows multiple small nodules, suggesting a miliary pattern
5. The chest radiograph shows symmetric, basal predominant fine linear and reticular abnormalities without architectural distortion

Reference as: Jensen EA, Gotway MB. April 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(4):213-20. doi: http://dx.doi.org/10.13175/swjpcc037-14 PDF

Medical Image of the Week: Cervical Fracture and Dislocation

Figure 1. Panel A: Computerized tomography (CT) scan of the neck showing C5-C6 fracture and dislocation (arrow). Panel B: Accompanying magnetic resonance imaging (MRI) of the neck.

A 25 year old woman was a restrained driver in a rollover motor vehicle accident (MVA) and suffered a C5-C6 fracture-dislocation with spinal cord injury (Figure 1). She developed neurogenic stunned myocardium, symptomatic bradycardia and neurogenic shock. Her cardiac ultrasound has been previously presented and can be viewed by clicking here. After developing the adult respiratory distress syndrome and multi-system organ failure she had multiple cardiac arrests and died after 5 days in the intensive care unit.

Evan D. Schmitz, MD

Richland, Washington

Reference as: Schmitz ED. Medical image of the week: cervical fracture and dislocation. Southwest J Pulm Crit Care. 2014;8(4):204. doi: http://dx.doi.org/10.13175/swjpcc030-14 PDF 

Medical Image of the Week: Granulation Tissue

Figure 1. Subglottic space showing the presence of granulation tissue (arrows).

Figure 2. Argon Plasma Coagulation of the granulation tissue

A 57 year old woman presented with a tickling sensation in the back of throat and intermittent bleeding from the healing stoma one month after decannulation of her tracheostomy tube. On bronchoscopy a granuloma with surrounding granulation tissue was present in the subglottic space (Figure 1). Argon plasma coagulation (APC) was performed to cauterize the granulation tissue (Figure 2).

Formation of granulation tissue after tracheostomy is a common complication which can result in tracheal stenosis. APC and electrocautery using flexible bronchoscopy has been shown to safely and effectively remove the granulation tissue.

Aarthi Ganesh, MBBS and  James Knepler, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona

Tucson, AZ

Reference

1. Epstein SK. Late complications of tracheostomy. Respir Care. 2005;50(4):542-9. [PubMed] 

Reference as: Ganesh A, Knepler J. Medical image of the week: granulation tissue. Southwest J Pulm Crit Care. 2014;8(3):192-3. doi: http://dx.doi.org/10.13175/swjpcc029-14 PDF