November 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 38-year-old non-smoking woman presented with complaints of intermittent dry cough, occasional vomiting, and dyspnea, occasionally with fever and chills. She indicated that she has suffered recurrent bouts of bronchitis and pneumonia annually over the previous 10 years. The patient had a history of upper arm localized melanoma resection 10 years earlier. She had smoked for 10 years, but quit one year prior to presentation. Her past medical and surgical histories were otherwise unremarkable.

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

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

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

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows mild, bilateral, streaky central opacities, possibly reflecting airway thickening
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows volume loss involving the right thorax with a mass-like opacity projected over the right hilum

Reference as: Gotway MB. November 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(5):264-77. doi: http://dx.doi.org/10.13175/swjpcc147-14 PDF

Medical Image of the Week: Persistent Left Superior Vena Cava

Figure 1. Left subclavian central line courses in a left paramediastinal location.

Figure 2. Axial CT image of the chest shows a vessel coursing lateral to the aortic arch consistent with a persistent left superior vena cava.

A 19 year old man with acute lymphocytic leukemia was admitted to the ICU with septic shock. Due to areas of cellulitis on the right side of the chest and neck and femoral venous thrombi, a left subclavian central access was attempted. The chest x-ray obtained after line placement is shown below (Figure 1). Blood gas done from the line was consistent with venous blood and venous tranduction was seen. A CT of the chest (Figure 2) confirmed the diagnosis of persistent left superior vena cava (PLSVC).

A persistent left superior vena cava is the most common congenital thoracic venous anomaly, seen in 0.3-0.5% of the population (1). Incidence is increased in patients with congenital heart disease to 5%. In most patients a right sided SVC is also present; hence the term SVC duplication has also been used. Embryologically a PLSVC is formed when the left anterior cardinal vein is not obliterated during fetal development to form the ‘Ligament of Marshall’. It usually drains in to the coronary sinus.

Diagnosis is usually made incidentally on CT scan, echocardiography or,like in our case, after a left sided central access. Practically, its presence may complicate left sided central access including Swan Ganz Catheter placement, implantable cardioverter defibrillator (ICD) placement and during cardiac surgery including during administration of retrograde cardioplegia or cardiac transplant.

Emad Hammode MD¹, Khaled Hamed MD¹, Mohammad Hudeeb MD¹, Veronica Arteaga MD²

¹Department of Internal Medicine

²Department of Thoracic Imaging

University of Arizona Medical Canter

Tucson, AZ

Reference

1. Povoski SP, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol. 2011;9:173. [CrossRef] [PubMed]

Reference as: Hammode E, Hamed K, Hudeeb M, Arteaga V. Medical image of the week: persistent left superior vena cava. Southwest J Pulm Crit Care. 2014;9(4):242-3. doi: http://dx.doi.org/10.13175/swjpcc132-14 PDF

Medical Image of the Week: Pulmonary Arteriovenous Malformations

Figure 1. Cardiac ultrasound showing right to left shunting.

Figure 2. Thoracic CT scan showing arteriovenous malformations (AVM's, arrows).

A 34 year old woman presented to the clinic with exertional dyspnea since childhood. Oxygen saturations in clinic were 92% on room air. On review of systems she admitted to recurrent epistaxis and her daughter also suffered from frequent epistaxis. Bubble contrast echocardiography showed severe right to left shunting without evidence of intracardiac shunt (Figure 1). Computed tomography angiogram of the chest revealed multiple bilateral arteriovenous malformations (AVM’s), the largest measuring 9mm on coronal images (Figure 2). MRI of the brain was negative for AVM’s. She was referred to interventional radiology for microcoil embolization. She met two of four Curaçao criteria for the diagnosis of hereditary hemorrhagic telangiectasia (HHT), giving her “possible HHT”. She was referred for genetic testing to confirm the diagnosis.

Chris Strawter MD and Laura Meinke MD

University of Arizona

Tucson, Arizona

References

1. Lacombe P, Lacout A, Marcy PY, et al. Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview. Diagn Interv Imaging. 2013;94:835-48. [CrossRef] [PubMed]
2. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158:643-61. [CrossRef] [PubMed]
3. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2011;48:73-87. [CrossRef] [PubMed]

Reference as: Strawter C, Meinke L. Medical image of the week: pulmonary arteriovenous malformations. Southwest J Pulm Crit Care. 2014;9(4):238-9. doi: http://dx.doi.org/10.13175/swjpcc131-14 PDF 

Medical Image of the Week: Aortic Ring

Figure 1. Post-intubation chest radiograph showing a widened right paratracheal stripe (arrow).

A 78 year old man presented with altered mental status and was found to have an intraventricular hemorrhage. He was intubated for airway protection. On the post-intubation chest radiograph (Figure 1), the patient was noted to have a widening of the right paratracheal stripe.

A CT chest (Figure 2) was obtained to characterize this finding and revealed an aortic ring which encircles the trachea and esophagus.

Figure 2. Axial (Panel A) and coronal (Panel B) of thoracic CT soft tissue windows showing the aortic ring.

Vascular rings are uncommon congenital abnormalities, accounting for approximately 1% of congenital heart disease. Complete vascular rings can occur with a right aortic arch with a ligamentum arteriosum or with a double aortic arch, such as with our patient (1). This ring can cause airway compression, stridor, esophageal compression, or no symptoms at all. As the embryo develops, the left fourth pharyngeal arch normally persists to become the aortic arch while the right fourth pharyngeal arch regresses. If both fourth pharyngeal arches persist, a right aortic arch can form and surround the trachea and esophagus (2).

Candy Wong MD¹, Tammer Elaini MD², Soyoung Park MD², Scott Rosen MD², and Sai Parthasarathy MD¹

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

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Turner A, Gavel G, Coutts J. Vascular rings-presentation, investigation and outcome. Eur J Pediatr. 2005;164(5):266-70. [CrossRef] [PubMed]
2. Vatish J, McCarthy R, Perris R. A double aortic arch presenting in the 7^th decade of life. J Surg Case Rep. 2013.(10):pii:rjt081. [CrossRef] [PubMed]

Reference as: Wong C, Elaini T, Park S, Rosen S, Parthasarathy S. Medical image of the week: aortic ring. Southwest J Pulm Crit Care. 2014;9(4):121-2. doi: http://dx.doi.org/10.13175/swjpcc130-14 PDF

Medical Image of the Week: Partial Anomalous Pulmonary Venous Return

Figure 1. Chest radiograph status post left internal jugular central line placement with arrow pointing to tip of catheter.

   

Figure 2. Axial (Panel A) and coronal (Panel B) views of contrast CT chest showing anomalous pulmonary venous return (yellow arrow). Middle Panel: Video of selected axial sections. Lower Panel: Video of selected coronal sections.

A 69 year old woman presented with septic shock secondary to a urinary tract infection. A chest radiograph (Figure 1) done after uneventful placement of a left internal jugular central line showed  aberrant position of the catheter.

Review of a past contrast-enhanced CT chest (Figure 2) revealed an anomalous pulmonary venous return with a pulmonary vein draining to the brachiocephalic vein.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital defect which results in a left-to-right shunt. The prevalence was 0.1% in one retrospective study of 45,538 contrast-enhanced chest CT scans (1). Diagnosis can be made with echocardiography, angiography, right heart catheterization, or computed tomography. PAPVR is traditionally associated with atrial septal defects, and patients are often asymptomatic. Clinical manifestations occur when there is significant shunting and include syncope, right heart failure, and pulmonary hypertension (2).

Candy Wong MD¹; Tammer Elaini MD²; Naser  Mahmoud MD¹, and Josh Malo MD¹

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

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Ho M, Bhalla S, Bierhals A,Gutierrez F. MDCT of partial anomalous pulmonary venous return (PAPVR) in adults. J Thorac Imaging. 2009;24(2):89-95. [CrossRef] [PubMed]
2. Kivisto S, Hanninen H, Holmstrom M. Partial anomalous pulmonary venous return and atrial septal defect in adult patients detected with 128-slice multidetector computed tomography. J Cardiothorac Surg. 2011;6:126. [CrossRef] [PubMed]

Reference as: Wong C, Elaini T, Mahmoud N, Malo J. Medical image of the week: partial anomalous pulmonary venous return. Southwest J Pulm Crit Care. 2014;9(4):219-20. doi: http://dx.doi.org/10.13175/swjpcc129-14 PDF

October 2014 Imaging Case of the Month

Sameh Sakla, M.D.

Clinton Jokerst, M.D.

Department of Medical Imaging

University of Arizona Medical Center

Tucson, AZ

A 53-year-old man presents with fatigue and dyspnea on exertion. An admission chest radiograph (Figure 1) was obtained.

Figure 1. Admission chest radiograph.

What is the best term or phrase used to describe the salient radiographic abnormality?

1. Diffuse thick-walled cavitary lesions
2. Interstitial and alveolar pulmonary edema with effusions
3. Miliary nodules
4. Patchy consolidation
5. Tension pneumothorax

Reference as: Sakla S, Jokerst C. October 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(4):214-8. doi: http://dx.doi.org/10.13175/swjpcc126-14 PDF 

Medical Image of the Week: Pulmonary Herniation

Figure 1. Thoracic CT scan.

  Figure 2. Saggital view of thoracic CT scan.

A 49-year-old obese gentleman with a known history of chronic obstructive pulmonary disease, diabetes mellitus and GERD presented with complaints of a popping sensation in his left chest with coughing and deep breathing, associated with pain at the same site. Physical examination showed small bulge at the level of the herniation that was most obvious with coughing. CT scan of chest done 2 months ago showed 2. 5 cm pulmonary hernia identified at the left 7-8 costal interspace (Figures 1 and 2). This was thought to have resulted from an open lung biopsy of his left lung done 4 years before presentation to evaluate for acute respiratory failure or chest tube insertion at same site 3 years prior to presentation for treatment of a pneumothorax. Surgical repair was done with round Bard Kugel hernia patch. His symptoms resolved after the procedure.

Ramasubramanian Baalachandran MD, Naser Mahmou  MD, and Laura Meinke MD

Department of Medicine

University of Arizona – School of Medicine

Tucson, Arizona.

Reference

1. Fackeldey V, Junge K, Hinck D, Franke A, Willis S, Becker HP, Schumpelick V. Repair of intercostal pulmonary herniation. Hernia. 2003;7(4):215-7. [CrossRef] [PubMed]

Reference as: Baalachandran R, Mahmou N, Meinke L. Medical image of the week: pulmonary herniation. Southwest J Pulm Crit Care. 2014;9(4):197-8. doi: http://dx.doi.org/10.13175/swjpcc122-14 PDF

Medical Image of the Week: Pneumomediastinum

Figure 1. Chest X-ray PA view.

Figure 2. CT scan of chest.

A 38-year-old gentleman was flown to the emergency room after being involved in a motor vehicle accident. In the field, he had a Glasgow Coma Scale of about 7 and cricothyrotomy was performed to establish an airway. He sustained severe head and chest injuries, with extensive subcutaneous emphysema.  Chest X-ray (Figure 1) and CT scan (Figure 2) revealed pneumomediastinum with classical “continuous diaphragm sign” (red arrows), lucent streaks outlining the ascending aorta (blue arrows) and extensive subcutaneous emphysema (block arrows). Subdural and subarachnoid hemorrhage was detected on CT scan of head. His neurological status worsened over next 24 hours and he was confirmed brain dead.

Ramasubramanian Baalachandran MD, Naser Mahmoud MD, and Laura Meinke MD

Department of Medicine

University of Arizona

Tucson, Arizona

References

1. Bejvan SM, Godwin JD. Pneumomediastinum: old signs and new signs. AJR Am J Roentgenol. 1996;166:1041-8. [CrossRef] [PubMed]
2. Levin B. The continuous diaphragm sign. A newly-recognized sign of pneumomediastinum. Clin Radiol.1973;24(3):337-8. [CrossRef] [PubMed]

Reference as: Baalachandran R, Mahmoud N, Meinke L. Medical image of the week: pneumomediastinum. Southwest J Pulm Crit Care. 2014;9(3):189-90. doi: http://dx.doi.org/10.13175/swjpcc123-14 PDF

Medical Image of the Week: Septic Emboli

Figure 1. Panels A-F: Selected static images from the thoracic CT showing numerous septic pulmonary emboli with cavitation. Lower panel: movie of selected images from thoracic CT scan.

A 46-year-old man was admitted with altered mental status. His past medical history included HIV/AIDS on HAART therapy, hepatitis B and C, non-Hodgkin's lymphoma (NHL), deep venous thrombosis with insertion of an inferior vena caval filter, and poly-substance abuse. Vitals revealed fever and tachycardia. On exam, he was lethargic and confused, and had bilateral crackles on lung auscultation. Computerized axial tomography (CT) of the head was unremarkable and chest X-ray revealed patchy nodular infiltrates in the right upper lobe and bilateral lower lobes. Work up for an infectious cause was initiated including opportunistic infections and he was started on empiric antibiotics for pneumonia. On Day 2, his roommate who came to visit him, revealed that he was recently admitted in another hospital for headache and flu-like symptoms, and discharged with a peripherally inserted central catheter (PICC) in place as he was scheduled for a positron emission tomography (PET) the next morning for evaluation of recurrence of NHL. However, he presented for the PET scan 10 days after discharge, during which period he was abusing heroin through the PICC line. A thoracic CT was also obtained which showed innumerable scattered cavitary pulmonary opacities with peripheral ground glass opacities consistent with septic pulmonary emboli in the right and left upper lobe and right middle lobe (Figure 1). Blood and urine cultures grew methicillin-resistant Staphylococcus aureus, CD4 count was 180, cryptococcus and histoplasma antigens were negative, as were urine antigens for pneumococcus and legionella. He was also found to have deep venous thrombosis of the right upper extremity. Trans-esophageal echocardiogram was negative for valvular vegetations. He was successfully treated with vancomycin and rifampin and discharged home.

Septic pulmonary emboli are embolization of infectious particles into the lungs via the pulmonary arterial system. Septic pulmonary emboli can occur from varying sources. Patients may be asymptomatic or present with sepsis. CXR shows multiple nodules in the periphery of the lower lobes. CT chest may show feeding vessel sign (a vessel coursing directly to a nodule or mass) in 50% of patients. Early diagnosis and prompt treatment can lead to a successful outcome.

Nanditha Malakkla MD and Chandramohan Meenakshisundaram MD

St. Francis Hospital

Evanston, IL

References

1. Fidan F, Acar M, Unlu M, Cetinkaya Z, Haktanir A, Sezer M. Septic pulmonary emboli following infection of peripheral intravenous cannula. Eur J Gen Med. 2006;3:132–5.
2. Kuhlman JE, Fishman EK, Teigen C. Pulmonary septic emboli: Diagnosis with CT. Radiology. 1990;174:211–3. [CrossRef] [PubMed]
3. Hind CR. Pulmonary complications of intravenous drug misuse. 1. Epidemiology and non-infective complications. Thorax 1990; 45:891-8. [CrossRef] [PubMed]

Reference as: Malakkla N, Meenakshisundaram C. Medical image of the week: septic emboli. Southwest J Pulm Crit Care. 2014;9(3):183-4. doi: http://dx.doi.org/10.13175/swjpcc120-14 PDF 

Medical Image Of The Week: Secondary Pneumonia Presenting as Hemoptysis

Figure 1. A-C: Axial images of the chest demonstrating bilateral consolidation of the lung with air bronchograms. D: Chest radiograph on presentation. E: BAL findings. F: Bronchoscopic images of diffuse airway sloughing; this is the main carina.

A 44 year-old man with a history of asthma presented to the hospital with encephalopathy, severe hypoxia and what was reported to be hematemesis. The patient was intubated in the Emergency Department and mechanical ventilation was instituted. Upper endoscopy was performed but source of bleeding could not be identified. Imaging of the chest showed pulmonary consolidation on both plain radiograph (D) and computed tomography (A-C). Bronchoscopy revealed a very friable mucosa with sloughing of the respiratory epithelium from the main carina (F) to at least the subsegmental level. Bronchoalveolar lavage (BAL) returned bloody fluid (E) but without any increase in blood with subsequent aliquots of fluid. The patient had progressively worsening hypoxia consistent with the acute respiratory distress syndrome (ARDS) requiring rescue maneuvers including paralysis, airway pressure release ventilation, and inhaled nitric oxide but we were unable to implement proning or transfer for extracorporeal life support due to profound cardiovascular collapse refractory to treatment. Ultimately, he succumbed from multiorgan failure. On laboratory evaluation of the BAL both Staphylococcus aureus and Influenza B virus were detected.

Bacterial pneumonia is a common complication of influenza infection. Historically, patients at the extremes of age have been most susceptible to secondary pneumonia. However, during the recent 2009 influenza pandemic an unusually high rate of secondary pneumonia among young adults was observed (1). The most common bacterial pathogens isolated following influenza infection include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus mitis, Streptococcus pyogenes and Haemophilus influenzae (2). A number of pathogenic mechanisms for synergies between influenza and bacteria have been proposed including disruption of the respiratory epithelium leading to enhanced bacterial adhesion (3).

Cameron Hypes MD MPH^1,2, Christian Bime MD MSc¹, Kevin Sun MD³, and Elizabeth Ulliman MD³

¹ Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona Medical Center; Tucson, AZ

² Department of Emergency Medicine, University of Arizona Medical Center; Tucson, AZ

³ Department of Medicine, University of Arizona Medical Center; Tucson, AZ

References

1. Chowell G, Bertozzi SM, Colchero MA, Lopez-Gatell H, Alpuche-Aranda C, Hernandez M, et al. Severe respiratory disease concurrent with the circulation of H1N1 influenza. New Engl J Med. 2009;361(7):674-9. [CrossRef] [PubMed]
2. Centers for Disease Control and Prevention (CDC). Bacterial coinfections in lung tissue specimens from fatal cases of 2009 pandemic influenza A (H1N1) - United States, May-August 2009. MMWR Morb Mortal Wkly Rep. 2009;58(38):1071-4. [PubMed]
3. Metersky ML, Masterton RG, Lode H, File Jr TM, Babinchak T. Epidemiology, microbiology, and treatment considerations for bacterial pneumonia complicating influenza. Int J Infect Dis. 2012;16(5):e321-e31. [CrossRef] [PubMed]

Reference as: Hypes C, Bime C, Sun K, Ulliman E. Medical image of the week: secondary pneumonia presenting as hemoptysis. Southwest J Pulm Crit Care. 2014;9(3):177-8. doi: http://dx.doi.org/10.13175/swjpcc116-14 PDF

September 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 57-year-old non-smoking woman presented to her physician as an outpatient with complaints of worsening cough, fever, chills, and shortness of breath. The patient’s past medical history includes systemic lupus erythematosus diagnosed 18 years earlier, for which the patient has been variably treated with corticosteroids, hydroxychloroquine, and azathioprine. Additional past medical and surgical history includes migraines, mood disorder, diabetes mellitus treated with metformin, hysterectomy for endometriosis, and iron-deficient anemia. The patient was also diagnosed with small lymphocytic lymphoma 3 years earlier following a right breast biopsy when an abnormal opacity was discovered incidentally at routine screening breast imaging. She has not been treated for this neoplasm as no B symptoms have been reported.

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

Figure 1. Panel A: Initial frontal chest x-ray. Panel B: Initial lateral chest x-ray.

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 asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows linear and curvilinear opacities suggesting cystic lung disease
4. The chest radiograph shows mild streaky central opacities, possibly reflecting airway thickening
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. September 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(3):161-76. doi: http://dx.doi.org/10.13175/swjpcc117-14 PDF 

Medical Image of the Week: Severe Atelectasis with Tracheal Shift

 

Figure 1. Panel A: Initial chest x-ray shows left lower lobe collapse due to mucus plugging and atelectasis with a significant shift of the trachea to the left (arrow). Panel B: Follow up chest x-ray shows marked improvement in aeration of the left lung and return of the trachea to midline (arrow).

A 59-year-old woman with severe oxygen dependent COPD presented with acute respiratory distress requiring intubation and was found to have left lower lobe collapse with tracheal shift. Her past medical history consists of severe malnutrition, alcohol abuse, and emphysema with recurrent pneumonias associated with acute respiratory failure often requiring intubation. She has greater than a 50-pack year history of tobacco use. She has undergone bronchoscopy and multiple CT Chest imaging without evidence of an endobronchial lesion or malignancy. Postural drainage and percussion along with antibiotics and inhaled bronchodilators resulted in marked improvement in the left lower lobe.

Ishna Poojary MD, Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference as: Poojary I, Campion J. Medical image of the week: severe atelectasis with tracheal shift. Southwest J Pulm Crit Care. 2014;9(3):160. doi: http://dx.doi.org/10.13175/swjpcc115-14 PDF

Medical Image of the Week: Scimitar Syndrome

Figure 1. Axial CT in lung windows at the level of the right atrium shows a dilated anomalous vein (arrow) coursing in close proximity to the major fissure (star).

Figure 2. Coronal CT in soft tissue windows at the level of the right hemi diaphragm shows evidence of post surgical repair with the anomalous vein draining into the left atrium (arrow).  Note the right hemi-diaphragm is elevated suggesting some degree of pulmonary hypoplasia.

A 38 year-old woman presented for evaluation of palpitations and chronic progressive dyspnea on exertion accompanied by chest tightness and fatigue. Chest radiograph was normal except for low lung volumes. An echocardiogram revealed normal left ventricular size and function with an ejection fraction of 60%, normal right ventricular size and function and moderate tricuspid insufficiency with an estimated right ventricular systolic pressure of 36 mm Hg plus central venous pressure and a mildly enlarged right atrium. Computed tomography (CT) of the heart with contrast showed normal coronary arteries, enlarged right atrium and partial anomalous pulmonary venous return from the right lung to the inferior vena cava (IVC) (Figure 1). Cardiac catheterization with selective angiography confirmed anomalous pulmonary venous drainage from the right upper and right lower lobe to the hepatic portion of the inferior vena cava with obstruction (8 mm Hg gradient between the anomalous vein and the right atrium). The calculated pulmonary to systemic flow ratio (Qp:Qs) was 1.3:1. The pulmonary vascular resistance was 7.6 Woods units and the mean pulmonary artery pressure was 24 mmHg.  The diagnosis of Scimitar syndrome was made.

The patient underwent surgical repair of partial anomalous pulmonary drainage and pulmonary vein stenosis as well as ligation of an aortopulmonary collateral artery found intraoperatively. The anomalous pulmonary vein was divided from the IVC, the caval end was oversewn and the anomalous vein was anastomosed to the left atrium with a CorMatrix patch (Figure 2). The patient recovered from surgery, however, her symptoms continued and Doppler pattern on a follow-up transthoracic echocardiogram suggested residual obstruction at the site of anastomosis to the left atrium.  Catheterization confirmed obstruction of the anastomosed vein at the level of insertion into the left atrium.  The patient underwent repeat sternotomy and repair of pulmonary vein obstruction using a CorMatrix patch and sutureless reconstruction of the right-sided pulmonary vein obstruction.  She recovered from this procedure with some improvement of her symptoms.

Scimitar syndrome is a rare congenital anomaly characterized by partial anomalous pulmonary venous connection of the right pulmonary veins to the IVC, anomalous systemic arterial supply to the right lung and a variable degree of right lung hypoplasia with or without sequestration (1).  Partial anomalous pulmonary venous return (PAPVR) is an uncommon congenital anomaly and accounts for less than 1% of congenital heart lesions. Scimitar syndrome comprises 3-5% of PAPVR (2). The term refers to the distinctively shaped vein, which resembles a short, curved Turkish sword called a scimitar (Figure 2). Most cases present in infancy and childhood and diagnosis in adulthood is quite rare. In adults, the clinical presentation is variable and the lesion may be discovered incidentally or patients can present with dyspnea, pulmonary hypertension and recurrent right-sided lung infection (1). The treatment of isolated PAPVR in adults is controversial due to rare occurrence of the disease, complexity of surgical repair and risk of re-stenosis. Surgical repair involves re-implantation of the anomalous vein into the left atrium and can be a complex and difficult procedure, however it can be accomplished with low morbidity and mortality at specialized centers (3). Thrombosis or stenosis of the scimitar vein is a serious complication of surgery. Our patient demonstrates some of the challenges in diagnosis and treatment and illustrates some of the post-operative complications of this rare disease.

Jamie Colombo, DO¹

Linda Snyder, MD²

Veronica Arteaga, MD³

Daniela Lax, MD⁴

¹Department of Pediatrics

²Department of Medicine, Division of Pulmonary/Critical Care Medicine

³Department of Medical Imaging

⁴Department of Pediatrics, Division of Pediatric Cardiology

University of Arizona

Tucson, AZ

References

1. Yehia BR, Bachmann JM, Traill TA. Scimitar syndrome: a rare cause of dyspnea in adults. South Med J. 2010;103:578-580. [CrossRef] [PubMed]
2. Haest RJ, van den Berg CJ, Goei R, Baur LH. Scimitar syndrome; an unusual congenital abnormality occasionally seen in adults. Int J Cardiovasc Imaging. 2006;22:565-568. [CrossRef] [PubMed]
3. Majdalany DS, Phillips SD, Dearani JA, Connolly HM, Warnes CA. Isolated partial anomalous venous connections in adults: twenty-year experience. Congenit Heart Dis. 2010;5:537-545. [CrossRef] [PubMed]

Reference as: Colombo J, Snyder L, Arteaga V, Lax D. Medical image of the week: scimitar syndrome. Southwest J Pulm Crit Care. 2014;9(2):137-9. doi: http://dx.doi.org/10.13175/swjpcc111-14 PDF

Medical Image of the Week: Coccidioidomycosis

Figure 1. Preoperative x-ray (Panel A) demonstrating a right upper lobe cavitary lesion. X-ray (Panel B) status post lobectomy.

Figure 2. Coronal (Panel A) and axial (Panel B) images from a chest CT further demonstrating a right upper lobe cavitary lesion.

Figure 3. The 200x magnification H&E image (Panel A) demonstrates one of the numerous granulomas seen in the lung specimen. A low magnification (40x) (Panel B) H&E image showing the granulomatous infection, prominent at the left, surrounded by a wall made up of collagen.

Figure 4. Two images, both at 400x magnification, are of GMS stained tissue.  Panel A shows the numerous branching hyphae of the lesion.  Panel B shows a granuloma with a central Coccidioides spherule, marked by the red arrow.

A 41-year-old Hispanic man with a history of uncontrolled type 2 diabetes and coccidioidomycosis, presented to the emergency department with a two year history of hemoptysis and recent onset lower chest pain. Patient was found to have a right upper lobe cavitary lesion on x-ray (Figure 1). Due to concern for pulmonary and pericardial tuberculosis the patient was placed on isolation, and QuantiFERON Gold testing, Coccidioides antibodies and computed tomography of the chest were ordered. At this time the patient revealed that he had taken only 30 days of treatment for his coccidioidomycosis 2 years ago due to his understanding this was the complete course. The CT (Figure 2) demonstrated an irregular, spiculated, and thin-walled right apical cavitary lesion with satellite nodules. QuantiFERON Gold testing and Coccidioides testing were both positive. Surgical resection was performed due to ongoing hemoptysis. The surgical specimen demonstrated hyphae (Figure 4A), a rare spherule (Figure 4B) and caseating granulomas (Figure 3) consistent with coccidioidomycosis. Acid-fast stains were negative. Indications for surgery in coccidioidomycosis are continued or progressing symptoms following 3 months of treatment, complications (such as rupture, pneumothorax or effusion), and large size of abscess (1,2).

Kareem Hassan BA, Spencer Paulson MD, Carlos Tafich Rios MD

Departments of Medicine and Pathology

University of Arizona 

Tucson, AZ

References

1. Jaroszewski DE, Halabi WJ, Blair JE, et al. Surgery for pulmonary coccidioidomycosis: a 10-year experience. Ann Thorac Surg. 2009; 88:1765-72. [CrossRef] [PubMed]
2. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis. 2005;41: 1217-23. [CrossRef] [PubMed]

Reference as: Hassan K, Paulson S, Rios CT. Medical image of the week: coccidioidomycosis. Southwest J Pulm Crit Care. 2014;9(2):128-9 . doi: http://dx.doi.org/10.13175/swjpcc106-14 PDF

Medical Image of the Week: Pneumatocele

Figure 1. Portable AP film showing a large cystic lesion in the left lower lobe in addition to small bilateral pleural effusions and adjacent consolidation.

Figure 2. Axial enhanced CT scan section showing a large cystic space with an air-fluid level with adjacent consolidated atelectasis. No perceptible wall is seen.

A 50-year-old man presented with polymicrobial pneumonia which included Proteus mirabilis, Enterobacter cloacea and MRSA pathogens. A large cystic lesion with an air-fluid level was found on chest imaging in a region of pneumonia (Figure 1). There was associated mass effect onto the adjacent lung. No perceptible wall was noted which would be more associated with a cyst rather than a cavity or abscess. Directed aspiration of this lesion resulted in decompression without further complication. Minimal sterile fluid was recovered. Therefore the proposed diagnosis was a pneumatocele within the setting of infection. Pneumatoceles may be challenging at times to distinguish from a cavity particularly when surrounded by airspace disease however merit consideration in the differential diagnosis particularly in the absence of findings of a thick irregular wall.

The exact mechanism causing development of a pneumatocele is not known, but believed to develop due to a check valve type bronchiole or bronchiolar obstruction (1). Pneumatoceles most commonly undergo spontaneous remission within weeks to months without any known long term implications. Complications occur rarely and include pneumothorax, tension pneumatocele, and secondary infection of a pneumatocele. Usual treatment is directed towards the underlying pneumonia with appropriate antibiotics. In rare cases percutaneous drainage may be necessary and is ideally performed with a small bore catheter to minimize trauma. The role of positive pressure ventilation in development of a pneumatocele is unclear.

Bhupinder Natt, MD and Veronica Arteaga, MD

Divisions of Pulmonary and Thoracic Imaging

University of Arizona College of Medicine

Tucson, AZ

Reference

1. Lysy J, Werczberger A, Globus M, Chowers I. Pneumatocele formation in a patient with Proteus mirabilis pneumonia. Postgrad Med J. 1985;61(713):255-7. [CrossRef] [PubMed]

Reference as: Natt B, Arteaga V. Medical image of the week: pneumatocele. Southwest J Pulm Crit Care. 2014;9(2):126-7. doi: http://dx.doi.org/10.13175/swjpcc102-14 PDF

Medical Image of the Week: Idiopathic Pulmonary Artery Hypertension

Figure 1. EKG showing sinus rhythm, right bundle branch block and peaked ('pulmonary') p waves (arrow).

Figure 2. Two view chest X-ray showing right ventricular hypertrophy (arrows, note filling of the retrosternal space by an enlarged right ventricle in the lateral view) and enlarged central pulmonary arteries (arrowhead).

 

  Figure 3. Axial CT angiogram of the chest below the carina showing dilated pulmonary artery (diameter of pulmonary artery greater than aorta, arrow).

 

Figure 4. Panel A: Parasternal short axis view shows septal bowing to the left, a severely dilated right ventricle and a D-shaped left ventricle. Panel B: Four chamber view shows right atrial and ventricular dilatation.

A 39-year-old woman presented to the clinic with a history of progressive shortness of breath of 6-month duration associated with bilateral lower extremity edema, fatigue, lightheadedness, palpitations and occasional substernal chest pain. Her past medical history was unremarkable other than mild anemia. On physical exam her respiratory rate was 20 breaths per minute and O2 saturation 94% on room air by pulse oximetry. There was jugular venous distention at 12 cm, 2+ bilateral lower extremity edema, a 5/6 systolic murmur over the left sternal border with a sternal heave. Labwork was unremarkable except for an elevated BNP 657 (normal value < 100 pg/mL).

EKG (Figure 1) showed sinus rhythm with right bundle branch block. A 2-view chest X-ray (Figure 2) showed an enlarged right ventricle as well as dilated pulmonary arteries with no parenchymal infiltrates. CT angiography confirmed CXR findings (Figure 3) and was negative for pulmonary embolism. A 2D echocardiogram revealed a preserved left ventricle ejection fraction with right ventricular pressure of 80 mmHg + CVP, severe tricuspid regurgitation, decreased right ventricular function (as assessed by a Tricuspid annular plane systolic excursion of 10 mm) and flattened septum, suggestive of right ventricular overload (Figure 4). A right heart catheterization was performed revealing pulmonary pressures of 105/45 mmHg with a mean of 63 mmHg, a wedge pressure of 11 mmHg, a pulmonary vascular resistance of 13.19 Wood units and a cardiac output of 3.94 L/min.

The patient was admitted to the intensive care unit to start treatment with intravenous treprostinil and was eventually discharged home with subcutaneous treprostrinil.

Pulmonary arterial hypertension (PAH) is a disease of the pulmonary circulation characterized by a progressive elevation in pulmonary vascular resistance that leads to right ventricular failure and premature death. It is defined as a mean pulmonary artery pressure at rest of 25 mmHg or higher (1). Idiopathic (group 1) PAH requires the exclusion of parenchymal pathology or venous thromboembolic disease as well as a mean wedge pressure less than 15 mmHg. The initial symptoms of PH are the result of an inability to adequately increase cardiac output during exercise which eventually will progress to signs and symptoms of right ventricular failure such as lower extremity edema, syncope/presyncope and chest pain (2,3). Early recognition is of paramount importance to institute adequate treatment.

Roberto J. Bernardo, MD and Carlos Tafich Rios, MD

Internal Medicine Residency, Department of Medicine

University of Arizona, Tucson, AZ

References 

1. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College. Circulation. 2009. 119:2250-94. [CrossRef] [PubMed] 
2. Runo JR, Loyd JE. Primary pulmonary hypertension. Lancet. 2003. 361:1533-44. [CrossRef] [PubMed]
3. Peacock AJ. Primary pulmonary hypertension. Thorax. 1999;54:1107-18. [CrossRef] [PubMed]

Reference as: Bernardo RJ, Rios CT. Medical image of the week: idiopathic pulmonary artery hypertension. Southwest J Pulm Crit Care. 2014;9(2):101-3. doi: http://dx.doi.org/10.13175/swjpcc101-14   PDF

August 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 42-year-old non-smoking woman presented with a history of relatively sudden onset left chest pain and shortness of breath. Her past medical history was remarkable for psoriasis, treated with Enbrel® (etanercept). She also had a history of partial hysterectomy for fibroids and right oophorectomy. Frontal and lateral chest radiography (Figure 1) were 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 shows a left-sided pneumothorax
2. The chest radiograph shows a mediastinal mass
3. The chest radiograph shows bilateral linear and reticular opacities
4. The chest radiograph shows multifocal, bilateral consolidation
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. August 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(2):83-90. doi: http://dx.doi.org/10.13175/swjpcc104-14 PDF

Medical Image of the Week: Pneumocephalus

Figure 1. Coronal CT Scan Image (Brain Lab Protocol) showing air in continuity with the frontal sinuses where there is no bone between the frontal sinus and the brain.

A 53-year-old woman underwent left craniotomy at an outside hospital after a trauma related to a motor vehicle accident. She was recovering well from her surgery. Two months later she started having headache and noticed progressive difficulty with word finding. She also reported periodic rhinorrhea upon further questioning. She presented to the emergency room at an outside hospital where a CT head was done. She was subsequently transferred to our ICU for higher level of care. Her CT Head revealed pneumocephalus involving the left frontal lobe along with regional mass effect leading to left to right shift of the anterior interhemispheric fissure. A dedicated brain lab protocol showed air in continuity with the frontal sinuses with a bone defect between the frontal sinus and the brain. She was evaluated by ENT and Neurosurgery services. She was placed on 100% oxygen via non-rebreather mask, frequent neuro-checks and a redo of the left frontal craniotomy for repair of the skull base defect was performed.

Administration of postsurgical supplemental oxygen through a non-rebreather mask has shown to significantly increase the absorption rate of postcraniotomy pneumocephalus as compared with breathing room air (1). In a prospective study of thirteen patients with postoperative pneumocephalus that was estimated to be > 30 ml were alternately assigned to breathe 100% oxygen using a nonrebreather mask (treatment group) or to breathe room air (control group) for 24 hours. There was a significant difference (p = 0.009) between the mean rate of pneumocephalus volume reduction in the treatment (65%) and control groups (31%) per 24 hours.

Tauseef Afaq Siddiqi MD, Enas M. Al Zaghal MD, and Sairam Parthasarathy MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ

Reference

1. Gore PA, Maan H, Chang S, Pitt AM, Spetzler RF, Nakaji P. Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus. J Neurosurg. 2008;108(5):926-9. [CrossRef] [PubMed] 

Reference as: Siddiqi TA, Zaghal EM, Parthasarathy S. Medical image of the week: pneumocepahlus. Southwest J Pulm Crit Care. 2014;9(1):57-8. doi: http://dx.doi.org/10.13175/swjpcc095-14 PDF

Medical Image Of The Week: Septic Pulmonary Emboli Misdiagnosed As Metastatic Disease

Figure 1. Representative thoracic CT axial images showing multiple pulmonary nodules (red arrows).

A 54-year-old previously healthy man presented with acute onset of left-sided, sharp pleuritic chest pain and dry cough. He denied having fever, hemoptysis, shortness of breath, or unintentional weight loss. Review of system was positive for bright blood per rectum for the last year. He had a root canal procedure done 3 weeks prior to presentation. His is a 30 pack-year smoker, drinks alcohol occasionally, but denied any IV drug use.

On admission, he was afebrile and hemodynamically stable. Clinical examination was positive for fecal occult blood test. CBC revealed WBC of 12,800/mm³ and his hemoglobin was11.9 g/dL. Thoracic CT scan with contrast was negative for pulmonary embolism, but showed multiple bilateral pulmonary nodules suspicious for malignancy (Figure 1). The left upper lobe showed a subpleural 2.4 x 1.5 cm rounded opacity and emphysematous changes. CT of the abdomen and pelvis showed folds in the stomach but was otherwise unremarkable.

Esophagogastroduodenoscopy was negative. Colonoscopy showed non-bleeding internal hemorrhoids. He underwent percutaneous CT guided lung biopsy. Pathology report showed distended alveoli filled with polymorphonuclear leukocytes mixed with fibrin consistent with septic emboli and no evidence of malignancy.  Special stains for organisms were negative. Blood cultures were negative, Trans-esophageal echocardiograph was normal. Mandibular film done was negative for dental abscess. HIV serology, Quantiferon gold, ß-d glucan, Aspergillus, and mycobacterial culture of sputum were negative. During his hospital stay he developed a fever and his WBC count increased. He was empirically started on broad spectrum antibiotics and he clinically improved significantly.

Septic pulmonary embolus (SPE) is a serious and uncommon condition that poses a diagnostic challenge and carries a high mortality (1,2). Presenting symptoms are often non-specific. Blood cultures may be negative initially. Similarly, chest radiography is not helpful to establish a diagnosis. CT is more useful, usually showing multiple peripheral nodular opacities. SPE can be suspected by the presence of potential source of underlying infection, febrile illness and multiple pulmonary nodules.

Dima Dandachi MD and Sathish Krishnan MD

Department of Internal Medicine

Saint Francis Hospital

Evanston, IL

References

1. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med 2014;108(1):1-8. [CrossRef] [PubMed]
2. Shiota Y, Taniguchi A, Yuzurio S, Horita N, Hosokawa S, Watanabe Y, Tohmori H, Ono T; Okayama Respiratory Disease Study Group. Septic pulmonary embolism induced by dental infection. Acta Med Okayama. 2013;67(4):253-8. [PubMed] 

Reference as: Dandachi D, Krishnan S. Medical image of the week: septic pulmonary emboli misdiagnosed as metastatic disease. Southwest J Pulm Crit Care. 2014;9(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc083-14 PDF

Medical Image of the Week: Vascular Occlusion

Figure 1. Left arm angiogram showing complete occlusion of ulnar artery (red arrow).

Figure 2. Angiogram showing left radial artery complete occlusion (red arrow).

Figure 3. Left hand with necrotic fingers.

The patient is a 39 year-old woman with no significant past medical history presenting with progressive left hand pain for five days. The patient denied a history of Raynaud’s phenomenon or clotting disorders. She had no radial pulse on presentation and angiogram showed severe complete occlusion of the radial and ulnar arteries (Figures 1 and 2). She had an initial partial response with intra-arterial verapamil and nitroglycerin but her hand ischemia did not improve on heparin or with intra-arterial tissue plasminogen activator. Autoimmune and coagulation work-ups were negative. Her left hand finger necrosis at time of discharge is shown (Figure 3).  Further evaluation is ongoing for coagulation disorders.

Allison Shapiro MD, Carmen Luraschi-Monjagatta MD, Matthew Schreiber MD.

Department of Internal Medicine, Pulmonary and Critical Care, University of Nevada School of Medicine, Las Vegas, NV

Reference as: Shapiro A, Luraschi-Mongagatta C, Schreiber M. Medical image of the week: vascular occlusion. Southwest J Pulm Crit Care. 2014;9(1):36-7. doi: http://dx.doi.org/10.13175/swjpcc093-14 PDF