Medical Image of the Week: DBS Polysomnogram Artifact

Safal Shetty, MD

Kenneth S. Knox, MD 

Pulmonary, Allergy, Critical Care & Sleep Medicine

Banner University Medical Center

Tucson, AZ 

Figure 1. Thirty second epoch showing DBS artifact obscuring all recording channels except flow, efforts belts and the EKG channels. 

Figure 2. Ten second epoch showing the electrical artifact due to DBS.

A 79-year-old man with known Parkinson’s disease and status post deep brain stimulator (DBS) implantation underwent an overnight polysomnogram for clinical suspicion of obstructive sleep apnea. Artifact was seen on the polysomnogram recording (Figures 1 & 2).

Patient-related electrical artifacts may be seen from devices such as pacemakers, deep brain stimulators and vagal nerve simulators. Abrupt discontinuation of DBS is associated with a high likelihood of worsening of symptoms in patients with Parkinson’s disease (1). Patients with DBS are most commonly programmed in monopolar mode. Bipolar configuration, forms a short electrical dipole that affects a relatively smaller volume of tissue and generates far less artifact, suggesting that this may be an effective option in a Parkinsonian patient with indications for polysomnography (2).

References

1. Chou KL, Siderowf AD, Jaggi JL, Liang GS, Baltuch GH. Unilateral battery depletion in Parkinson's disease patients treated with bilateral subthalamic nucleus deep brain stimulation may require urgent surgical replacement. Stereotact Funct Neurosurg. 2004;82(4):153-5. [CrossRef] [PubMed]
2. Frysinger RC, Quigg M, Elias WJ. Bipolar deep brain stimulation permits routine EKG, EEG, and polysomnography. Neurology. 2006;66(2):268-70. [CrossRef] [PubMed]

Cite as: Shetty S, Knox KS. Medical image of the week: DBS polysomnogram artifact. Southwest J Pulm Crit Care. 2015;11(4):151-2. doi: http://dx.doi.org/10.13175/swjpcc096-15 PDF

October 2015 Imaging Case of the Month

Philip W. Ho, MD

Stacey Black, MD

Clinton Jokerst, MD

Department of Medical Imaging

Banner University Medical Center

Tucson, AZ

Clinical History: A 68-year old Hispanic man presented to the emergency department with dry cough for two days and was found to be hypoxic, with O₂ saturation in the high 80’s. The patient’s clinical history is significant for remote 3 year smoking history and former occupation as a miner. Frontal and lateral chest radiography (Figure 1) was obtained.

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

Based on the appearance of the chest radiograph, which of the following is the least likely diagnosis? (Click on the correct answer to proceed to the second of five panels)

1. Osteophyte
2. Peripheral nerve sheath tumor
3. Pneumonia
4. Pulmonary arteriovenous malformation (AVM)

Cite as: Ho PW, Black S, Jokerst C. October 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(4)144-50. doi: http://dx.doi.org/10.13175/swjpcc117-15 PDF 

Medical Image of the Week: Hydropneumothorax

Figure 1. Gastrograffin Esophagram revealing the presence of contrast in the right pleural space (arrow).

Figure 2. Chest CT revealing right hydropneumothorax containing Gastrograffin. Note the presence of Gastrograffin in the esophagus as well as pleural space (arrow).

Figure 3. Chest CT showing a communicating channel between the esophagus and right pleural space (arrow).

A 67-year-old woman who underwent a robotic laparoscopic surgical repair secondary to a large paraesophageal hernia with gastric volvulus. Post-operatively, she developed respiratory distress and a chest CT revealed a large right hydropneumothorax. A Gastrograffin esophagram was done showing Gastrograffin in the esophagus, stomach as well as in the right pleural space suggesting an esophageal-pleural fistula (Figure 1). A chest tube was placed and contrast was present revealing a esophageal-pleural fistula (Figures 2 and 3).

Esophageal perforation should be considered in all patients with unexplained chest pain. Rapid recognition and diagnosis is key as delay in treatment is associated with increased mortality and morbidity (1). Causes of esophageal perforations include upper endoscopy, Boerhaave’s syndrome, foreign body ingestion, trauma, malignancy and intra-operative injury (2). Treatment depends on the location and the extent of the perforation as surgical intervention is the gold standard.

Bassel Saksouk MD¹, Choua Thao MD¹ and Carmen Luraschi MD²

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Division of Pulmonary and Critical Care

Las Vegas, NV

References

1. Iannettoni MD, Vlessis AA, Whyte RI, Orringer MB. Functional outcome after surgical treatment of esophageal perforation. Ann Thorac Surg. 1997;64(6):1606-9. discussion 1609-10. [PubMed]
2. Bayram AS, Erol MM, Melek H, Colak MA, Kermenli T, Gebitekin C. The success of surgery in the first 24 hours in patients with esophageal perforation. Eurasian J Med. 2015;47(1):41-7. [CrossRef] [PubMed] 

Cite as: Saksouk B, Thao C, Luraschi C. Medical image of the week: hydropneumothorax. Southwest J Pulm Crit Care. 2015;11(3):124-5. doi: http://dx.doi.org/10.13175/swjpcc095-15 PDF

Medical Image of the Week: Pulsus Paradoxus

Figure 1. Arterial line (red) showing pulsus paradoxus.

A 75 year-old man was admitted for suspected septic shock and acute renal failure requiring hemodialysis. He did not required mechanical ventilation. An arterial line was placed and he was found to have pulsus paradoxus (Figure 1). A transthoracic echocardiogram showed early right atrial diastolic collapse consistent with cardiac tamponade and he underwent a pericardial window.

Pulsus paradoxus is the drop in more than 10 mm Hg of systolic pressure during the inspiratory phase (1). Causes of pulsus paradoxus include cardiac tamponade, constrictive pericarditis, severe asthma and chronic obstructive pulmonary disease, restrictive cardiomyopathy, tension pneumothorax, tracheal compression, and circulatory shock (2). With early recognition of this clinical sign, prompt treatment of the underlying etiology can produce a more desirable outcome.

Choua Thao MD¹, Mohanad Hasan MD¹, Hamayon Babary MD¹, and Carmen Luraschi MD²

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Division of Pulmonary and Critical Care

Las Vegas, NV

References

1. Hamzaoui O, Monnet X, Teboul JL. Pulsus paradoxus. Eur Respir J. 2013;42(6):1696-705 [CrossRef] [PubMed]
2. Swami A, Spodick DH. Pulsus paradoxus in cardiac tamponade: a pathophysiology continuum. Clin Cardiol. 2003;26(5):215-7. [CrossRef] [PubMed]

Cite as: Thao C, Hasan M, Babary H, Luraschi C. Medical image of the week: pulsus paradoxus. Southwest J Pulm Crit Care. 2015:11(3):116. doi: http://dx.doi.org/10.13175/swjpcc093-15 PDF

Medical Image of the Week: Superior Vena Cava Syndrome

Figure 1. Contrast-enhanced CT of the chest in the arterial phase in the coronal plane demonstrates a large paratracheal mass (blue circle) that is invading the SVC resulting in the tumor thrombus noted in right heart chambers.

Figure 2. Contrast-enhanced CT of the chest in the arterial phase at the level of the right atrium (blue arrow), tricuspid annulus (yellow arrow), and right ventricle (green arrow) demonstrates a thrombus extending from the right atrium across the tricuspid valve in to the right ventricle.

A 65 year old Native American man with past medical history significant for hypertension presented with a two week history of generalized edema, most prominent in the face and upper extremities. The patient had gained 30 lbs in the previous 6 months. He denied any fever, night sweats, dyspnea, hemoptysis, change in voice, chest pain, abdominal pain, nausea, vomiting, or hematemesis but did acknowledge a 40+ pack-year smoking history. Family history was significant for two brothers deceased from lung cancer. On presentation, he was hemodynamically stable, had visibly distended neck veins and collateral veins on the chest and abdomen. Routine laboratory tests included a comprehensive metabolic panel remarkable for mild transaminitis, complete blood count with thrombocytopenia (69,000) and mild anemia (hemoglobin 13.5).  Urinalysis and infectious workup were unremarkable. A CT chest/abdomen/pelvis confirmed superior vena cava (SVC) syndrome from a thrombus in the right atrium extending cephalad into the SVC and left brachiocephalic vein. Patient was started on dexamethasone 4mg every 6 hours and a heparin drip. A fine needle biopsy of the large mediastinal paratracheal mass showed non-small cell lung carcinoma.  He received cycle 1 of carboplatin and docetaxel. Five days after chemotherapy, patient had large volume hemoptysis. Repeat CTA chest demonstrated enlargement of the right suprahilar mass invading the mediastinum/SVC with extension into the right atrium and crossing into the right ventricle (Image 1 and 2). Considering severity of the disease and poor prognosis patient and patient’s family accepted comfort care.

SVC syndrome results from mechanical obstruction of the SVC. Dyspnea, facial swelling and distended neck veins are the characteristic clinical manifestations (1). In the era of antibiotics, 70-90% of cases are due to mediastinal malignancies (2). Symptomatic relief with steroids, radiation/chemotherapy and intravascular stents are mainstays of emergent treatment (1). However, similar to our case, due to aggressive nature of the disease the mortality is inevitable.

Manjinder Kaur DO, Charity Adusei MS III, Tammer Elaini MD, and Laura Meinke MD

Department of Medicine

The University of Arizona and Sourthern Arizona VA Health Care System

Tucson, AZ, USA

References

1. Khan UA, Shanholtz CB, McCurdy MT. Oncologic mechanical emergencies. Emerg Med Clin North Am. 2014;32(3):495-508. [CrossRef] [PubMed]
2. Rossow CF, Luks AM. A 68-year-old woman with hoarseness and upper airway edema. Ann Am Thorac Soc. 2014;11(4):668-70. [CrossRef] [PubMed]

Cite as: Kaur M, Adusei C, Elaini T, Meinke L. Medical image of the week: superior vena cava syndrome. Southwest J Pulm Crit Care. 2015;11(3):114-5. doi: http://dx.doi.org/10.13175/swjpcc084-15 PDF

Medical Image of the Week: Septated Pleural Effusion

Figure 1. Thoracic ultrasound showing pleural effusion with multiple septations.

An 83 year old man with a history of metastatic malignant melanoma and atrial fibrillation on warfarin was admitted for shortness of breath. He underwent a diagnostic and therapeutic thoracentesis for a large right sided pleural effusion, suspected to be malignancy related. Three days later, he had transferred to the ICU for respiratory distress. An ultrasound of the thorax revealed a large loculated effusion with multiple septations (Figure 1). A large bore chest tube was placed and revealed a hemothorax, which may have been related to the previous thoracentesis.

In an observational study of ultrasound characteristics of pleural effusions, complex septations were more commonly seen in non-malignant effusions than malignant effusions (25.4% vs. 7.5%). In non-malignant effusions, the septated pattern was associated with infections, specifically tuberculosis and pneumonia (1).

While metastases in melanoma commonly involve the thoracic cavity, malignant pleural effusions are rare and are seen in about 2% of cases. In very rare instances, effusions from metastatic melanoma can be black in appearance (2). There has also been a case report of a massive hemothorax related to melanoma implants on the pleura (3).

Candy Wong, MD¹; Soyoung Park, MD²; Courtney Walker, DO²; and Laura Meinke, MD¹

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

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Bugalho A, Ferreira D, Dias SS, Schuhmann M, Branco JC, Marques Gomes MJ, Eberhardt R. The diagnostic value of transthoracic ultrasonographic features in predicting malignancy in undiagnosed pleural effusions: a prospective observational study. Respiration. 2014;87:270-8. [CrossRef] [PubMed]
2. Liao WC, Chen CH, Tu CY. Black pleural effusion in melanoma. CMAJ. 2010;182(8):E314. [CrossRef] [PubMed]
3. Gibbons JA, Devig PM. Massive hemothorax due to metastatic malignant melanoma. Chest. 1978;73(1):123. [CrossRef] [PubMed]

Cite as: Wong C, Park S, Walker C, Meinke L. Medical image of the week: septated pleural effusion. Southwest J Pulm Crit Care. 2015;11:110-1. doi: http://dx.doi.org/10.13175/swjpcc085-15 PDF

September 2015 Imaging Case of the Month

Philip W. Ho, M.D.

Clinton Jokerst, M.D.

Department of Medical Imaging

Banner University Medical Center

Tucson, AZ

Clinical History: A 51-year-old white man with a past medical history significant for weight, loss, hypertension and a 60 pack-year smoking history presented to the emergency department with hemoptysis and chest pain. He was afebrile with an unremarkable CBC. Frontal chest radiography (Figure 1) was obtained.

Figure 1. Frontal chest radiography.

There are multiple large pulmonary nodules scattered throughout both lungs. Which is the least likely diagnosis? (Click on the correct answer to proceed to the second of five panels)

1. Fungal infection
2. Granulomatosis with polyangiitis (GPA)
3. Metastatic disease
4. Septic emboli

Reference as: Ho PW, Jokerst C. September 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(3):105-9. doi: http://dx.doi.org/10.13175/swjpcc109-15 PDF

Medical Image of the Week: Fluorescent Urine

Figure 1. Panel A: urine in Foley catheter collection bag is seen to fluoresce under UV light. Panel B: urine placed in a glass vial (left) relative to saline placed in a glass vial (right) under UV illumination.

A 49-year-old woman presented to the emergency department (ED) via EMS after being found lying on the ground on a hiking path with depressed mental status and confusion. Paramedics found empty bottles of medication surrounding her including quetiapine, clonazepam, and flurazepam, as well as syringes allegedly filled with antifreeze. Because of her severe encephalopathy on presentation, she was intubated shortly after arrival for airway protection. A Foley catheter was placed, and the urine was examined under UV light, revealing fluorescent urine. Ethylene glycol toxicity was suspected given this finding and the history given by EMS; however, initial and then repeat lab studies demonstrated no anion gap, metabolic acidosis, or osmolar gap, and none of these findings developed later during her ICU course. Fomepizole was not administered due to the lack of suggestive lab findings. The patient recovered and was successfully weaned from mechanical ventilation. After extubation, she admitted to taking the medications but explained that she was unable to draw up the antifreeze into the syringe to inject it as planned and did not drink any.

The finding of urine fluorescence can be suggestive of ethylene glycol poisoning, as many antifreeze products contain fluorescein, a fluorescent dye added to assist in identifying coolant leaks. Fluorescein is excreted in the urine when ingested. This fluorescent urine has been suggested as an adjunct test in the diagnosis of ethylene glycol toxicity. In one study, healthy volunteers were given fluorescein doses equivalent to that found in the minimum lethal dose of ethylene glycol (1). Urine fluorescence was found in 75% of these subjects at 1-2 hours post-ingestion and in 48% at 4-6 hours post-ingestion. A study of pediatric patients found a high rate of fluorescence in the urine of normal pediatric volunteers suggesting a poor specificity for the detection of ethylene glycol poisoning (2). Antifreeze products containing propylene glycol, which also contain fluorescein, are now available, and many other substances, including many drugs, nutrients, and food or cosmetic additives have been described to cause urine fluorescence (2). This makes the finding of urine fluorescence under UV light suggestive in the correct clinical setting, but not sufficiently specific to be diagnostic of ethylene glycol ingestion.

Cameron Hypes MD MPH^1,2, Phillip Hoverstadt MD MPH², J. Scott Lowry MD², Nicholas B. Hurst MD, MS^2,3, and F. Mazda Shirazi, MD, PhD^2,3

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

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

³ Arizona Poison & Drug Information Center, College of Pharmacy, University of Arizona; Tucson, AZ

References

1. Wallace KL, Suchard JR, Curry SC, Reagan C. Diagnostic use of physicians' detection of urine fluorescence in a simulated ingestion of sodium fluorescein–containing antifreeze. Ann Emerg Med.2001;38(1):49-54. [CrossRef] [PubMed]
2. Casavant MJ, Shah MN, Battels R. Does fluorescent urine indicate antifreeze ingestion by children? Pediatrics. 2001;107(1):113-4. [CrossRef] [PubMed] 

Cite as: Hypes C, Hoverstadt P, Lowry JS, Hurst NB, Shirazi FM. Medical image of the week: fluorescent urine. Southwest J Pulm Crit Care. 2015;11(3):103-4. doi: http://dx.doi.org/10.13175/swjpcc083-15 PDF

Medical Image of the Week: Panlobular Emphysema

Figure 1. PA chest radiograph showing predominately lower lobe emphysematous changes.

A 60 year old female, non-smoker with a past medical history of chronic rhinosinusitis with nasal polyps presented with an eight year history of productive cough and dyspnea. Previous treatment with inhaled corticosteroids, courses of systemic corticosteroids and antibiotics provided modest improvement in her symptoms. Pulmonary function testing revealed a severe obstructive ventilatory defect without significant bronchodilator response and reduced diffusing capacity (DLCO). Chest x-ray surprisingly revealed lower lobe predominant emphysematous changes (Figure 1). Alpha-1-antitrypsin level was within normal range at 137 mg/dL.

Panlobular emphysema represents permanent destruction of the entire acinus distal to the respiratory bronchioles and is more likely to affect the lower lobes compared to centrilobular emphysema (1). Panlobular emphysema is associated with alpha-1-antitrypsin deficiency, intravenous drug abuse specifically with methylphenidate and methadone, Swyer-James syndrome, and obliterative bronchiolitis. Whether this pattern is seen as part of normal senescence in non-smoking individuals remains controversial (2). Panlobular emphysema may represent a phenotypically more severe disease than centrilobular emphysema and may coexist along a continuum with centrilobular emphysema (3).

Ashish Mathur MD and Tara Carr MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona College of Medicine

Tucson, Arizona

References

1. Litmanovich D, Boiselle PM, Bankier AA. CT of pulmonary emphysema-current status, challenges, and future directions. Eur Radiol. 2009;19(3): 537-51. [CrossRef] [PubMed]
2. Takahashi M, Fukuoka J, Nitta N et al. Imaging of pulmonary emphysema: a pictorial review. Int J Chron Obstruct Pulmon Dis. 2008;3(2):193-204. [PubMed]
3. Finkelstein R, Ma HD, Ghezzo H, Whittaker K, Fraser RS, Cosio MG. Morphometry of small airways in smokers and its relationship to emphysema type and hyperresponsiveness. Am J Respir Crit Care Med. 1995;152(1):267-76. [CrossRef] [PubMed]

Reference as: Mathur A, Carr T. Medical image of the week: panloubular emphysema. Southwest J Pulm Criti Care. 2015;11(2):86-7. doi: http://dx.doi.org/10.13175/swjpcc081-15 PDF

Medical Image of the Week: Necrotizing Pancreatitis

Figure 1. Contrast-enhanced CT of the abdomen and pelvis demonstrates innumerable foci of gas adjacent to the pancreatic head/body junction (red arrow) with marked inflammation of the pancreatic head (blue arrow). These findings are consistent with necrotizing pancreatitis.

A 60-year-old man with a past medical history significant for coronary artery disease status post percutaneous coronary intervention was admitted to Banner University Medical Center for acute pancreatitis complicated by a pericardial effusion requiring pericardiocentesis. The following day, the patient developed severe shortness of breath requiring increasing amounts of supplemental oxygen. The patient was emergently transferred to ICU for noninvasive bilevel positive airway pressure ventilation, but he subsequently required intubation. Throughout his worsening condition, he denied any abdominal pain, only relaying ongoing substernal chest pain. His troponins, however, remained negative and echocardiography failed to show any reaccumulation of the pericardial effusion.

CT scan of the chest failed to show any pulmonary embolism. But, CT abdomen displayed acute pancreatitis complicated by peripancreatic gas consistent with necrotizing pancreatitis (Figure 1). Emergent laparotomy was completed. There were no signs of stomach or duodenal perforation. Purulent fluid was removed from the lesser sac and an irrigating stump was placed.

Hem Desai MD¹, Tammer Elani MD¹, Nour Alhoda Parsa MD¹ and Kareem Ahmad MD²

¹Department of Internal Medicine and ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona

Tucson, AZ

Reference

1. Thoeni RF. The revised Atlanta classification of acute pancreatitis: Its importance for the radiologist and its effect on treatment. Radiology. 2012;262(3):751-64. [CrossRef] [PubMed]

Reference as: Desai H, Elani T, Parsa NA, Ahmad K. Medical image of the week: necrotizing pancreatitis. Southwest J Pulm Crit Care. 2015;11(2):84-5. doi: http://dx.doi.org/10.13175/swjpcc080-15 PDF

Medical Image of the Week: Pancoast Tumor

Figure 1. Chest radiograph demonstrating pleural and parenchymal mass in the right lung apex (red arrow) with tracheal deviation to the left (blue arrow).

Figure 2. Right shoulder radiograph demonstrating the apical mass (blue arrow).

Figure 3. Chest CT (axial image) demonstrating a large mass in the right lung apex with tracheal deviation to the left.

A 39 year-old man presented to the Emergency Department with right shoulder, back and abdominal pain. He had no significant medical problems except for a 20 pack-year history of smoking. Laboratory work and an abdominal ultrasound were unremarkable and he was discharged. Approximately one week later he returned to the Emergency Department with persistent right shoulder and back pain and mild numbness and tingling of the second, third and fourth digits of his right hand. He also described weakness of his right upper eyelid and noticed he was sweating only on the left side of his face.  On physical exam, anisocoria was noted with the right pupil being smaller than the left pupil.

A chest x-ray and right shoulder x-ray revealed extensive pleural and parenchymal mass in the right apex and tracheal deviation to the left (Figures 1 and 2). A CT chest with contrast showed findings consistent with extensive Pancoast neoplasm in right upper lobe, left tracheal deviation, and partial destruction of right first rib and transverse process of first dorsal vertebral body, with evidence of extension into right lower neck (Figure 3). An MRI revealed widespread metastatic disease of the spine with right-sided T10 intraspinal extradural neoplasm causing severe thoracic spinal cord compression.  He underwent surgical decompression. Biopsy of the lung lesion revealed poorly differentiated sarcomatoid carcinoma. The patient received chemotherapy with doxorubicin and ifosfamide and radiation to the right lung, cervical and thoracic spine.

Pancoast’s syndrome includes Horner’s syndrome (ptosis, miosis and anhidrosis), upper extremity pain, and atrophy of the hand muscles. These symptoms result from an apical thoracic mass, most commonly a bronchogenic carcinoma that invades into the thoracic inlet and causes destruction of the cervical sympathetic nerves and brachial plexus (1). Shoulder pain is the most common initial symptom and patients may receive treatment for osteoarthritis or bursitis resulting in delay in diagnosis. While malignancy is the most common cause, infectious etiologies are an important consideration as well. A recent review documented 31 cases of Pancoast’s syndrome secondary to a variety of infectious causes including bacterial, fungal, mycobacterial and parasitic organisms (2).  

Emily Des Champs MS, ACNP-BC, ACHPN, CCRN¹ and Linda Snyder MD²

¹Department of Medicine, Geriatrics, Palliative and General Medicine, Banner University Medical Center-Tucson

²Department of Medicine, Pulmonary, Critical Care and Palliative Medicine, Banner University Medical Center-Tucson

References

1. Glassman LR, Hyman K. Pancoast tumor: a modern perspective on an old problem. Curr Opin Pulm Med. 2013;19:340-3. [CrossRef] [PubMed]
2. White HD, White BA, Boethel C, Arroliga AC. Pancoast's syndrome secondary to infectious etiologies: a not so uncommon occurrence. Am J Med Sci. 2011;341(4):333-6. [CrossRef] [PubMed] 

Reference as: Des Champs E, Snyder L. Medical image of the week: Pancoast tumor. Southwest J Pulm Crit Care. 2015;11(2):82-3. doi: http://dx.doi.org/10.13175/swjpcc069-15 PDF 

August 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology 

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 69-year-old man with a history of hairy cell leukemia, in remission, and “smoldering” multiple myeloma (IgG kappa and M-spike with IgM kappa light chain), as well as obstructive sleep apnea treated with continuous positive airway pressure, presents with slowly progressive dyspnea, occasional cough (sometimes productive of yellow sputum) and fatigue, the latter associated with difficulty sleeping and daytime somnolence. Overnight oximetry disclosed 75% of the patient’s oxygen saturations were less than 90%. He is a former smoker (2.5 cigarettes / day for 15 years), but uses cannabis chronically. A chest radiograph (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 second of nine panels)

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows bilateral nodules and masses
4. The frontal chest radiograph shows large lung volumes with a cystic appearance
5. The frontal chest radiograph shows no abnormal findings

Reference as: Gotway MB. August 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(2):70-81. doi: http://dx.doi.org/10.13175/swjpcc108-15 PDF

Medical Image of the Week: Post-Anginal Sepsis Syndrome

Figure 1.  Computed tomography of soft tissue of neck showing enhancing fluid density (red arrow) within the left palatine tonsil compatible with peritonsillar abscess.

Figure 2. Anterior-posterior (panel A) and lateral (panel B) of the contrast-enhanced computed tomography of soft tissue of the neck showing filling defect throughout the entire left internal jugular vein from the skull base to its insertion at the left subclavian vein consistent with total occluding thrombus (yellow arrows).

A 22-year-old woman presented to our hospital with complaints of a persistent sore throat and intermittent low grade fever associated with chills for 10 days despite 5 days of antibiotics. During this time she had also developed progressive difficulty in swallowing due to associated pain that had progressed to limited mouth opening for past 2 days. Her vital signs were normal except for low grade fever. On limited oral cavity exam bilateral tonsils appeared enlarged and erythematous; tenderness was noted on palpation of left side of the antero-lateral neck with restriction of neck movements to the left. Basic labs revealed leukocytosis (WBC of 20.2 k/mm³) but was otherwise normal. Contrast-enhanced computed tomography of soft tissue of the neck was obtained which revealed bilaterally enlarged tonsils with  small abscess within left palatine tonsil, filling defect throughout the entire left internal jugular vein from the skull base to its insertion at the left subclavian vein consistent with acute thrombosis (Figures 1 and 2). She improved considerably with intravenous antibiotics. Rapid strep test, blood and throat culture were negative. HIV, Epstein-Barr virus and cytomegalovirus antibodies were also negative. As she clinically improved we discharged her home with oral antibiotics and did not start her on anticoagulation.

Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein (IJV) commonly caused by anaerobic oro-pharyngeal flora usually by Fusobacteirum necrophorum although a wide range of bacteria may cause the syndrome (1,2). Infection is usually followed by fulminant sepsis. The infection typically originates in the palatine tonsils or peritonsillar tissue which spreads into the lateral pharyngeal space causing septic thrombophlebitis of IJV which is usually followed by distal septic embolization, resulting in multi-organ involvement with lung being the most commonly affected. Diagnosis is usually established on the presence of thrombus in IJV and a positive blood culture, but cultures can be negative in about 12 % of cases. Computed tomography of neck with contrast is the diagnostic modality of choice to demonstrate the thrombus. Prolonged course of Intravenous antibiotic (3-6 weeks) covering F. necrophorum and oral streptococci is the cornerstone of treatment. Currently there are no clear guidelines for the use of anticoagulation due to its rarity and lack of randomized controlled studies.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD and Venu Ganipisetti, MD

Department of Internal Medicine,

Presence Saint Francis Hospital

Evanston, IL

References

1. Srivali N, Ungprasert P, Kittanamongkolchai W, Ammannagari N. Lemierre's syndrome: An often missed life-threatening infection. Indian J Crit Care Med. 2014;18(3):170-2. [CrossRef] [PubMed]
2. Pinheiro PE, Miotto PD, Shigematsu NQ, Tamashiro E, Valera FC, Anselmo-Lima WT. Lemierre's syndrome: a pharyngotonsillitis complication. Braz J Otorhinolaryngol. 2015;81(1):115-6. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: post-anginal sepsis syndrome. Southwest J Pulm Crit Care. 2015;11(2):66-7. doi: http://dx.doi.org/10.13175/swjpcc074-15 PDF

Medical Image of the Week: Teenage Tonsils

Figure 1. Tonsils showing shallow ulcers (arrows) secondary to coxsakievirus.

Figure 2. Enlarged tonsils R>L secondary to infectious mononucleosis.

An 18 year old woman complained of gradual onset throat pain and symptoms of a viral URI with nasal congestion, conjunctivitis and coryza. Later, faint macular rash appeared on her hands. Shallow ulcers developed on her tonsils (Figure 1). She was diagnosed with coxsakie viral infection and treated conservatively with ibuprofen.

A 19 year old man was seen for fatigue, malaise and odynophagia. Because of concern for peritonsilar abscess due to R>L tonsil enlargement (Figure 2) he was given intravenous steroids and antibiotics. His pain improved dramatically and he tested positive for infectious mononucleosis.

Adam M. Knox and Alexander G. Chiu, MD

Department of Otolaryngology

University of Arizona, Tucson

Reference as: Knox AM, Chiu AG. Medical image of the week: teenage tonsils. Southwest J Pulm Crit Care. 2015;11(1):51-2. doi: http://dx.doi.org/10.13175/swjpcc071-15 PDF

Medical Image of the Week: Focal Myopericarditis

Figure 1. Transverse view (panel A) and longitudinal view (panel B) of MRI with gadolinium enhanced contrast of chest showing abnormal enhancement at the level of the cardiac apex and also at the mid aspect of the infero-lateral wall and near the cardiac base within the lateral wall, consistent with the clinically suspected diagnosis of focal myopericarditis.

A 44-year-old man with no significant past medical history was admitted with a history of two episodes of substernal chest pain unrelated to exertion which had resolved spontaneously. Admission vital signs were within normal limits and physical examination was unremarkable. Basic lab tests were normal and urine toxicology was negative. Electrocardiogram was unremarkable with no ST/T changes. Troponin I was elevated at 4.19 which trended up to 6.57. An urgent cardiac angiogram was done which revealed normal patent coronaries. His transthoracic echocardiogram was also reported to be normal. He continued to have intermittent episodes of chest pain that was partially relieved by morphine. Erythrocyte sedimentation rate and C-reactive protein were elevated. Work up for autoimmune diseases, vasculitis, myocarditis panel were insignificant. Later, magnetic resonance imaging (MRI) with gadolinium enhanced contrast (Figure 1) was obtained which showed abnormal epicardial/subepicardial myocardial enhancement within the inferolateral wall and cardiac apex consistent with focal myopericarditis. He was started on Ibuprofen and colchicine. His chest pain significantly improved and he is currently following up as an outpatient.

Acute myo-pericarditis is primarily a pericarditic syndrome with variable myocardial involvement which is usually seen in male adolescents (1,2). There are 3 main etiologic categories: idiopathic, infectious or immune mediated. Patients present with chest pain that is sharp in nature with gradual onset radiating to the interscapular region, increasing with inspiration and easing with leaning forward. Pericardial friction rub on physical exam is considered pathognomonic. A typical pattern of ECG evolution includes diffuse ST segment elevation and PR depression, followed by normalization of ST and PR segments and then diffuse T wave inversion. Troponin I levels may be elevated, provides a rough estimate of the extent of myocardial inflammation. Cardiac MRI with gadolinium contrast is the best imaging modality to define the extent of myocardial involvement and patency of coronary system which is not always readily available. Therapy of choice is aspirin (1-1.5 g/day as mean dose) or nonsteroidal anti-inflammatory drugs such as ibuprofen for 7-10 days until symptom resolution. Colchicine should be the initial therapy in all refractory cases and in recurrent pericarditis. Physical exercise is contraindicated for at least 6 months from the onset of illness.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD, and Venu Ganipisetti MD

Department of Internal Medicine,

Presence Saint Francis Hospital

Evanston, IL USA

References

1. Imazio M, Cooper LT. Management of myopericarditis. Expert Rev Cardiovasc Ther. 2013;11(2):193-201. [CrossRef] [PubMed]
2. Sharma J, Fernandes N, Alvarez D, Khanna S.Acute myopericarditis in an adolescent mimicking acute myocardial infarction. Pediatr Emerg Care. 2015;31(6):427-30. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: focal myopericaditis. Southwest J Pulm Crit Care. 2015;11(1):47-8. doi: http://dx.doi.org/10.13175/swjpcc064-15 PDF

Medical Image of the Week: Boerhaave's Syndrome During Colonoscopy

Figure 1. Chest X ray showing bilateral subcutaneous emphysema extending from the supraclavicular area and above to the neck.

Figure 2. Video of representative coronal views of the thoracic CT scan showing subcutaneous emphysema in the supraclavicular area and neck.

Figure 3. Fluoroscopic esophagram revealing a focus of oral contrast actively extravasating (white arrow) approximately at 2.5 cm above the gastro-esophageal junction consistent with a small perforation.

A 76-year-old woman with no significant past medical history underwent outpatient screening colonoscopy. The procedure was difficult due to a tortuous colon and only multiple diverticula were visualized. She vomited once during the procedure. In the immediate postoperative period, she complained of neck swelling. Her vital signs were stable. On examination, right sided neck and facial swelling with palpable crepitations were noticed as well as coarse breath sounds heard on auscultation of both lung fields. Immediate chest X-ray (Figure 1) was obtained which showed bilateral subcutaneous emphysema extending from the supraclavicular area and above to the neck. Subsequent thoracic CT scan showed extensive subcutaneous air within the soft tissues of the neck bilaterally, extending into the mediastinum and along the anterior chest wall (Figure 2). An esophagram (Figure 3) revealed a focus of oral contrast actively extravasating approximately at 2.5 cm above the gastro-esophageal junction consistent with a small perforation. She underwent left thoracotomy with esophageal repair. Further hospital course was uncomplicated and she was discharged to a sub-acute rehabilitation facility. 

Boerhaave's syndrome is a spontaneous perforation of the esophagus due to sudden increase in intra-esophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting (1). The tear usually occurs at the left posterolateral wall of the lower third of the esophagus. Usually patients have severe retching and vomiting which is followed by excruciating retrosternal chest and upper abdominal pain after perforation. Other manifestations are odynophagia, tachypnea, dyspnea, fever, and shock. On physical examination subcutaneous emphysema (crepitation) is an important diagnostic feature. Chest radiograph usually reveals mediastinal or free peritoneal air as the initial manifestation, and hours to days later pleural effusion with or without pneumothorax, widened mediastinum, and subcutaneous emphysema are typically seen. The diagnosis of esophageal perforation can also be confirmed by water-soluble contrast esophagram using Gastrograffin, which reveals the location and extent of extravasation of contrast. Treatment depends upon the size and location of the perforation. Surgery is generally required for thoracic perforations while cervical perforations can often be managed conservatively with continuous nasogastric suction, intravenous broad-spectrum antibiotics, and parenteral nutrition.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD and Venu Ganipisetti MD

Department of Internal Medicine

Presence Saint Francis Hospital

Evanston, IL USA

Reference

1. Nirula R. Esophageal perforation. Surg Clin North Am. 2014;94(1):35-41. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: Boerhaave's syndrome during colonoscopy. Southwest J Pulm Crit Care. 2015;11(1):42-44. doi: http://dx.doi.org/10.13175/swjpcc058-15 PDF 

Medical Image of the Week: Pott’s Disease

Figure 1. Axial CT scan showing a heterogeneous dense mass-like consolidation in the medial aspect of the right lung apex (arrow).

Figure 2. MRI C-spine (axial T2-weighted images). Panel A: soft tissue marrow edema surrounding the posterior process of the C7 vertebral body and it’s contiguous with a heterogeneous infiltrative process of the right medial lung apex (arrow).  Panel B: C7 vertebral body compression (arrow).

Figure 3. Right upper lung biopsy showing necrotizing granulomas (arrow) and histiocytes aggregates.

A 22 year-old man with a history of asthma presented with a two-month history of progressive right upper extremity weakness with back pain, weight loss, and night sweats. CT scan of the chest revealed mass-like infiltrative mass in the right lung apex with mediastinal and hilar lymphadenopathy (Figure 1). An MRI cervical spine showed a large infiltrating process at the right medial lung apex with vertebral body compression (Figure 2).

A CT-guided lung biopsy was performed and it showed necrotizing granulomatous inflammation (Figure 3). Pott’s disease was diagnosed and the patient started on anti-tuberculous treatment with a good recovery.

Pott’s disease is a common cause of spinal infection and its clinical presentations are nonspecific. Early findings on imaging may reveal loss of vertebral body height, bone sequestration, sclerosis, and paraspinal mass with calcification (1).  A diagnosis of this condition must be made early as prompt treatment may reduce significant morbidity such as spine deformities to neurologic deficits.

Choua Thao MD¹, David G. Kuykendall MD², Matthew P. Schreiber MD, MHS⁴, and Carmen Luraschi MD³

University of Nevada School of Medicine: Las Vegas

¹Department of Internal Medicine

²Department of Family Medicine

³Division of Pulmonary and Critical Care

Las Vegas, NV

⁴MedStar Georgetown University Hospital/Washington Hospital Center, Washington, DC

Reference

1. Rivas-Garcia A, Sarria-Estrada S, Torrents-Odin C, Casas-Gomila L, Franquet E. Imaging findings of Pott's disease. Eur Spine J. 2013;22:567-78. [CrossRef] [PubMed]

Reference as: Thao C, Kuykendall DG, Schreiber MP, Luraschi C. Medical image of the week: Pott's disease. Southwest J Pulm Crit Care. 2015;11(1):36-7. doi: http://dx.doi.org/10.13175/swjpcc066-15 PDF 

July 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology 

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 40-year-old woman with a history of left breast malignancy diagnosed 11 years earlier, initially treated with lumpectomy, radiation, and chemotherapy (doxorubicin, cyclophosphamide, paclitaxel, followed by Herceptin), later treated with mastectomy following recurrence 2 years after diagnosis, presented with a several month history of upper respiratory infectious symptoms, including congestion, productive cough, and rhinorrhea. The patient also complained of some fatigue, although she was still active; she denied shortness of breath initially, but claimed that increasing breathlessness had developed more recently, limiting her exercise tolerance. The patient denied gastrointestinal, gynecological, musculoskeletal, or neurological complaints and no weight loss had occurred.

On admission to the hospital, her white blood cell count was mildly elevated at 14 x 10⁹ cells/L, with anemia as well (hemoglobin / hematocrit= 10 gm/dL / 28%, respectively). Her platelet count was also borderline decreased at 183 x 10⁹ cells/L. Electrolyte and liver panels showed normal values.

A frontal chest radiograph (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 second of six panels)

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows large lung volumes with a cystic appearance
4. The frontal chest radiograph shows mildly enlarged central pulmonary arteries
5. The frontal chest radiograph shows no abnormal findings

Reference as: Gotway MB. July 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(1):26-35. doi: http://dx.doi.org/10.13175/swjpcc090-15 PDF

Medical Image of the Week: Healthcare-associated Pneumonia Secondary to Aspiration

Figure 1. Panel A: Axial computed-tomography image demonstrating a foreign body within the right main-stem bronchus, with consolidation and volume loss of right lung. Panel B: Coronal view.

Figure 2. Panel A: bronchoscopy revealing an ingested foreign body in the right main-stem bronchus. Panel B: forceps retrieval yielded a large piece of broccoli.

A 57 year-old bedbound paraplegic man developed a worsening productive cough after being hospitalized for several days. He was brought to the radiology suite for a CT scan of the chest, revealing a soft tissue density within his right main-stem bronchus, with volume loss of his right lung (Figure 1). Bronchoscopy was performed, yielding a 2 cm piece of broccoli, successfully removed with forceps (Figure 2). Culture from the bronchial aspirate was positive for Pseudomonas aeruginosa. The patient’s respiratory status dramatically improved after removal of the foreign body and commencement of pathogen-directed antibiotics. This study illustrates a dramatic example of healthcare-associated pneumonia (HCAP) secondary to aspiration, as described by the American Thoracic Society / Infectious Diseases Society of America (1).

Lavi Nissim MD, Sam Alnajjar MD and Edward Vivio RT

Phoenix Baptist Hospital

2000 W. Bethany Home Road

Phoenix, AZ 85015

Reference

1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]

Reference as: Nissim L, Alnajjar S, Vivio E. Medical image of the week: healthcare-associated pneumonia secondary to aspiration. Southwest J Pulm Crit Care. 2015;11(1):1-2. doi: http://dx.doi.org/10.13175/swjpcc065-15 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1: Panel A: Axial view of the thoracic CT angiography showing aortic dissection in descending aorta where the true lumen (yellow arrow) with outer-wall calcification (red arrow) as well as false lumen with contrast (orange arrow) is seen.  Panel B: Coronal view showing the true (T) and false (F) lumen.

An 85-year-old gentleman with the past medical history significant for hypertension, smoking, and coronary artery disease presented to the emergency department (ED) with complains of sudden onset of chest pain.  His pain was described as squeezing and radiating to the back, associated with nausea and vomiting. His chest pain improved with nitroglycerin in ED.  Chest x-ray showed a tortuous aortic knob and widened mediastinum.

He underwent a CT angiogram, which showed, Stanford Type B aortic dissection, from distal aortic arch to renal arteries (Figure 1).  He was managed in the hospital conservatively with tight blood pressure control given the type of dissection and no surgical intervention was done. He was uneventfully discharged with follow up arranged with vascular surgery.

Aortic dissection is classified by Stanford Criteria as Type A which involves the ascending aorta and arch and Type B when it involves the descending aorta. Type A dissection is a surgical emergency and guidelines suggest medical / non-surgical management for Type B dissection except in cases where the pain is not controlled despite BP control, acute expansion of the false lumen, peri-aortic hematoma or distal mal-perfusion.

Hem Desai MD¹, Aung Bajaj MD¹, Kamalani Hanamaikai MD¹ & Bhupinder Natt MD²

¹Department of Internal Medicine and the ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine  

University of Arizona

Tucson, AZ USA

References

1. LePage MA, Quint LE, Sonnad SS, Deeb GM, Williams DM. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol. 2001;177(1):207-11. [CrossRef] [PubMed]
2. von Kodolitsch Y, Nienaber CA, Dieckmann C, Schwartz AG, Hofmann T, Brekenfeld C, Nicolas V, Berger J, Meinertz T. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116(2):73-7. [CrossRef] [PubMed]

Reference as: Desai H, Bajaj A, Hanamaikai K, Natt B. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2015;10(6):348-9. doi: http://dx.doi.org/10.13175/swjpcc063-15 PDF