January 2017 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 35-year-old woman presented with complaints of increasing shortness of breath and a non-productive cough. She had no significant past medical history.

Laboratory data, including a white blood cell count, coagulation profile, and serum chemistries, were within normal limits. Oxygen saturation on room air was normal.

Frontal and lateral chest radiographs (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 proceed to the second of seven pages)

1. Frontal and lateral chest radiography shows abnormal mediastinal contours
2. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
3. Frontal and lateral chest radiography shows multifocal pleural thickening
4. Frontal and lateral chest radiography shows numerous small nodules
5. Frontal and lateral chest radiography shows upper lobe, bilateral perihilar masses

Cite as: Gotway MB. January 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(1):16-23. doi: https://doi.org/10.13175/swjpcc001-17 PDF

Medical Image of the Week: NG Tube Misplacement with a Pneumothorax

Figure 1.  CXR AP view showing misplaced NG tube in the right lung with small pneumothorax.

Figure 2. Follow up CXR AP view showing enlarged right pneumothorax after withdrawal of the NG tube.

Figure 3. CXR AP view post chest tube placement showing reinflation of the right lung.

Nasogastric tube (NG) placement is a common procedure performed in the inpatient hospital setting. They are often challenging to insert and therefore carry a risk of tracheobronchopleural, intravascular and enteral complications.

Our patient is a 90-year-old man who was admitted to the hospital with complaints of productive cough, fever, worsening of shortness of breath and confusion. He was diagnosed with viral upper respiratory tract infection, Legionella pneumonia and exacerbation of heart failure. Throughout his hospitalization patient had repeated episodes of delirium and had failed a swallowing evaluation. A NG was inserted for administration of enteral feeds and medications. There was no resistance to the passage of the tube when initially placed. However, post procedure CXR showed a misplaced nasogastric tube going into the right main bronchus and down into right lower lobe with a small apical pneumothorax (Figure 1). Follow up chest X-ray two hours later showed enlargement of the pneumothorax (Figure 2).  A 14 Fr pigtail catheter was promptly inserted in right pleural space. A repeat chest X-ray confirmed placement of the chest tube and showed re-inflation of the lung (Figure 3).

The reported incidence of misplacement of nasogastric tubes into the airways ranges from 0.3% to 15% and is more common after chest trauma or mechanical ventilation (1). This may be because of the need for adequate coordination of swallowing. Nasogastric tubes are generally considered safe, but there is a risk of significant pulmonary complications from blind insertion of small-caliber nasogastric tubes with a stiff stylet, particularly in elderly patients with altered mental status as well as with poor swallowing function (2).

Santhosh G. John MD, Vivian Keenan MD, Naveen Tyagi MD, and Priya Agarwala MD

Division of Pulmonary and Critical Care Medicine

Winthrop University Hospital

Mineola, New York USA

References

1. Agha R, Siddiqui MR. Pneumothorax after nasogastric tube insertion. JRSM Short Rep. 2011 Apr 6;2(4):28. [CrossRef] [PubMed]
2. Nazir T, Punekar S. Images in clinical medicine. Pneumothorax--an uncommon complication of a common procedure. N Engl J Med. 2010 Jul 29;363(5):462. [CrossRef] [PubMed] 

Cite as: John SG, Keenan V, Tyagi N, Agarwala P. Medical image of the week: NG tube misplacement with a pneumothorax. Southwest J Pulm Crit Care. 2017:14(1):14-5. doi: https://dx.doi/10.13175/swjpcc133-16 PDF

Medical Image of the Week: Subcutaneous Calcification in Dermatomyositis

Figure 1. Thoracic CT scan in lung windows showing non-specific interstitial disease secondary to dermatomyositis.

Figure 2. Pelvic CT scan showing subcutaneous calcifications (encircled).

A 36-year old woman was referred to our Interstitial Lung Disease (ILD) clinic for evaluation of dyspnea. A high-resolution CT scan of the chest showed perivascular reticular and ground glass opacities with air trapping, consistent with non-specific interstitial pneumonitis (Figure 1). She was diagnosed with connective tissue associated ILD. On review of previous images extensive subcutaneous calcifications were seen (Figure 2).

Calcinosis is an uncommon manifestation of dermatomyositis in adults (1). It is usually seen around areas of frequent trauma like the hands and elbows. In her case, a pelvic inflammatory disease may have been a trigger for this calcinosis. Calcinosis is a difficult complication to treat with some success seen with diltiazem, aluminum hydroxide, and even alendronate in children. Surgical excision may be required in some cases.

Bhupinder Natt MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson (AZ)

Reference

1. Chander S, Gordon P. Soft tissue and subcutaneous calcification in connective tissue diseases. Curr Opin Rheumatol. 2012 Mar;24(2):158-64. [CrossRef] [PubMed]

Cite as: Natt B. Medical image of the week: subcutaneous calcification in dermatomyositis. Southwest J Pulm Crit Care. 2016;13(6):317-8. doi: https://doi.org/10.13175/swjpcc130-16 PDF 

Medical Image of the Week: Spirochetemia

Figure 1. Spirochetes (encircled) in the peripheral blood smear.

A 64-year-old woman with hypertension, hypothyroidism and prior episode of pericarditis treated with steroids presents with complaints of generalized fatigue, fevers, rigors and body aches for 5 days. The patient recently was evaluated at an outside facility and was found to have normal routine labs and negative blood cultures. She was told that her symptoms were likely related to a viral illness. Further history taking revealed that the patient had recently being staying in a cabin located in the White Mountains of Arizona about one month prior. She was exposed to the outdoors but does not recall any insect bites and did not remove any ticks. The cabin was sprayed with insecticides prior to their arrival.

The patient was initially afebrile but exhibiting tachycardia, hypotension, and tachypnea. Repeat complete blood counts revealed Leukopenia (WBC 2.9 x 10³/microL) and profound thrombocytopenia (PLT 32 x 10³/microL). Patient was admitted to the hospital with repeat blood cultures and initiation of broad spectrum antibiotics. A peripheral blood smear was reviewed with the hematopathologist which revealed visible spirochetes on microscopy (Figure 1). She was started on oral doxycycline 100 mg twice daily. The stay was complicated by acute kidney injury, elevated transaminases, and rising lactate dehydrogenase. She also suffered worsening leukopenia (WBC 9 x 10³/micro) and thrombocytopenia (18 x 10³micro/L) prior to a rising trend on hospital day 3. Patient responded appropriately to oral doxycycline therapy and at the time of discharge her symptoms had significantly subdued. Thrombocytopenia and leukopenia had resolved along with her acute kidney injury and hepatocellular injury.

Serological testing for various Borrelia and Rickettsial spp. are still pending. Given this clinical scenario and geographic location of the exposure this patient most likely contracted Borrelia hermsii from the bite of a soft-bodied tick (Ornithodoros hermsi) leading to the development of tick-borne relapsing fever (TBRF) (1). Often patients who develop TBRF will not know they were been bitten by a tick as in this case. Taking a good history of potential exposure risks and geographic locations the patient traveled to will help clinicians narrow in on diagnosing TBRF. Doxycycline is the mainstay of therapy for the treatment of TBRF with often good clinical response and complete resolution of this arthropod-borne infection.

Norman Beatty MD¹, Brentin Roller DO², John Po MD, PhD²

¹ Department of Medicine. Banner-University Medical Center South, Tucson (AZ)

²Division of Infectious Diseases. Banner-University Medical Center, Tucson (AZ)

Reference

1. Dworkin MS, Schwan TG, Anderson DE Jr, Borchardt SM. Tick-borne relapsing fever. Infect Dis Clin North Am. 2008 Sep;22(3):449-68. [CrossRef] [PubMed]

Cite as: Beatty N, Roller B, Po J. Medical image of the week: spirochetemia. Southwest J Pulm Crit Care. 2016;13(6):324-5. doi: https://doi.org/10.13175/swjpcc131-16 PDF

Medial Image of the Week: Purpura Fulminans

Figure 1.  A: Purpura fulminans. B: Close up view of the left lower extremity.

A 54-year-old man with coronary artery disease, fibromyalgia and chronic sacral ulcers was brought to the emergency department due to acute changes in mentation and hypotension. He suffered a cardiac arrest shortly after arrival to the emergency department during emergent airway management. After successful resuscitation, he was admitted to the medical intensive care unit and treated for septic shock with fluid resuscitation, vasopressors and broad spectrum antibiotics. Laboratory results were significant for disseminated intravascular coagulopathy (DIC)- thrombocytopenia, decreased fibrinogen and elevated PT, PTT and D-dimer levels. Profound metabolic acidosis and lactate elevation was also seen. Blood Cultures later revealed a multi-drug resistant E. coli bacteremia. Images of the lower extremities (Figure 1) were obtained at initial assessment and are consistent with purpura fulminans. He did not survive the stay.

Purpura fulminans, also referred to as skin mottling, is an evolving skin condition which is characterized by an acutely worsening reticular pattern of ecchymosis, tissue thrombosis and eventual hemorrhagic skin necrosis. Traditionally associated with either an inherited and/or acquired protein C deficiency, it is more commonly seen in DIC. It is generally considered a poor prognostic indicator when associated with DIC. In our patient, the DIC was secondary to septic shock. When encountered in this clinical scenario it should be considered an acute life threatening emergency.

Emilio Perez Power MD¹, Norman Beatty MD¹ and Bhupinder Natt MD²

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

Banner-University Medical Center South Campus

University of Arizona

Tucson, AZ USA

Cite as: Power EP, Beatty N, Natt B. Medical image of the week: purpura fulminans. Southwest J Pulm Crit Care. 2016;13(6):307-8. doi: https://doi.org/10.13175/swjpcc129-16 PDF

Medical Image of the Week: Osmotic Demyelination

Figure 1. MRI of the brain with FLAIR hyperintensity within the pons (see arrow), no stroke or watershed infarction.

A 59 year-old woman with past medical history of diabetes mellitus type II and end stage renal disease (ESRD) on hemodialysis (HD) presented with a right ankle fracture. She missed two days of HD. Fifteen minutes into HD, she became confused, hypotensive, bradycardic and then unresponsive with generalized body stiffness for approximately one minute. She never lost her pulse. Her vital signs returned to normal spontaneously after this episode. Patient was intubated for airway protection because she was obtunded.

On examination, while she was off sedation, her eyes were open but she did not track or follow commands. She had a positive cough, gag and corneal reflex but oculocephalic reflex was absent with dysconjugate gaze. She had intact brainstem reflexes but absence of deep tendon reflexes. She had no movements of her upper extremities and did not withdraw to painful stimulus. MRI of the brain was obtained to rule out acute stroke and showed FLAIR hyperintensity within the pons, no stroke or watershed infarction (Figure 1). Laboratory showed no acute changes of sodium levels or glucose level.

After 7 days of hospitalization, she started to track with her eyes and follows commands. She was extubated on day 15 of hospital stay and was discharged to a rehabilitation center after a total of 25 days of hospital stay. She was awake, alert and oriented to time, place, and person and able to talk and move all four of her extremities.

The rapid deterioration of mental status with acute neurological changes in this case is typical for osmotic demyelination syndrome (ODS). The exact mechanism behind the demyelination remains not well understood but involves the inability of brain cells to respond to rapid changes in osmolality, and hence destruction of myelin and neurons. It can also occur in chronically debilitated patients without osmolality shift and ESRD may be a risk factor (1,2). MRI images may show large symmetrical lesions in the basis pontis, usually sparing the ventral pons, or there may be smaller “butterfly” or trident-shaped lesions in the base of the pons. The initial MRI images may reveal nothing abnormal especially in the acute phase (3).

ODS should be considered in ESRD patients who present with any neurological symptoms, unexplained behavioral disorder or neurologic signs related to the pons or brainstem region. ODS secondary to dialysis has favorable prognosis.

Jennifer J. Huang, DO¹

Judy Dawod, MD²

¹Sarver Heart Center and ²Neurology Department

University of Arizona

Tucson, AZ USA

References

1. Miller MG, Baker HL, Okazaki H, Whistant J. Central pontine myelinolysis and its imitators: MR findings. Radiology. 1988;168:795-802. [CrossRef] [PubMed]
2. Tarhan NC, Agildere AM, Benli US, Ozdemir FN, Aytekin C, Can U. Osmotic demyelination syndrome in end-stage renal disease after recent hemodialysis: MRI of the brain. AJR Am J Roentgenol. 2004 Mar;182(3):809-16. [CrossRef] [PubMed]
3. Moriwaka F, Tashiro K, Maruo Y, Nomura M. Hamada K, Kashiwaba. MR imaging of pontine and extrapontine myeliolysis. J. Computer Assist. Tomogr. 1988;12(3):446-9. [CrossRef] [PubMed] 

Cite as: Huang JJ, Dawod J. Medical image of the week: osmotic demyelination. Southwest J Pulm Crit Care. 2016;13(6):303-4. doi: https://doi.org/10.13175/swjpcc111-16 PDF

December 2016 Imaging Case of the Month

Eric A. Jensen, MD

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Eric A. Jensen, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 47-year-old woman presented for medical evaluation prior to trans-sphenoid hypophysectomy for pituitary adenoma for Cushing syndrome. The patient had an extensive past medical history, including kidney minimal change disease treated with corticosteroids between 5-7 years previously (no longer on corticosteroid therapy), type II diabetes mellitus, focal segmental glomeruloscleroosis on renal biopsy, morbid obesity, gout, obstructive sleep apnea on continuous positive airway pressure (CPAP) supplemented with oxygen for the previous 8 years, hypertension, and recent-onset atrial fibrillation, as well as a history of several pneumonias, perhaps related to chronic immunosuppression. Her past surgical history included bilateral partial knee replacement, lower extremity vein ablation, and breast reduction. Her medication list was extensive, including allopurinol, anti-hypertensives, anti-depressants, colchicine, oxygen, and Tacrolimus, among others, including over-the-counter medications.

Laboratory data, include white blood cell count, coagulation profile, and serum chemistries were within normal limits. Oxygen saturation on room air was 95%.

Frontal and lateral chest radiographs (Figure 1) were performed. A previous chest radiograph performed 2 years earlier is presented for comparison (Figure 2).

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

Figure 2.  Frontal chest radiography performed 2 years prior to presentation.

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

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows a mass projected over the right paratracheal region
3. Frontal and lateral chest radiography shows asymmetric hyperlucency affecting the right thorax
4. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
5. Frontal and lateral chest radiography shows cardiomegaly only, but is unchanged from prior

Cite as: Jensen EA, Gotway MB. December 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(6):290-301. doi: https://doi.org/10.13175/swjpcc135-16 PDF 

Medical Image of the Week: Pulsus Alternans

Figure 1. Telemetry display including arterial pressure waveform, which demonstrates alternating beats of large (large arrows) and small (small arrows) pulse pressure. Concurrent pulse oximetry could not be performed at the time of the image due to poor peripheral perfusion.

A 52 year old man with a known past medical history of morbid obesity (BMI, 54.6 kg/m²), heart failure with preserved ejection fraction, hypertension, untreated obstructive sleep apnea, and obesity hypoventilation syndrome presented with increasing dyspnea over several months accompanied by orthopnea and weight gain that the patient had treated at home with a borrowed oxygen concentrator. On arrival to the Emergency Department, the patient was in moderate respiratory distress and hypoxic to SpO2 70% on room air. Physical examination was pertinent for pitting edema to the level of the chest. Assessment of jugular venous pressure and heart and lung auscultation were limited by body habitus, but chest radiography suggested pulmonary edema. The patient refused aggressive medical care beyond supplemental oxygen and diuretic therapy. Initial transthoracic echocardiography was limited due to poor acoustic windows but suggested a newly depressed left ventricular ejection fraction (LVEF) of <25%. The cause, though uncertain, may have been reported recent amphetamine use. The patient deteriorated, developing shock and respiratory failure; after agreeing to maximal measures, ventilatory and inotropic/vasopressor support was initiated.

Shortly after placement of the arterial catheter, the ICU team was called to the bedside for a change in the arterial pressure waveform (Figure 1), which then demonstrated alternating strong (arrow) and weak beats (arrow head) independent of the respiratory cycle. The waveform was recognized as pulsus alternans. Repeat bedside echocardiography suggested severe biventricular systolic impairment and LVEF of approximately 5-10%, later confirmed by formal transesophageal ehocardiography performed prior to a cardioversion for atrial flutter.

Pulsus alternans was first formally described in 1872 and associated with severe left ventricular systolic dysfunction (1). The pattern of pulsus alternans is detectable by palpation, arterial pressure waveform analysis, and Doppler echocardiography. Competing theories in the early 20^th century attempted to explain this finding. Wenkebach and Straub, using the Starling relationship, suggested that the alternating force of the pulse is due to alternating filling volumes: greater diastolic volumes accommodated by increased fiber length caused forceful contraction/greater stroke volume with subsequently reduced end systolic and therefore end diastolic volumes for the next (weaker) beat; the consequently reduced force left again greater end systolic and end diastolic volumes for the next (more powerful) beat thereafter. Gaskell, Hering, and Wiggers alternatively proposed the phenomenon was rooted in myocardial contractility fluctuations independent of volumes. Laboratory and animal data supported both theories, but seminal clinical work in the 1960s using concurrent ventriculography and ventricular pressure measurements demonstrated that both mechanisms, in fact, occur in different human subjects (2). The second, Starling-independent mechanism is now thought to be due at least in part to delayed intracellular calcium cycling leading to rhythmic fluctuations in excitation-contraction coupling (3).

Regardless of the underlying physiology, the significance of pulsus alternans as a harbinger of severe ventricular dysfunction and poor prognosis has been recognized and unquestioned since its description. This was unfortunately true in the case of our patient, who developed multiorgan failure despite resuscitative efforts and died three days after admission.

Luke M. Gabe, MD

University of Arizona College of Medicine

Department of Internal Medicine

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

1501 N. Campbell Ave.

Tucson, AZ USA

References

1. Traube L. Ein fall von pulsus bigeminus nebst bemerkungen tiber die lebershwellungen bei Klappenfehlern und über acute leberatrophic. Ber Klin Wschr. 1872;9:185.
2. Cohn KE, Sandler H, Hancock EW. Mechanisms of pulsus alternans. Circulation. 1967 Sep;36(3):372-80. [CrossRef] [PubMed]
3. Euler DE. Cardiac alternans: mechanisms and pathophysiological significance. Cardiovasc Res. 1999 Jun;42(3):583-90. [CrossRef] [PubMed]

Cite as: Gabe LM. Medical image of the week: pulsus alternans. Southwest J Pulm Crit Care. 2016;13(5):266-7. doi: https://doi.org/10.13175/swjpcc123-16 PDF 

Medical Image of the Week: Bronchial Clot Removal via Cryotherapy

Figure 1. Chest x-ray showing complete opacification of the left hemithorax.

Figure 2. Flexible bronchoscopy with cryotherapy was used to remove clot that formed casts of the bronchial tree. Black arrow: depicts segmental branch of the left upper lobe.

A 38-year-old man with a history of non-ischemic dilated cardiomyopathy presented with decompensated heart failure, acute renal failure, and possible sepsis. He underwent right cardiac catheterization but developed hemoptysis with concern for pulmonary artery rupture. Subsequently, the patient suffered a cardiac arrest but was resuscitated. Emergent bronchoscopy revealed copious amounts of blood and clot that could not be cleared at the time. The patient was then taken to the operating room and placed on A-A ECMO (left ventricle to aorta). The following morning chest x-ray (Figure 1) revealed a completely opacified left lung. Flexible bronchoscopy showed blood clot along the entire left bronchial tree. Initial attempts to remove the clot with suction and endobronchial graspers was unsuccessful. Ultimately, cryotherapy was used to remove the majority of the clot in fragments (Figure 2).

The use of cryotherapies and specifically, in this case, a cryoprobe, has been shown to safely and effectively remove thrombus from the bronchial tree. The basis behind this technique is the use of pressurized nitrous oxide or carbon dioxide to cool a metal probe tip. The probe then freezes any substance it comes in direct contact with, such as a blood clot. Thus, cryoadherence of the probe to the clot allows for effective removal via flexible endoscopy.  Sriratanaviriyakul et al. (1) reported success rates for cryoextraction of blood clots to be >90%.

Cathy V. Ho MD, Ryan Matika MD, and Mimi Amberger MD

¹Division of Trauma, Critical Care, Burn and Emergency Surgery. Department of Surgery

²The Department of Anesthesia

University of Arizona

Tucson, AZ USA

Reference

1. Sriratanaviriyakul N, Lam F, Morrissey BM, Stollenwerk N, Schivo M, Yoneda KY.Safety and clinical utility of flexible bronchoscopic cryoextraction in patients with non-neoplasm tracheobronchial obstruction: a retrospective chart review. J Bronchology Interv Pulmonol. 2015 Oct;22(4):288-93. [CrossRef] [PubMed] 

Cite as: Ho CV, Matika R, Amberger M. Medical image of the week: bronchial clot removal via cryotherapy. Southwest J Pulm Crit Care. 2016;13(5):253-4. doi: https://doi.org/10.13175/swjpcc109-16 PDF 

Medical Image of the Week: Extrapleural Pneumolysis for Tuberculosis

Figure 1. PA (A)/Lateral (B) chest films showing a mass like opacity of the left upper lung field.

Figure 2. Representative image from the thoracic CT in soft tissue windows showing a well-circumscribed, oval-shaped, heterogeneous density within the left upper and mid anterior chest with some expansion and destruction of overlying ribs.

The advent of antibiotics revolutionized the management of tuberculosis, a disease that even in the 1950s was a top 10 cause of death in the United States. The first drug to be developed was streptomycin, approved after a clinical trial in 1946. The following decade saw the addition of ethambutol, rifampin, and isoniazid (1). Though we take for granted the use our multidrug regimens nowadays, physicians once had limited interventions for this frequent and devastating infection. Such interventions included surgical techniques to collapse the affected lobes, starving the mycobacterium of their preferred oxygen rich environment. One such technique was known as plombage, or extrapleural pneumolysis. Plombage is a term derived from the Latin for lead or plumbum and entails the insertion of a space occupying material into the pleural space with subsequent compression of the affected lung portion. This was seen as an alternative to the use of thoracoplasty, which required removal of multiple ribs allowing the chest wall to collapse, leading to deformity and a loss of lung function (2). Though rarely seen now, we present the imaging of an elderly female with endometrial cancer with lung metastasis who interestingly had undergone such a procedure when she developed cavitary tuberculosis as a teenager in 1952.

Tuffler first developed extrapleural pneumolysis in 1891; he placed fat into the pleural cavity reporting successful control of tuberculosis infection. The technique over the subsequent decades became popular especially as a response to the endemic tuberculosis seen post- the Second World War. Many attempts were made to designate an ideal inert material for use. Though unclear in our patient given the remote history of the procedure, published reports include placement of muscle, fat, air, mineral oil, gauze, paraffin, rubber sheeting, and even inflated Lucite balls. Fortunately, complications of the procedure, even decades later, are rarely seen now. Complications listed in the literature, however, do include infection, hemorrhage, fistula formation, migration of material, and even malignancy. Despite its popularity, there were mixed results in effectiveness and variable complication rates, in one series nearly 50% of patients developed an infection (3). In our patient, it was successful, with no history of recurrence with negative sputum and serologic testing. She did notably report having been treated with a long course of antibiotics as well.

Kareem Ahmad, MD

Department of Internal Medicine

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

University of Arizona

Tucson, AZ, USA

References

1. Zumla A, Nahid P, Cole ST. Advances in the development of new tuberculosis drugs and treatment regimens. Nat Rev Drug Discov. 2013 May;12(5):388-404. [CrossRef] [PubMed]
2. Young FH. Extraperiosteal plombage in the treatment of pulmonary tuberculosis. Thorax. 1958; 13(2):130-5. [CrossRef] [PubMed]
3. Murphy JD, Elrod PD, et al. Surgical treatment of residual cavities following thoracoplasties for tuberculosis. Dis Chest. 1948 Sep-Oct;14(5):694-706. [CrossRef] [PubMed]

Cite as: Ahmad K. Medical image of the week: extraplerural pneumolysis for tuberculosis. Southwest J Pulm Crit Care. 2016;13(5):244-5. doi: https://doi.org/10.13175/swjpcc106-16 PDF

Medical Image of the Week: Intraventricular Hemorrhage Casting

Figure 1. Panel A: Computerized tomography of the head without contrast taken at an outlying facility displayed a right thalamic intraparenchymal hematoma, measuring 3.4 x 4.2 cm, with vasogenic edema and intraventricular rupture (blue arrow). Intraventricular hemorrhage casting is visualized in the right lateral ventricular causing obstructive hydrocephalus (red arrow). Panel B: Repeat non-contrast CT of the head 6 hours later revealed an increase in size of thalamic hematoma to 4.3 x 5.2 x 4.8 cm, an increase in amount of Intraventricular hemorrhage, progression of hydrocephalus from cast obstruction, and worsening vasogenic edema causing 5 mm left midline shift.

An 80-year-old woman with a past medical history of hypertension and hypercholesterolemia presented to an outlying hospital at 11:00 hours with slurred speech, left arm drift, and headache. A non-contrast CT of the head revealed an intraparenchymal hematoma in the right thalamus measuring 3.4 x 4.2 cm with an associated intraventricular rupture (Figure 1A, blue arrow). An intraventricular hemorrhage cast with secondary hydrocephalus was also noted on initial imaging (Figure 1A, red arrow). She was placed on a nicardipine drip for blood pressure control and subsequently transferred to OSF St. Francis Medical Center (OSFMC) for a higher level of care.

Upon arrival to OSFMC, the patient was poorly responsive, non-verbal, and could not follow commands.  She was directly admitted to the Neuroscience Intensive Care Unit for further management. Vitals signs were stable on presentation. Neurologic examination revealed a comatose patient with asymmetric and minimally reactive pupils, absent gag reflex, right gaze preference, brisk corneal reflex on the right and absent response on the left, absent deep tendon reflexes on the left upper and lower extremity, with absent response to painful stimuli on the left upper and lower extremity. Patient had a Glasgow Coma Scale score of 6, NIH stroke scale score of 23, and an Intracerebral Hemorrhage Score of 5. A repeat non-contrast CT scan of the head was performed at 17:00 hours to monitor for expansion of hematoma and progression of secondary hydrocephalus. Imaging revealed an interval increase in the size of the acute intraparenchymal hematoma, measuring 4.3 x 5.2 x 4.8 cm. In addition, there was an increase in amount of intraventricular hemorrhage, progression of hydrocephalus, and worsening vasogenic edema causing a mass effect with a 5 mm left midline shift (Figure 1B). At the request of the patient’s family members, her code status changed to DNR and she was made comfort care. No interventions were pursued and patient entered hospice care. 

Intracerebral hemorrhage (ICH) occurs in about 15% of strokes per year (1). The most common cause of spontaneous ICH is rupture of micro-aneurysms of small blood vessels in brain tissue, secondary to chronic hypertension. Hypertensive hemorrhages typically occur in the basal ganglia and thalamus, which are in close proximity to the cerebral ventricular system. Blood can accumulate at these sites forming an acute intraparenchymal hematoma, which can expand and exert mechanical pressure on the ventricular walls leading to intraventricular rupture and secondary intraventricular hemorrhage (IVH) (2). Intraventricular rupture occurs in approximately 45% of spontaneous ICH, which results in an expected mortality of 50-80% (1). Blood in the ventricular system can clot forming a “cast” (Figure 1A, red arrow). Ventricular casts are especially troublesome because the cast can block the outflow of cerebrospinal fluid causing an acute obstructive hydrocephalus, which can lead to increased intracerebral pressure (ICP), mass effect, and brain herniation (2). In Figure 1A, the intraventricular cast formation likely represents the patient’s normal ventricular size prior to ventriculomegaly from hydrocephalus. Figure 1B shows the typical progression of the intraparenchymal hematoma and obstructive hydrocephalus. There are several treatment options for management of an intraparenchymal hematoma with intraventricular rupture; they include reduction of ICP via ventriculostomy and medical therapy, surgical evacuation of the hematoma, and intraventricular thrombolytics to reduce casting and secondary obstructive hydrocephalus (2,3). Despite these interventions, the prognosis remains poor (3).

Melvin Parasram MS OMS4,¹ Mangala Gopal OMS4,² Lee Raube DO MS,³ Editha Johnson DO,⁴ Deepak Nair MD^4,5

¹Midwestern University, Arizona College of Osteopathic Medicine, Glendale, AZ USA

²Des Moines University, College of Osteopathic Medicine, Des Moines, IA USA

³Departments of Emergency Medicine and ⁴Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL USA  

⁵Illinois Neurological Institute, OSF St. Francis Medical Center, Peoria, IL USA

References

1. Hinson HE, Hanley DF, Ziai WC. Management of intraventricular hemorrhage. Curr Neurol Neurosci Rep. 2010 Mar;10(2):73-82. [CrossRef] [PubMed]
2. Hanley DF. Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage. Stroke. 2009 Apr;40(4):1533-8. [CrossRef] [PubMed]
3. Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A. Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol. 2000 Feb;247(2):117-21. [CrossRef] [PubMed] 

Cite as: Parasram M, Gopal M, Raube L, Johnson E, Nair D. Medical image of the week: intraventricular hemorrhage casting. Southwest J Pulm Crit Care. 2016;13(5):220-3. doi: http://dx.doi.org/10.13175/swjpcc094-16 PDF 

November 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 38-year-old man presented to his primary care physician with complaints of pruritus, jaundice, and poor appetite. The patient had been diagnosed with hypertension one year earlier and was treated with hydrochlorothiazide and an angiotensin-converting enzyme inhibitor, but evidently did not tolerate the regimen well, and developed “tea-colored” urine following initiation of this therapy. He was also recently diagnosed with diabetes mellitus and also complained of intermittent right upper quadrant pain.

Laboratory data, including white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 99%.

Frontal and lateral chest radiographs (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 proceed to the second of seven pages)

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows a focal, poorly defined right base opacity
3. Frontal and lateral chest radiography shows bilateral peribronchial and mediastinal lymph node enlargement
4. Frontal and lateral chest radiography shows cardiomegaly
5. Frontal and lateral chest radiography shows upper lobe bilateral linear and reticular abnormalities

Cite as: Gotway MB. November 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(5):207-15. doi: http://dx.doi.org/10.13175/swjpcc112-16 PDF 

Medical Image of the Week: Lynch Syndrome

Figure 1. Coronal CT of the chest showing bilateral filling defects in pulmonary arteries representing pulmonary emobolism.

Figure 2. Coronal CT of the abdomen/pelvis showing periaortic lymphadenopathy suggestive for metastatic disease.

Figure 3. Coronal CT of the abdomen/ pelvis showing a 13 x 13.6 cm solid and cystic mass above and to the right of the uterus concerning for right ovarian neoplasm.

A 43-year-old woman with a history of anemia, thrombocytopenia, and recent treatment for pyelonephritis was transferred to our hospital for increasing shortness of breath. Four months prior to admission, she developed unprovoked bilateral deep vein thrombosis (DVT) and pulmonary emboli (PE) and was started on rivaroxaban at that time. At presentation, she was complaining of worsening shortness of breath, heavy menstrual bleeding and pain in her calves. CT angiography of chest showed multiple pulmonary emboli to the lower lobes and left upper lobe (Figure 1) and lower extremity venous Doppler showed extensive, acute deep vein thrombosis involving the femoral, popliteal and calf veins bilaterally.

Rivaroxaban was held due to anemia and thrombocytopenia and there was concern for respiratory failure since she developed new DVT and PE. She was transfused with 1 unit of packed red blood cells and started on a heparin drip. She continued to have significant menorrhagia, the heparin drip was discontinued, and subsequently, an inferior vena cava filter was placed.

On further questioning, the patient reported a 26 pound weight loss over the past three weeks. This combined with her menorrhagia requiring blood transfusion prompted further imaging. CT of the abdomen and pelvis showed a 13 x 13.6 cm solid and cystic mass representing a right ovarian neoplasm that was contiguous with the uterus as well as periaortic adenopathy suggestive of metastasis (Figures 2 and 3). Further investigation into the patient’s family history identified significant history for breast and ovarian cancers on her maternal side. Genetic testing of the patient showed a germline mutation in the MSH2 gene, consistent with Lynch syndrome.

Lynch syndrome, also known as hereditary non-polyposis colorectal cancer, is a hereditary cancer syndrome characterized by mutations in DNA mismatch repair genes. The majority of affected individuals will develop colorectal or endometrial malignancies; however these individuals are also at increased risk for developing ovarian neoplasms. The lifetime risk of developing ovarian cancer in women with Lynch syndrome is 7% (3-14%) compared to 1.4% in the general population (1). However, there is no survival difference between women with Lynch syndrome and the general population (1). If ovarian malignancy is present at diagnosis of Lynch syndrome, prophylactic hysterectomy and bilateral salpingo-oophorectomy is recommended (2). Otherwise, management can include prophylactic surgery or screening with annual pelvic exams and transvaginal ultrasounds. Persons with lynch syndrome should also receive surveillance for other associated malignancies such as colorectal or endometrial cancer (1,2).

Abha Athale MS¹, Christopher Morrison MD², Robert Betancourt MD³ and Jennifer Segar MD³

¹ Midwestern University Arizona College of Osteopathic Medicine

² Tucson Hospitals Medical Education Program

³ Department of Internal Medicine, Banner University Medical Center-Tucson Medical Center, Tucson, AZ

References

1. Koornstra JJ, Mourits MJ, Sijmons RH, Leliveld AM, Hollema H, Kleibeuker JH. Management of extracolonic tumours in patients with Lynch syndrome. Lancet Oncol. 2009 Apr;10(4):400-8. [CrossRef] [PubMed]
2. Lindor NM, Petersen GM, Hadley DW, Kinney AY, Miesfeldt S, Lu KH, Lynch P, Burke W, Press N. Recommendations for the care of individuals with an inherited predisposition to Lynch syndrome: a systematic review. JAMA. 2006 Sep 27;296(12):1507-17. [CrossRef] [PubMed]

Cite as: Athale A, Morrison C, Betancourt R, Segar J. Medical image of the week: Lynch syndrome. Southwest J Pulm Crit Care. 2016;13(5):202-4. doi: http://dx.doi.org/10.13175/swjpcc087-16 PDF 

Medical Image of the Week: Tracheobronchial Foreign Body Aspiration

Figure 1. Panel A: The chest x-ray failed to show the aspirated foreign body. Panels B and C: Flexible bronchoscopy was performed and the insulin syringe cap was visualized in the right mainstem bronchus and retrieved with forceps.

Figure 2. Panel A: CT chest shows interval development of ground glass opacities and air fluid level in the right middle lobe (arrow). Panel B: The foreign body is visualized in the right lower lobe bronchus as an endobronchial-filling defect (arrow). Panel C: Flexible bronchoscopy was performed and cashew piece was retrieved with suction.

Case 1 (Figure 1) is a 58-year-old man who accidentally inhaled his insulin syringe cap while swinging on his recliner with the cap perched in his mouth. He developed a dry irritating cough. On exam he had mild stridor in the upper airways and bilateral wheezing. The insulin cap was visualized by bronchoscopy in the right mainstem bronchus and retrieved with forceps.

Case 2 (Figure 2) is a 65-year-old man with chronic dysphagia and poor dentition who choked on a cashew. It took repeated coughing attempts to produce the cashew, but it was unclear whether the entire content was cleared. He then developed non-massive hemoptysis that persisted for 2 weeks. Thoracic CT showed ground glass opacities and an air fluid level in the right middle lobe. The foreign body was visualized in the right lower lobe bronchus as an endobronchial-filling defect. Bronchoscopy revealed a cashew piece in the right lower lobe bronchus. Forceps trials failed due to fragility of the foreign body, which was ultimately retrieved with scope suction.

Rigid bronchoscopy is the gold standard for diagnosis and management of tracheobronchial foreign body aspiration, but flexible bronchoscopy is another accepted method that is also more comfortable for the patient (1). Virtual bronchoscopy is a noninvasive procedure that can assist with localizing the foreign body and may have a role to play in follow-up assessment of airway patency (2). Pneumonia and atelectasis are common complications. Less common complications include bronchiectasis, bronchostenosis, hemoptysis, tracheal perforation, pneumomediastinum, and even cardiopulmonary arrest (3). Tracheal foreign bodies pose more danger than bronchial foreign bodies; in such cases the foreign body should be pushed to distal airways, crumbled if it is organic, and then extracted (1).

Khushboo Goel, MD¹, Huthayfa Ateeli, MBBS², Joshua Dill, DO2, Dena L’Heureux MD³

¹Department of Internal Medicine, University of Arizona, Tucson, AZ, USA

²Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA

³Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Southern Arizona VA Health Care System, Tucson, AZ, USA

References

1. Altunas B, Aydin Y, Eroglu A. Foreign bodies in trachea: a 25 year experience. Eurasian J Med. 2016;48(2):119-123. [CrossRef] [PubMed]
2. Kshatriya RM, Khara NV, Paliwal RP, Patel SN. Role of virtual and flexible bronchoscopy in the management of a case of unnoticed foreign body aspiration presented as a nonresolving pneumonia in an adult female. Lung India. 2016; 33(4):420-423. [CrossRef] [PubMed]
3. Altunas B, Aydin Y, Eroğlu A. Complications of tracheobronchial foreign bodies. Turk J Med Sci. 2016;46(3):785-800. [CrossRef] [PubMed]

Cite as: Goel K, Ateeli H, Dill J, L’Heureux D. Medical image of the week: tracheobronchial foreign body aspiration. Southwest J Pulm Crit Care. 2016;13(4):184-5. doi: http://dx.doi.org/10.13175/swjpcc092-16 PDF

Medical Image of the Week: Arachnoid Cyst

Figure 1. Axial T1 MRI of mass.

Figure 2. Coronal T2 weighted MRI demonstrating compressions onto mesial temporal lobes and stretching of the optic chiasm and tracts; upward displacement of the hypothalamus, third ventricle small in caliber and mild posterior displacement of the midbrain.

A 40 year-old woman with adult attention deficit hyperactive and bipolar 1 disorder presents with an altered mental status.  Per her family, she had been non-verbal, with reduced oral intake, confusion and sedated for the past three days. Per her husband, she had episodes of diarrhea and abdominal discomfort. She was on multiple medications including ramelteon 8mg nightly, atomoxetine 40mg daily, hydroxyzine 25mg twice daily, bupropion 75mg twice daily and risperidone 2mg daily with recent addition of lithium ER 1200mg/daily started one month prior to presentation with unknown adherence.

Upon arrival, vital signs were within normal limits. Physical exam revealed an overweight Caucasian woman with a significant coarse tremor visible at rest, restlessness and diaphoresis. Neurological examination was limited by patient hesitancy, however, it did not demonstrate focal deficits except for altered consciousness with Glasgow Coma Scale of 10. Notable laboratory findings were Na⁺ 134 mEq/L, K⁺ 3.2 mEq/L, and lithium level of 3.9 mmol/L, urine toxicology positive for cocaine, and EKG showed QT prolongation. Toxicology and psychiatry were consulted.

CT of her head without contrast showed a large midline lesion in the sellar/suprasellar estimated to be 5.2x 2.1x 3.2cm. On hospital day number 2 the patient was more somnolent with down trending lithium level of 2.6 mmol/L. Later that day the patient had an observed generalized tonic clonic seizure which required abortive therapy with lorazepam and levetiracetam. A MRI revealed large arachnoid cyst measuring 3.6x3.1x3.5cm causing mass effect on adjacent tissue. (Figures 1 and 2). Neurology was consulted and recommended neurosurgery evaluation who deferred intervention to an outpatient basis given her lithium overdose as a more likely etiology of her seizure and not the arachnoid cyst.

Arachnoid cysts are cerebral spinal fluid filled sacs located between the brain or spinal cord and the arachnoid membrane. They can be either primary, which are present at birth due to developmental abnormalities of the brain and spinal cord, or they may be secondary, which are the result of head injury, meningitis, tumors, or a complication of brain surgery. Symptoms are based on the size and location of the cyst and include headache, nausea and vomiting, seizures, hearing and visual disturbances, vertigo, and difficulties with balance and walking. If the cyst compresses the spinal cord or nerve roots, then individual may experience progressive back and leg pain and tingling or numbness in the legs or arms.

Diagnosis is usually via MRI which distinguishes between fluid-filled arachnoid cysts from other types of cysts. The treatment depends on the location and the size of the cyst. If the cyst is small and does not compress any of the surrounding structures, with an absence of symptoms, no treatment is necessary. The two main ways of treating symptomatic cysts include surgery or placing a permanent shunt to drain the fluid. Surgical approaches include microscopic open surgical fenestration procedure in which the neurosurgeon opens the skull to gain access to the cyst, then opens the cyst to release pressure, allowing contents to be absorbed by the brain. Another surgical approach involves endoscopic cyst fenestration in which an endoscope is used to drain the cyst internally without having to perform an open surgery. In some instances, formal craniotomy with excision/marsupialization of the cyst into the subarachnoid space is performed. The procedure performed depends on the surgeon’s comfort with the technique and the size/location of the cyst.

Matthew Erisman MD, Rozina Parbtani MS IV, and Faraz Jaffer MD.

Department of Internal Medicine

University of Arizona at South Campus

Tucson, Arizona USA

References

1. Al-Holou WN, Terman S, Kilburg C, Garton HJ, Muraszko KM, Maher CO. Prevalence and natural history of arachnoid cysts in adults. J Neurosurg. 2013 Feb;118(2):222-31. [CrossRef] [PubMed]
2. Eidlitz-Markus T, Zeharia A, Cohen YH, Konen O. Characteristics and management of arachnoid cyst in the pediatric headache clinic setting. Headache. 2014 Nov-Dec;54(10):1583-90. [CrossRef] [PubMed]

Cite as: Erisman M, Parbtani R, Jaffer F. Medical image of the week: arachnoid cyst. Southwest J Pulm Crit Care. 2016;13(4):181-3. doi: http://dx.doi.org/10.13175/swjpcc074-16 PDF

Medical Image of the Week: Chilaiditi Syndrome

Figure 1. An X-ray of the chest showing a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (arrow).

Figure 2. CT scan of the chest showing gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (arrow).

X-ray evidence of air under right hemi-diaphragm in proper clinical context is almost a definitive sign of gastrointestinal tract perforation except in an extremely rare clinical entity called "Chilaiditi Syndrome". We present this unique image and clinical scenario to expand on physician`s knowledge to identify this rare clinical syndrome and to help distinguish it from a dreaded condition like gastrointestinal perforation.

An 81-year-old man with multiple co-morbidities was admitted to the intensive care unit with a diagnosis of acute hypoxic respiratory failure. An X-ray of the chest showed a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (Figure 1). Due to radiological concern of gastrointestinal perforation, an emergent CT scan was performed to rule out perforation. CT scan revealed gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (Figure 2). The patient had no gastro-intestinal tract symptoms and no pathological signs were specifically identified on clinical examination; a diagnosis of the Chilaiditi Syndrome was made. Chilaiditi Syndrome occurs due to interposition of a loop of large intestine in between the liver and the diaphragm. The incidence of Chilaiditi Syndrome is 0.025 to 0.28% and occurs because of congenital anatomical variations of falciform ligament (1). It can also be due to functional abnormalities such as constipation, aerophagia, cirrhosis, paralysis of the diaphragm, chronic lung disease which can cause enlargement of the lower thoracic cavity, obesity, and processes which increase intra-abdominal pressure (1,2). Initial management includes conservative therapy - Bed rest, intravenous fluid hydration, and bowel decompression. Surgical options can be considered (3).

Priyanka Makkar, M.D.¹, Rishabh Mishra, M.D.¹, and Shivanck Upadhyay, M.D.²

¹Internal Medicine department, St. Barnabas Hospital, Bronx, New York

²Department of Pulmonary Critical Care Medicine, St. Barnabas Hospital, Bronx, New York

References

1. Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome. Arch Surg. 2008 Jan;143(1):93-4. [CrossRef] [PubMed]
2. Fisher AA, Davis MW. An elderly man with chest pain, shortness of breath, and constipation. Postgrad Med J. 2003 Mar;79(929):180, 183-4. [CrossRef] [PubMed]
3. Blevins WA, Cafasso DE, Fernandez M, Edwards MJ.Minimally invasive colopexy for pediatric Chilaiditi syndrome. J Pediatr Surg. 2011 Mar;46(3):e33-5. [CrossRef] [PubMed]

Cite as: Makkar P, Mishra R, Upadhyay S. Medical image of the week: Chilaiditi syndrome. Southwest J Pulm Crit Care. 2016;13(4):179-80. doi: http://dx.doi.org/10.13175/swjpcc077-16 PDF

Medical Image of the Week: Abdominal Hematoma

 

Figure 1. Contrast-enhanced CT abdomen/pelvis showing A) coronal and B) sagittal views of a LLQ hematoma (blue braces) with active contrast extravasation (red arrow). Lines represent the level of respective axial images. C-F) Axial images demonstrating the hematoma within and expanding the rectus abdominis sheath (blue braces) as well as active contrast leak (red arrow).

Figure 2. A) Arteriogram demonstrating the large hematoma (solid arrow) with active extravasation of contrast from the inferior epigastric artery (arrowhead) arising from the external iliac artery (empty arrow). B) Coils in the inferior epigastric artery (arrow) block flow to the hematoma.

A 59 year-old man presented to clinic with acute-on-chronic non-productive cough along with sore throat and myalgias for 2 weeks and lower left quadrant (LLQ) abdominal pain for 2-3 days. He was a current smoker with history significant for COPD and mild “smoker’s cough” controlled with daily anticholinergic and as-needed beta-agonist, paroxysmal atrial fibrillation on dabigatran and diltiazem, hypertension controlled by diuretic, and a former alcoholic with hemochromatosis.

While getting an x-ray, he had a coughing fit resulting in abrupt worsening of his LLQ pain enough to inhibit ambulation. Due to his inability to walk, he came via ambulance to the emergency department, where he was mildly tachycardic with a 10cm firm, tender and ecchymotic LLQ mass.

Contrast-enhanced abdominal/pelvic CT demonstrated a large rectus abdominis hematoma. Figure 1 shows the hematoma within the rectus sheath measuring 16 cm with active contrast extravasation. The patient went directly to the interventional suite, where the left inferior epigastric artery was catheterized and subsequently embolized as shown in Figure 2.

The patient was noted to be in atrial fibrillation with rapid ventricular response (AFRVR), so was taken to the intensive care unit and placed on diltiazem drip, given digoxin and 1 unit of RBCs before his rhythm stabilized and he was transferred to the floor. His hemoglobin remained stable, and his cough and abdominal pain improved, so he was sent home off anticoagulation until follow-up with his cardiologist.

In the RE-LY trial, updated in 2010 (1), there was no difference in bleeding complications at this patient’s dosing of dabigatran compared to warfarin with INR of 2.0-3.0. However, this patient did not bleed into a critical area, require 2 units of RBCs, nor drop hemoglobin >2mg/dl, and would thus be considered having a minor bleeding event despite needing emergent embolization, losing enough blood to become tachycardic with resulting AFRVR, and getting 1 unit of RBC

Despite this particular bleeding complication, in a meta-analysis examining dabigatran vs warfarin, dabigatran uniformly was as good or better in preventing strokes with less devastating complications than warfarin (2). Additionally, although warfarin is touted as having vitamin K as its reversal agent, protein synthesis and secretion into the vasculature takes hours, similar in time to metabolically clear dabigatran (3).

In the end, after discussions about anticoagulants with the hospital team before discharge and his cardiologist thereafter, the patient elected to restart his dabigatran.

Michael Larson, M.D., Ph.D.

Banner-University Medical Center

University of Arizona

Medical Imaging Department

Tucson, AZ, USA

References

1. Connolly SJ, Ezekowitz MD, Yusuf S, Reilly PA, Wallentin L; Randomized Evaluation of Long-Term Anticoagulation Therapy Investigators. Newly identified events in the RE-LY trial. N Engl J Med. 2010 Nov 4;363(19):1875-6. [CrossRef] [PubMed]
2. Gómez-Outes A, Terleira-Fernández AI, Calvo-Rojas G, Suárez-Gea ML, Vargas-Castrillón E. Dabigatran, rivaroxaban, or apixaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of subgroups. Thrombosis. 2013;2013:640723. [CrossRef] [PubMed]
3. Ganetsky M, Babu KM, Salhanick SD, Brown RS, Boyer EW. Dabigatran: review of pharmacology and management of bleeding complications of this novel oral anticoagulant. J Med Toxicol. 2011 Dec;7(4):281-7. [CrossRef] [PubMed]

Cite as: Larson M. Medical image of the week: abdominal hematoma. Southwest J Pulm Crit Care. 2016:13(4): 176-8. doi: http://dx.doi.org/10.13175/swjpcc083-16 PDF

October 2016 Imaging Case of the Month

Michael B. Gotway, MD  

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 35-year-old woman presented with a several month history of slowly worsening shortness of breath and dry cough. Laboratory data, include white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 99%.

Frontal and lateral chest radiographs (Figure 1) were performed.

Figure 1. Frontal (A) and lateral (B) radiographs.

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

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows abnormally diminished lung volumes
3. Frontal and lateral chest radiography shows bilateral peribronchial and mediastinal lymph node enlargement
4. Frontal and lateral chest radiography shows cardiomegaly
5. Frontal and lateral chest radiography shows upper lobe bilateral linear and reticular abnormalities

Cite as: Gotway MB. October 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(4): . doi: http://dx.doi.org/10.13175/swjpcc100-16 PDF

Medical Image of the Week: Bronchopleural Fistula

Figure 1. The blue arrow indicates a fistulous communication between bronchus and the pleura.

Figure 2. Red arrow indicates radiotracer trapping in the pleural space and adjacent right anterior lower lung field.

A 58-year-old man with past medical history significant for chronic smoking and seizures was referred to the emergency room after a chest x-ray done by his primary care physician for evaluation of cough showed a hydropneumothorax. His symptoms included dry cough for past 2 months without fever, chills or other associated symptoms. He did not have any thoracic procedures performed and had no past history of recurrent infections. He was hemodynamically stable. Physical examination was only significant with decreased breath sounds on the right side of the chest.

Thoracic CT with contrast was performed which showed complete collapse of the right lower lobe, near complete collapse of right middle lobe as well as an air-fluid level. There was a suspicion of a direct communication between bronchi and pleural space at the posterior lateral margin of the collapsed right lower lobe (Figure 1). The presence of bronchopleural fistula (BPF) was confirmed with the help of lung scintigraphy, which showed trapping of radiotracer in the right lung at a location consistent with the chest CT findings of BPF (Figure 2). The patient was admitted and extensive infectious work up was negative. Biopsy of the right pleura was negative for malignancy. He underwent video-assisted thoracoscopic surgery (VATS) decortication of his right lung and was stable on subsequent follow up with complete resolution of his cough.

BPF has mortality rate between 18 to 67% (1). CT of the chest can occasionally demonstrate a direct fistulous communication, as seen in our case.  However, Westcott and Volpe (2) have shown sensitivity of CT chest to be 50%. Other useful noninvasive imaging techniques include lung scintigraphy. In this modality, the fistula is identified by seeing a trapping of radioisotope labeled gas as there is no mechanism for a clearance of gas after its diffusion into the pleural space.  Raja et al. (3) demonstrated that lung scintigraphy had 83% sensitivity and 100% specificity in diagnosing BPF.  

As seen in this case lung nuclear scintigraphy offers a cheaper, more sensitive, and less invasive approach to diagnosis of BPF.

Hem Desai MD, MPH and Anthony Witten DO

Department of Internal Medicine

University of Arizona

Tucson, AZ USA

References

1. Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg. 1997 May;63(5):1391-6; discussion 1396-7. [CrossRef] [PubMed]
2. Westcott JL, Volpe JP. Peripheral bronchopleural fistula: CT evaluation in 20 patients with pneumonia, empyema, or postoperative air leak. Radiology. 1995 Jul;196(1):175-81. [CrossRef] [PubMed]
3. Raja S, Rice TW, Neumann DR, Saha GB, Khandekar S, MacIntyre WJ, Go RT. Scintigraphic detection of post-pneumonectomy bronchopleural fistulae. Eur J Nucl Med. 1999 Mar;26(3):215-9. [CrossRef] [PubMed] 

Cite as: Desai H, Witten A. Medical image of the week: bronchopleural fistula. Southwest J Pulm Crit Care. 2016;13(3)150-1. doi: http://dx.doi.org/10.13175/swjpcc069-16 PDF

Medical Image of the Week: Renal Cell Carcinoma Metastasis

Figure 1. Panel A: Axial CT image noncontrast showing small pulmonary nodules concerning for metastasis. Panel B: Axial CT image depicting 15 cm mass, originating from the right acetabulum and adjacent iliac bone. Panel C: Coronal CT image showing prominent left renal cyst measuring almost 40 mm. Panel D: Coronal CT image displaying femoral head intact but surrounded by abnormal soft tissue, concerning for neoplasm. There is bony destruction and lytic process in the anterior and posterior pillars of the right acetabulum.

A 65-year-old man was complaining of progressive weakness and right knee pain with limping since November 2014 was admitted recently to a local hospital and treated for chronic kidney disease related anemia, Klebsiella urinary tract infection and methicillin-sensitive Staphylococcus aureus wound infections. He was discharged to rehab, but continued to have progressive weakness, pain and limping. He was sent to our hospital for further evaluation and imaging.

CT of the abdomen and pelvis non contrast, due to decreased glomerular filtration rate, revealed a 15 cm mass originating from the right acetabulum and adjacent iliac bone with bony destruction and lytic processes (Figure 1). The femoral head is also surrounded by abnormal soft tissue (Figure 1D). There were also small pulmonary nodules (Figure 1A), small lymph nodes in the transverse mesocolon and retroperitoneum, and an enlarged left adrenal gland concerning for other metastasis.

CT guided biopsy of the lesion revealed a neoplastic process composed of atypical cells with centrally placed nuclei, abundant clear cytoplasm arranged in a vascular network. Immunohistochemical stains demonstrated positivity for the following: vimentin, low molecular weight keratin, CD10, RCCA, and PAX-8. These findings are consistent with metastatic renal cell carcinoma.

A total body bone scan with Tc-99m methylene diphosphonate, performed to locate other osseous metastasis, was negative for distant metastasis other than the large destructive lesion destroying the right ileum previously noted on CT.

Renal cell carcinoma (RCC) is a cortical tumor with malignant cells originating from the epithelial lining of the proximal tubules. Renal cancer is amongst the 10 most common cancers in both men and women, with RCC accounting for about 80% of the total incidence and mortality (1). RCC has been referred to as “the internist’s tumor” as it can cause systemic symptoms unrelated to the renal cancer. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in at most 9 percent of patients (1). Most cases of RCC are diagnosed incidentally on radiographic investigation done for other reasons. Unfortunately, many patients are asymptomatic until the disease is advanced. At presentation, approximately 25% of individuals either have distant metastases or advanced local disease (2). Biopsy is not usually required to diagnose RCC. Contrast-enhanced CT can be used to diagnosis and stage RCC. 

Stage IV disease has a median survival of about 12 months with systemic cytokine therapy and 28 months with targeted therapies, based on analyses from the International Metastatic RCC Database Consortium (IMDC) (1,3).

Erin Yen MS¹, Benjamin Rayikanti MD², Yunuen Valenzuela MD³, Jennifer Segar MD³

¹ Midwestern University Arizona College of Osteopathic Medicine, Phoenix

² Tucson Hospitals Medical Education Program

³ Department of Internal Medicine, Banner University Medical Center Tucson

Tucson AZ USA

References

1. American Cancer Society. Cancer Facts & Figures 2016. Atlanta, GA: American Cancer Society; 2016. Available at: http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/ (accessed 9/14/16).
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Cite as: Yen E, Rayikanti B, Valenzuela Y, Segar J. Medical image of the week: renal cell carcinoma metastasis. Southwest J Pulm Crit Care. 2016;13(3):135-6. doi: http://dx.doi.org/10.13175/swjpcc068-16 PDF