Medical Image of the Week: A Positive Sniff Test

Figure 1.  Image from thoracic CT scan shows persistent elevation of the right hemi diaphragm, complete right lower lobe and partial middle lobe atelectasis with patent airways on chest computed tomography.

Figure 2. Diaphragm fluoroscopy demonstrating the paradoxical upward movement of the right hemi diaphragm during inspiration confirming right hemi diaphragmatic paralysis.

A 66-year-old man with a history of hypertension, morbid obesity, emphysema, type 2 diabetes complicated by extensive peripheral neuropathy presented for evaluation of persistent fatigue, shortness of breath and increased oxygen requirements.

Approximately 18 months prior to presentation the patient required intubation for septic shock with multifocal pneumonia and right lower lobe collapse. The patient left the hospital after 10 days on 4 liters of oxygen and had been oxygen dependent since then with no improvement despite aggressive pulmonary rehabilitation. A pulmonary function test (PFT) demonstrated a moderate, restrictive ventilatory defect with low diffusion capacity; while his thoracic computed tomography showed persistent elevation of the right hemi-diaphragm with right lower lobe and partial middle lobe atelectasis (Figure 1). No evidence of endobronchial lesions, mediastinal or cervical masses, or enlarged lymph nodes seen.

The patient underwent a fluoroscopic sniff test that confirmed paralysis of the right hemi-diaphragm (Figure 2) (1). Phrenic nerve palsy has been associated with cardiac surgery due to both cooling and stretching mechanisms, cervical and thoracic compression of the phrenic nerve, trauma and iatrogenic injury, Herpes zoster, poliomyelitis, neurologic amyotrophic, brachial plexopathy have been associated with unilateral and bilateral diaphragmatic paralysis (2). In our patient, extensive history, physical exam, neurologic evaluation, laboratory tests and imaging failed to reveal a provoking insult to the right phrenic nerve. Therefore, diabetes related phrenic nerve palsy was entertained as a working diagnosis due to the patient’s extensive history of diabetes related neuropathy. The patient was started on noninvasive positive pressure ventilation with a BiPAP machine and showed remarkable symptomatic improvement at bedtime, but his functional status has been significantly limited during the day. He is currently being evaluated for possible diaphragmatic plication surgery.

Surgical plication of the paralyzed hemi diaphragm has shown very good results in appropriately selected patients (3). This included improvement in lung function, exercise endurance, and dyspnea post surgery.

Richard Young, MD*, Ateeli Huthayfa, MBBS**, Afishin Sam, MD**.

*Department of Internal Medicine. **Department of Pulmonology and Critical Care

Banner University Medical Center, University of Arizona, Tucson, Arizona

References

1. Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics. 2012 Mar-Apr;32(2):E51-70. [CrossRef] [PubMed]
2. Gibson GJ. Diaphragmatic paresis: pathophysiology, clinical features, and investigation. Thorax. 1989 Nov;44(11):960-70. [CrossRef] [PubMed]
3. Hüttl TP, Wichmann MW, Reichart B, Geiger TK, Schildberg FW, Meyer G. Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy. Surg Endosc. 2004 Mar;18(3):547-51. [CrossRef] [PubMed]

Cite as: Young R, Huthayfa A, Sam A. Medical image of the week: a positive sniff test. Southwest J Pulm Crit Care. 2017;14(5):199-200. doi: https://doi.org/10.13175/swjpcc050-17 PDF 

Medical Image of the Week: Staphylococcal Pneumonia in a Patient with Influenza

Figure 1. Thoracic CT scan axial view demonstrating bilateral cavitary infiltrates.

A 63-year-old, obese diabetic man presented to his primary care physician with complaints of fever, headache, myalgias, and cough. A nasal swab specimen was positive for influenza A by fluorescent immunoassay. Therapy with oseltamivir was initiated. The patient’s symptoms progressed and he was transported to the emergency department , where he was found to have a room air oxygen saturation of 74%, bilateral basilar infiltrates on chest radiograph, a white blood count of 24.2 K/uL and a procalcitonin level of 12.66 ng/ml. He was placed on BIPAP with high flow supplemental oxygen,  started on empiric intravenous antibiotic therapy with vancomycin and piperacillin/tazobactam, and admitted to the intensive care unit.  Blood and sputum cultures were eventually positive for methicillin-sensitive Staphylococcus aureus, and the patient’s antibiotic therapy was de-escalated to nafcillin. On hospital day 5, a CT of the chest obtained to evaluate pleuritic pain revealed extensive bilateral cavitary infiltrates (Figure 1). The patient’s discomfort resolved without further intervention, he continued to improve, and was uneventfully transitioned to oral therapy. 

S. aureus pneumonia is characterized by high fever, productive cough, and a radiographic pattern of patchy, often multilobar, infiltrates which may exhibit cavitary change.  In the USA, approximately 2% of patients admitted to the hospital for treatment of community-acquired pneumonia demonstrate microbiologic evidence of S. aureus infection (1). There is a slight predominance of methicillin sensitive species (MSSA) compared to methicillin resistant species (MRSA).  Morbidity and mortality are both high, with over 80% of patients requiring care in the ICU, and a fatality rate of 13% (2).

Among patients admitted to the intensive care unit with a primary diagnosis of influenza, there is a 15% incidence of S. aureus pneumonia. Risk factors for co-infection in this setting  include obesity, HIV infection, and immunosuppressive medication. There is a robust association between bacteremia and mortality (3).  Early empiric antibiotic therapy with an agent active against S. aureus should be strongly considered for patients admitted to the ICU with influenza complicated by pneumonia, pending the return of blood and respiratory cultures.

¹Charles VanHook, ²Kristin Dahlem, and ¹Angela Taylor

¹Longmont United Hospital, Longmont, Colorado USA

²Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts USA

References

1. Jain S, Self WH, Wunderink R, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015 Jul 30;373(5):415-27. [CrossRef] [PubMed]
2. Self WH, Wunderink RG, Williams DJ, et al. Staphylococcus aureus community-acquired pneumonia: prevalence, clinical characteristics, and outcomes. Clin Infect Dis. 2016 Aug 1;63(3):300-9. [CrossRef] [PubMed]
3. Martin-Loeches I, J Schultz M, et al. Increased incidence of co-infection in critically ill patients with influenza. Intensive Care Med. 2017 Jan;43(1):48-58. [CrossRef] [PubMed]

Cite as: VanHook C, Dahlem K, Taylor A. Medical image of the week: staphylococcal pneumonia in a patient with influenza. Southwest J Pulm Crit Care 2017:14(4):170-1. doi: https://doi.org/10.13175/swjpcc045-17 PDF

Medical Image of the Week: Bronchopulmonary Sequestration

Figure 1. A) Chest x-ray PA view demonstrating an oblong soft tissue density in the retrocardiac region overlying the medical aspect of the left hemidiaphragm. B) Chest x-ray lateral view demonstrating the same opacity anterior to a lower thoracic vertebral body, suspicious for a lung mass.

Figure 2. Chest computed tomography A) axial and B) coronal sections demonstrating a lobulated, cystic structure within the left lower lobe with a feeding artery off the aorta, consistent with a pulmonary sequestration.

A 49-year-old woman was incidentally found to have a lung mass on a pre-operative chest x-ray done prior to an elective cholecystectomy (Figure 1). Chest computed tomography, ordered to further characterize this mass revealed a left lower lobe lobulated, cystic opacity with a feeding artery from the aorta, consistent with bronchopulmonary sequestration (BPS) (Figure 2). Given that she has not had any complications of BPS we elected to manage her conservatively with observation.

BPS is a rare congenital malformation of the lower airways characterized by abnormal lung tissue that does not communicate with the tracheobronchial tree and receives its blood supply from the systemic circulation (1). Our patient’s BPS was intralobar in location, occurring within a normal lobe but lacking its own visceral pleura. The posterior basal left lower lobe is the most common intralobar location. Among cases that escape clinical detection in infancy, BPS comes to light in childhood or adulthood as either an incidental radiographic finding or as a symptomatic presentation of a lung infection. While surgical resection is generally considered to be the treatment of choice given the risk of developing infection, hemorrhage or malignancy (2), some asymptomatic adults with BPS may be managed conservatively with observation with serial imaging (3).

Udit Chaddha MD¹, Niusha Damaghi MD¹, Ashley Prosper MD², and Ching-Fei Chang MD¹

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

Keck School of Medicine

University of Southern California

Los Angeles, CA USA

References

1. Biyyam DR, Chapman T, Ferguson MR, Deutsch G, Dighe MK. Congenital lung abnormalities: embryologic features, prenatal diagnosis, and postnatal radiologic-pathologic correlation. Radiographics. 2010 Oct;30(6):1721-38. [CrossRef] [PubMed]
2. Azizkhan RG, Crombleholme TM. Congenital cystic lung disease: contemporary antenatal and postnatal management. Pediatr Surg Int. 2008 Jun;24(6):643-57. [CrossRef] [PubMed]
3. Stanton M, Njere I, Ade-Ajayi N, Patel S, Davenport M. Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions. J Pediatr Surg. 2009 May;44(5):1027-33. [CrossRef] [PubMed]

Cite as: Chaddha U, Damaghi N, Prosper A, Cha C-F. Medical image of the week: bronchopulmonary sequestration. Southwest J Pulm Crit Care. 2017;14(4):168-9. doi: https://doi.org/10.13175/swjpcc036-17 PDF

Medical Image of the Week: Wolff-Parkinson-White Syndrome

Figure 1. Presenting EKG with supraventricular tachycardia at rate of 232.

Figure 2. Post-conversion EKG demonstrating a short PR interval, slurring of the initial QRS upslope (delta wave), widened QRS, and ST-T repolarization change; characteristic of Wolff-Parkinson-White Syndrome.

A 38-year-old man developed sustained rapid heart rate while rock climbing. The patient reported that he had experienced rare bouts of self-limited palpitations in the past. Blood pressure on arrival to the emergency department was 112/ 65 mm Hg. The patient’s initial EKG demonstrated a regular, narrow complex supraventricular tachycardia, with a rate of 232 (Figure 1). Intravenous adenosine was administered with no change in his rate or rhythm. The patient then received amiodarone by intravenous bolus, with subsequent conversion to sinus rhythm (Figure 2).

Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac condition present in approximately 0.15% of the general population. WPW is characterized by the abnormal presence of conduction tissue that creates an accessory atrioventricular pathway and thus potentiates reentrant tachycardia (1). The classic resting EKG findings in WPW are: a shortened PR interval (less than 0.12 seconds), an indistinct initial upslope of the QRS complex (known as the delta wave), a widened QRS complex (0.12 seconds or greater), and ST-T repolarization changes (2). In WPW presenting as a narrow complex tachycardia without hypotension, the initial treatment is adenosine or a calcium channel blocker, followed by amiodarone if unsuccessful. If the presenting rhythm is atrial fibrillation, atrial flutter, or an undefined wide complex tachycardia without hypotension, amiodarone is used. A hemodynamically unstable rhythm warrants immediate electrical cardioversion. Definitive evaluation and treatment of WPW requires electrophysiologic mapping and subsequent ablation of the accessory pathway.

Charles Van Hook MD, Cristina Demian MD, Douglas Tangel MD, Jennifer Blair MD, and Lisa Patel MD

Avista Adventist Hospital

Louisville, Colorado USA

References

1. Katritsis DG, Camm AJ. Atrioventricular nodal reentrant tachycardia. Circulation. 2010 Aug 24;122(8):831-40. [CrossRef] [PubMed]
2. Mark DG, Brady WJ, Pines JM. Preexcitation syndromes: diagnostic consideration in the ED. Am J Emerg Med. 2009 Sep;27(7):878-88. [CrossRef] [PubMed]
3. Khairy P, Van Hare GF, Balaji S, et al. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease. Heart Rhythm. 2014 Oct;11(10):e102-65. [CrossRef] [PubMed]

Cite as: Van Hook C, Demian C, Tangel D, Blair J, Patel L. Medical image of the week: Wolff-Parkinson-White syndrome. Southwest J Pulm Crit Care. 2017;14(4):164-5. doi: https://doi.org/10.13175/swjpcc046-17 PDF 

Medical Image of the Week: DISH with OPLL and C3 Fracture

Figure 1. CT imaging showing severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable cervical spinal fracture. A and C: Sagittal images showing “flowing” anterior osteophytes (red arrow) characteristic of DISH as well as OPLL (black arrow). A: An unstable C3 fracture with posterior subluxation resulting in >50% osseous narrowing of the spinal canal is present. B: Soft tissue window and D: bone algorithm and bone window showing severe narrowing of the spinal canal. B and D are at the level of the white line seen on A.

Figure 2. Occiput to C6 posterior fusion with C1-C6 laminectomies.

A 54-year old man presented after a fall while intoxicated, during which a small frontal sinus fracture was sustained. Upon initial presentation, he was minimally responsive and eventually developed cardiopulmonary arrest. After intubation and return of circulation, he was immediately transferred from Mexico to an Arizona tertiary medical center, where his head and cervical spine CT showed severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable C3 fracture with posterior subluxation and severe canal narrowing (Figure 1).

DISH, also known as Forestier disease, is a skeletal disorder, primarily affecting middle-aged and elderly patients, in which there is a buildup of calcified osseous tissue occurring in the ligaments of the spine. DISH is associated with ossifications occurring specifically in the posterior longitudinal ligaments of the spine, referred to as DISH with OPLL, which is twice as common in men compared to women (1).

DISH with OPLL is often asymptomatic in the early stages of the disease, and thus is often diagnosed either incidentally or after the disease has progressed significantly. Patients with this disease are predisposed to increased risk of spinal fractures, even with relatively minor trauma. Additionally, as DISH with OPLL can result in decreased range of motion, difficult intubation can result, possibly resulting in altered approaches to typical intubation procedures (1).

While the patient likely fractured his spine from the initial fall, it was not determined whether the intubation procedure could have contributed to the spinal fracture subluxation and/or spinal cord injury. Regardless, the patient underwent an occiput to C6 posterior fusion with C1-C6 laminectomies (Figure 2) and will receive long term neurologic rehabilitation.

Stephanie R. Fletcher, BSHS¹ and Michael Craig Larson, MD, PhD²

¹College of Pharmacy and ²Department of Radiology

University of Arizona

Tucson, AZ USA

Reference

1. Baxi V, Gaiwal S. Diffuse idiopathic skeletal hyperostosis of cervical spine - An unusual cause of difficult flexible fiber optic intubation. Saudi J Anaesth. 2010 Jan;4(1):17-9. [CrossRef] [PubMed]

Cite as: Fletcher SR, Larson MC. Medical image of the week: DISH with OPLL and C3 fracture. Southwest J Pulm Crit Care. 2017;14(4):157-8. doi: https://doi.org/10.13175/swjpcc041-17 PDF 

April 2017 Imaging Case of the Month

Michael B. Gotway, MD and John K. Sweeney, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: An 86-year-old man with a previous history of transcatheter aortic valve implantation 1 year earlier, coronary artery disease status-post coronary artery bypass grafting surgery 12 years earlier, atrial fibrillation on warfarin, and pacemaker placement 8 years earlier presented with altered mental status.

The patient’s white blood cell count was borderline elevated at 10.3 x 10³/mcl (normal, 4.8 – 10.8 x 10³/mcl)  and hyponatremia was noted (serum sodium = 129 mEq/L, normal =  136 – 145 mEq/L). The patient’s anticoagulation profile was within the therapeutic range (INR = 1.4), and the platelet count was normal. Oxygen saturation on room air was normal. The patient’s medication list included warfarin, digoxin, aspirin, metoprolol, montelukast, and atorvastatin.

Frontal chest radiography (Figure 1) was performed.

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

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

1. Frontal chest radiography shows a cavitary lung mass
2. Frontal chest radiography shows focal consolidation suggesting aspiration pneumonia
3. Frontal chest radiography shows increased pressure edema
4. Frontal chest radiography shows malposition of the patient’s left subclavian pacemaker
5. Frontal chest radiography shows rib fractures

Cite as: Gotway MB, Sweeney JK. April 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(4):141-52. doi: https://doi.org/10.13175/swjpcc042-17 PDF

Medical Image of the Week: Artery of Percheron Infarction

 

Figure 1. T2 weighted MRI demonstrating bilateral infarcts of the rostral midbrain (A, orange box) and thalami (B, orange box).

 

Figure 2. CT angiogram of posterior cerebral artery circulation demonstrating normal vascularization (A) and artery of Percheron (B, white arrow) (1).

A 55-year-old African-American man presented to the Emergency Department for acute altered mental status which started 4 hours ago. His medical history was significant for heart failure with reduced ejection fraction, diabetes mellitus, marijuana and opioid use. On admission, the patient appeared to be in a deep sleep, unarousable, with grimacing to noxious stimuli. He occasionally moved all extremities. He was intubated for airway protection. Initial CT head non-contrast demonstrated a previous right MCA infarct, with no new acute hemorrhage. MRI/MRA brain revealed complete infarction of the artery of Percheron (AOP), likely due to a left ventricular thrombus (Figure 1). The patient remained somnolent throughout hospitalization with minimal neurologic improvement, and was ultimately transferred to a long-term care facility after a tracheostomy and PEG placement.

The artery of Percheron is a rare, normal intracranial vascular variant in which a single arterial trunk originates from the posterior cerebral artery, giving rise to the vascular supply of both thalami and upper midbrain (Figure 2) (2). Acute occlusion of the artery results in posterior circulation infarction and is associated with impairment of consciousness, sleep and alertness. Diagnosis is usually based on magnetic resonance imaging demonstrating bilateral thalami and midbrain infarct. Management primarily consists of supportive measures, as reperfusion of cerebral microvascular carries significant surgical risk. Given the rarity of incidence, the prognosis of AOP infarct is unknown (3).

TC Ta¹, ET Vo¹, KS Goldlist², B Barcelo¹, JM Dicken³

¹Department of Internal Medicine

²Department of Internal Medicine at University of Arizona at South Campus

³University of Arizona College of Medicine.

University of Arizona

Tucson, AZ USA

References

1. Shetty A, Jones J. Artery of Percheron. Radiopedia. Available at: https://radiopaedia.org/articles/artery-of-percheron (accessed 3/24/17).
2. Lazzaro NA, Wright B, Castillo M, et al. Artery of Percheron infarction: imaging patterns and clinical spectrum. AJNR Am J Neuroradiol. 2010 Aug;31(7):1283-9. [CrossRef] [PubMed]
3. Amin OS, Shwani SS, Zangana HM, Hussein EM, Ameen NA. Bilateral infarction of paramedian thalami: a report of two cases of artery of Percheron occlusion and review of the literature. BMJ Case Rep. 2011 Mar 3;2011. [CrossRef] [PubMed] 

Cite as: Ta TT, Vo ET, Goldlist KS, Barcelo B, Dicken JM. Medical image of the week: artery of Percheron infarction. Southwest J Pulm Crit Care. 2017;14(3):127-8. doi: https://doi.org/10.13175/swjpcc037-17 PDF 

Medical Image of the Week: Papillomatosis

Figure 1. Chest roentgenogram.

Figure 2. Contrast enhanced computer tomography of chest.

A 24-year-old man with recurrent respiratory papillomatosis presented with a history of breathlessness and a change in voice for the last four months. He had undergone endoscopic debridement in the past for laryngeal papillomatosis. On initial evaluation, respiratory distress was thought to be due to recurrence of laryngeal papillomatosis as he improved after surgical de-bulking of laryngo-tracheal papillomas. However, he had some trickle of blood into bronchi with debridement under general anaesthesia. Post-operative chest roentgenogram showed bilateral patchy opacities giving the appearance of aspiration pneumonitis as shown in figure 1.

He also underwent contrast enhanced computer tomography of the chest which showed numerous but small cavitary lesions involving bilateral lung parenchyma as shown in figure 2. This lead to the diagnosis of pulmonary spread of laryngeal papillomatosis and the patient was given adjuvant treatment for this aggressive disease (1,2).

K Devaraja, MS, DNB and Kapil Sikka, MS, DNB

All India Institute of Medical Sciences

Ansari Nagar, New Delhi, India

References

1. Abe K, Tanaka Y, Takahashi M, Kosuda S, et al. Pulmonary spread of laryngeal papillomatosis: radiological findings. Radiat Med. 2006 May;24(4):297–301. [CrossRef] [PubMed]
2. Carifi M, Napolitano D, Morandi M, Dall'Olio D. Recurrent respiratory papillomatosis: current and future perspectives. Ther Clin Risk Manag. 2015;11:731–8. [CrossRef] [PubMed] 

Cite as: Devaraja K, Sikka K. Medical image of the week: papillomatosis. Southwest J Pulm Crit Care. 2017;14(3):123-4. doi: https://doi.org/10.13175/swjpcc025-17 PDF

Medical Image of the Week: VA Shunt Remnant Fibrosing into Right Atrium

Figure 1. Transthoracic echocardiography demonstrating tubular echo density in the right atrium (arrow).

Figure 2: Transesophageal echocardiography demonstrating the VA shunt remnant fibrosed (vs. calcified) in SVC (arrow) extending into right atrium (RA).

A 71-year-old man with a history of ventriculo-atrial (VA) shunt, removed in 2004 due to infection, was admitted to the hospital complaining of syncopal symptoms for one day’s duration. On presentation he denied any symptoms of syncope or focal weakness. The patient was placed on telemetry monitoring, and overnight observation demonstrated multiple sinus pauses with frequent episodes of premature atrial contractions. Stat transthoracic echocardiography (TTE) on the night of admission demonstrated a right tubular echodensity in the right atrium crossing the tricuspid valve (Figure 1). Follow up transesophageal echocardiography (TEE) redemonstrated evidence of a tubular structure in the SVC extending into the right atrium with evidence of fibrosis (?calcification)(Figure 2). These studies demonstrate the importance of echocardiographical work up in any patient with risk of retained foreign body even after reported removal (1).

Richard Young, MD; Joshua Sifuentes, MD; Joao Paulo Ferreira, MD

Department of Internal Medicine

Banner University Medical Center

University of Arizona

Tucson, Arizona USA

Reference

1. Choi CH, Elahi MM, Konda S. Iatrogenic retained foreign body in the right atrium. Lessons to Learn. Int J Surg Case Rep. 2013;4(11):985-7. [CrossRef] [PubMed]

Cite as: Young R, Sifuentes J, Ferreira JP. Medical image of the week: VA shunt remnant fibrosing into right atrium. Southwest J Pulm Crit Care. 2017;14(3): 117-8. doi: https://doi.org/10.13175/swjpcc023-17 PDF

March 2017 Imaging Case of the Month

Courtney M. Tomblinson, MD and Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 69-year-old man presented with long-standing complaints of dyspnea, progressing to dyspnea at rest, associated with some dysphagia to solids. He also noted symptoms consistent with exertional stertor (a respiratory sound characterized by heavy snoring or gasping). His past medical history was remarkable only for hypertension controlled with medication.

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

Frontal chest radiography (Figure 1) was performed.

Figure 1: Frontal 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 pages)

1. Frontal chest radiography shows a cavitary lung mass
2. Frontal chest radiography shows an abnormal mediastinal contour
3. Frontal chest radiography shows multiple small nodules
4. Frontal chest radiography shows peribronchial and mediastinal lymphadenopathy
5. Frontal chest radiography shows pleural effusion

Cite as: Tomblinson CM, Gotway MB. March 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(3):104-16. doi: https://doi.org/10.13175/swjpcc029-17 PDF 

Medical Image of the Week: Evolution of Low Grade Adenocarcinoma

Figure 1. Coned down chest CT images. Panels a-d: small ground glass focus in the right upper lobe demonstrating slow growth over a period of 10 years (yellow arrows) and gradual development of a soft tissue component (red arrows).

Ground glass lesions above 5 mm in greatest diameter found on chest computed tomography (CT) require initial followed up in 3 months according to the Fleischner Society Guidelines, to exclude a transient inflammatory focus (1). If persistent, surveillance for at least 24 months to confirm stability is recommended. Any change in size or density should warrant further action, ideally surgical consultation, given the suboptimal yield of percutaneous biopsy and risk of inappropriate staging if the whole lesion is not examined. This may result in the inability to recognize the transition from in-situ adenocarcinoma into minimally invasive or invasive lesions, which in turn results in inaccurate staging and prognosis.

Diana Palacio MD, Berndt Schmit MD, and Veronica Arteaga MD

Department of Medical Imaging

Banner-University Medical Center Tucson

Tucson, AZ USA

Reference

1. MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz EF Jr, Swensen SJ; Fleischner Society. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005 Nov;237(2):395-400. [CrossRef] [PubMed]

Cite as: Palacio D, Schmit B, Arteaga V. Medical image of the week: evolution of low grade adenocarcinoma. Southwest J Pulm Crit Care. 2017;14(3):103. doi: https://doi.org/10.13175/swjpcc026-17 PDF 

Medical Image of the week: Chronic Pulmonary Histoplasmosis

Figure 1. Chest radiography showing upper lobe fibrosis and cavitation secondary to chronic histoplasmosis.

Histoplasmosis is endemic to the Midwest US and commonly causes an acute infection that presents as a subacute pneumonia.  In patients with underlying lung disease, particularly COPD, a subacute pneumonia can evolve into chronic pulmonary histoplasmosis and is characterized by persistent or recurrent pulmonary symptoms, progressive lung infiltrates, fibrosis, and cavitation. Upper lobe infiltrates and cavities are characteristic, resembling the findings in tuberculosis (Figure 1). Progression is manifested by cavity enlargement, increased fibrosis and bronchopleural fistulae.  Misdiagnosis delays therapy and can be catastrophic.  Histoplasmosis titers and sputum cultures are useful tests.  Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy for culture may be needed when diagnosis remains elusive.

Kenneth S. Knox, MD¹ and Veronica A. Arteaga, MD²

¹Professor of Medicine

University of Arizona College of Medicine- Phoenix

Phoenix, AZ USA

²Associate Professor of Medicine

Medical Imaging

University of Arizona College of Medicine- Tucson

Tucson, AZ USA

Cite as: Knox KS, Artega VA. Medical image of the week: chronic pulmonary histoplasmosis. Southwest J Pulm Crit Care. 2017;14(3):88. doi: https://doi.org/10.13175/swjpcc022-17 PDF

Medical Image of the Week: Endovascular Intervention for Life-threatening Hemoptysis

Video 1. Pre-embolization video showing collateral vessels.

Video 2. Post embolization video showing the endovascular implants and cessation of collateral flow.

Idiopathic pulmonary arterial hypertension (PAH) is an uncommon life threatening disease characterized by a progressive increase in pulmonary vascular resistance with subsequent right ventricular failure and death. Hemoptysis is known to be one of the complications in PAH patients although the exact incidence and mechanism of hemoptysis remains unclear (1,2).

Ours is a case of a 40-year-old woman with known severe idiopathic pulmonary hypertension who was admitted for recurrent episodes of hemoptysis for the past one month. On her first presentation with non-massive hemoptysis, she underwent elective embolization with Amplatzer® vascular plug (St. Jude Medical, St. Paul, MN USA) of the aorto-pulmonary collaterals. These included a large collateral off the right subclavian artery, right internal mammary artery and a large collateral off the descending aorta to the right lung (Video 1). Her hemoptysis resolved. She was admitted seven days’ post first embolization with massive hemoptysis, and immediately underwent repeat embolization with Onyx® (Medtronic, Minneapolis, MN USA), a non-adhesive liquid embolic agent. Embolization was performed on the right intercostal arteries, left bronchial artery, with some abnormal vessels noticed (Video 2).  No active bleeding was visualized during the procedure. Hemoptysis resolved once again.

The management of hemoptysis in patients with PAH remains indeterminate. However, embolization of bronchial arteries has been recommended as an effective method of managing PAH patients with recurrent hemoptysis to control the acute hemorrhage (2,3).

See-Wei Low MBBS¹ Huthayfa Ateeli, MBBS²

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

Banner University Medical Center

Tucson, AZ, USA

References

1. Broberg C, Ujita M, Babu-Narayan S, Rubens M, Prasad SK, Gibbs JS, Gatzoulis MA. Massive pulmonary artery thrombosis with hemoptysis in adults with Eisenmenger's syndrome: a clinical dilemma. Heart. 2004;90:e63. [CrossRef] [PubMed]
2. Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest. 2002;121:789-95. [CrossRef] [PubMed]
3. Reesink HJ, van Delden OM, Kloek JJ, Jansen HM, Reekers JA, Bresser P. Embolization for hemoptysis in chronic thromboembolic pulmonary hypertension: report of two cases and a review of the literature. Cardiovasc Intervent Radiol. 2007;30:136-9. [CrossRef] [PubMed] 

Cite as: Low S-W, Ateeli H. Medical image of the week: endovascular intervention for life-threatening hemoptysis. Southwest J Pulm Crit Care. 2017;14(2):86-7. doi: https://doi.org/10.13175/swjpcc017-17 PDF

Medical Image of the Week: Fibrosing Mediastinitis

Figure 1. Panel A: Thoracic CT showing airway occlusion (arrowhead) from fibrosing mediastinitis. Panel B: pulmonary artery obstruction (arrow) from fibrosing mediastinitis.

Histoplasmosis is endemic to the Midwest US and commonly causes an acute infection that presents as a subacute pneumonia. Chronic sequelae of histoplasmosis range from asymptomatic nodules to debilitating fibrosing mediastinitis (1). Mediastinal fibrosis represents exuberant scarring in response to histoplasmosis infection. Fibrosis may occlude airways (Figure 1A, arrow head) obstruct pulmonary arteries (figure 1B, arrow) or veins and impinge upon the esophagus and other vital structures residing in the mediastinum. Chest imaging shows subcarinal or mediastinal widening. CT scans may reveal fibrotic encasing of mediastinal structures and calcification of regional lymph nodes. Recurrent and often serious hemoptysis results from lung or airway damage and vascular compromise. Respiratory failure can occur. Treatment rarely includes stenting of airways or surgery (2). Vascular stenting may be indicated in some cases. Regardless, these difficult cases must be referred to centers with experience in histoplasmosis related complications.

¹Kenneth S. Knox, MD and ²Veronica A. Arteaga, MD

¹University of Arizona College of Medicine- Phoenix

²University of Arizona College of Medicine- Tucson

References

1. Peikert T, Colby TV, Midthun DE, Pairolero PC, Edell ES, Schroeder DR, Specks U.Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response. Medicine (Baltimore). 2011 Nov;90(6):412-23. [CrossRef] [PubMed]
2. Hammoud ZT, Rose AS, Hage CA, Knox KS, Rieger K, Kesler KA. Surgical management of pulmonary and mediastinal sequelae of histoplasmosis: a challenging spectrum. Ann Thorac Surg. 2009 Aug;88(2):399-403. [CrossRef] [PubMed] 

Cite as: Knox KS, Arteaga VA. Medical image of the week: fibrosing mediastinitis. Southwest J Pulm Crit Care. 2017;14(2):85. doi: https://doi.org/10.13175/swjpcc015-17 PDF 

February 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 49-year-old man presented with complaint of slow worsening of shortness of breath over a period of several months. He was otherwise healthy with no significant past medical history.

Laboratory data, include white blood cell count, coagulation profile, and serum chemistries were within normal limits. Oxygen saturation on room air was 94%.

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 nine pages)

1. Frontal and lateral chest radiography shows a right paratracheal mass
2. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
3. Frontal and lateral chest radiography shows left-sided lung nodules
4. Frontal and lateral chest radiography shows lobulated left-sided pleural disease
5. Frontal and lateral chest radiography shows numerous small nodules

Cite as: Gotway MB. February 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(2):73-84. doi: https://doi.org/10.13175/swjpcc020-17 PDF

Medical Image of the Week: Disseminated Coccidioidomycosis

Figure 1. Thoracic CT with diffuse bilateral ground glass opacities with extensive nodularity. Though present throughout all lobes, it is worse in the upper lobes.

Figure 2. Scattered papular lesions with biopsy positive for coccidioidomycosis spherules.

A 67-year-old African American man with no significant past medical history presented with shortness of breath and flu-like symptoms. On exam, he was noted to be profoundly hypoxemic with imaging showing diffuse thoracic changes (Figure 1) and a diffuse papular rash (Figure  2). Initial workup included coccidioidomycosis serologies which returned positive with a titer of 1:128.

While exposure to coccidioidomycosis is very common in southern Arizona, dissemination is a rare occurrence.  The incidence is estimated between 0.2 and 4.7 percent. Patients at highest risk include those that are immunosuppressed or that are of African or Filipino ancestry. Common extra-pulmonary sites include skin or subcutaneous tissue, meninges of brain or spinal cord, and bones. Even rarer sites include the eyes, liver, prostate, mediastinum, and kidneys. Treatment is usually the same as with pulmonary infection which is an azole agent. However, if the patient’s symptoms are severe or if the lesions involve the spine, amphotericin is recommended instead. Steroid use is controversial but may be beneficial in severe cases. Unfortunately, our patient did not respond to the combination of fluconazole plus amphotericin and succumbed to his severe disease.

Tiffany Ynosencio, MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center

Tucson, AZ USA

References

1. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine (Baltimore). 2004 May;83(3):149-75. [CrossRef] [PubMed]
2. Adam RD, Elliott SP, Taljanovic MS. The spectrum and presentation of disseminated coccidioidomycosis. Am J Med. 2009 Aug;122(8):770-7. [CrossRef] [PubMed]
3. Galgiani JN. Manifestations and treatment of extrapulmonary coccidioidomycosis. UpToDate  Jan 02, 2017. Available at: http://www.uptodate.com/contents/manifestations-and-treatment-of-extrapulmonary-coccidioidomycosis (requires subscription).

Cite as: Ynosencio T. Medical image of the week: disseminated coccidioidomycosis. Southwest J Pulm Crit Care. 2017;14(2):65-6. doi: https://doi.org/10.13175/swjpcc011-17 PDF 

Medical Image of the Week: Pulmonary Metastases of Rectal Cancer

Figure 1. CT scan of the chest shows bilateral masses (white arrows), left sided pleural effusion and endobronchial mass (black arrow).

Figure 2: Endobronchial mass (A) before and (B) after removal.

A 51-year-old woman with known rectal cancer currently receiving systemic chemotherapy presented with 2 weeks of worsening dyspnea on exertion. The day prior to admission she developed persistent inspiratory and expiratory wheeze. CT scan demonstrated right main stem endobronchial mass and a heterogeneous mass comprising the entire left hemithorax (Figure 1). Flexible bronchoscopy demonstrated a fungating mass at the carina extending down both main stems (Figure 2). The mass was snared and removed with cryotherapy and pathology was consistent with metastatic rectal adenocarcinoma.

Michael Insel MD, Naser Mahmoud MD and Afshin Sam MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center Tucson

Tucson, AZ USA

Cite as: Insel M, Mahmoud N, Sam A. Medical image of the week: pulmonary metastases of rectal cancer. Southwest J Pulm Crit Care. 2017;14(2):43-4. doi: https://doi.org/10.13175/swjpcc008-17 PDF 

Medical Image of the Week: ICU Chest X-Ray

Figure 1. ICU portable chest x-ray. A: cardioversion pads. B: oro-gastric tube. C: right internal jugular dialysis catheter. D: endotracheal tube. E: left internnal jugular central venous catheter, incidentally seen terminating within the azygous vein. F: external EKG lead. G: chest tubes. H: staples along the thoracotomy incision. I: left lower lobe atelectasis and small pleural effusion.

A chest x-ray is probably the most commonly obtained radiographic image in the intensive care unit (ICU). Although not supported by evidence and recommended against, daily chest x-rays, especially in the intubated patients, are done in many ICUs (1,2). Multiple hardware placed for the support of the patient need to be identified for placement, position and potential complications. These can make reading a radiograph challenging specially the mediastinum. The accompanied radiograph serves as an example of an “ICU chest x-ray” with multiple “tube and lines”.

Janet Campion MD and Bhupinder Natt MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson (AZ)

References

1. Oba Y, Zaza T. Abandoning daily routine chest radiography in the intensive care unit: meta-analysis. Radiology. 2010 May;255(2):386-95. [CrossRef] [PubMed]
2. http://www.choosingwisely.org/wp-content/uploads/2015/02/SCCM-Choosing-Wisely-List.pdf 

Cite as: Campion J, Natt B. Medical image of the week: ICU chest x-ray. Southwest J Pulm Crit Care. 2017;14(1):39. doi: https://doi.org/10.13175/swjpcc007-17 PDF

Medical Image of the Week: Infected Emphysematous Bulla

Figure 1. Portable AP chest X-ray revealing dense opacity within the lingula of left lung.

Figure 2. Thoracic CT with contrast showing lobar consolidation with increased lucency compatible with emphysema.

Figure 3. (A) Chest CT one year prior demonstrating severe emphysema. (B) Chest CT on admission showing new fluid-filled bulla (red arrow) in the setting pneumococcal pneumonia.

A 65 year-old man with chronic obstructive lung disease (COPD), hypertension and alcohol abuse presented to the emergency department with complaints of feeling unwell and shortness of breath. He was tachycardic but otherwise hemodynamically stable, afebrile, and requiring 3 liters/min supplemental oxygen. Pertinent initial laboratory findings revealed a neutrophilic predominant leukocytosis (WBC 37.8 x 10³ micro/L) with lactic acidosis (2.7 mMol/L). Chest radiograph showed a dense opacity within the region of the lingula (Figure 1). Follow-up CT chest confirmed a consolidation likely representing lobar pneumonia in the setting of severe bullous emphysema (Figure 2). A large fluid-containing emphysematous bulla (Figure 3) was present which was not visualized one year prior. 

He was started on broad spectrum antibiotics after peripheral blood cultures were drawn which revealed Streptococcus pneumoniae. Broad spectrum antibiotics were discontinued and patient was started on intravenous ceftriaxone 2g every 24 hours. He improved clinically and was discharged home after 4 days.

Pneumococcal pneumonia remains the most common cause of community-acquired pneumonia and accounts for nearly 66% of all bacteremic pneumonias (1,2). Our patient had multiple risk factors for developing pneumococcal pneumonia including alcohol abuse, COPD, and history of cigarette smoking. Pneumococcal pneumonia often causes dense consolidation within the lung in a well-defined lobar or segmental distribution. In emphysema areas of lucency may be seen within the consolidation which may mimic other processes such as necrosis. The pathogenesis of fluid accumulation in an emphysematous bulla is not well understood but can be associated with severe lung infection (3). Percutaneous drainage is not recommended and bronchoscopy is not usually required unless there is another indication (3). Antibiotic therapy in those who are asymptomatic has not shown to add any benefit in resolution or preventing infection (3).

Norman Beatty MD¹, Kyle McKeown MPH², Kelly M. Hager MPH², and Stephen J. Scholand MD³

¹ Department of Medicine, Banner-University Medical Center South, Tucson, AZ USA

² University of Arizona College of Medicine, Tucson, AZ USA

³ Division of Infectious Diseases, Department of Medicine, MidState Medical Center, Meriden, CT USA

References

1. Torres A, Peetermans WE, Viegi G, Blasi F. Risk factors for community-acquired pneumonia in adults in Europe: a literature review. Thorax. 2013 Nov;68(11):1057-65. [CrossRef] [PubMed]
2. Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996 Jan 10;275(2):134-41. [CrossRef] [PubMed]
3. Chandra D, Rose SR, Carter RB, Musher DM, Hamill RJ. Fluid-containing emphysematous bullae: a spectrum of illness. Eur Respir J. 2008 Aug;32(2):303-6. [CrossRef] [PubMed]

Cite as: Beatty N, McKeown K, Hager KM, Scholand SJ. Medical image of the week: infected emphysematous bulla. Southwest J Pulm Crit Care. 2016;14(1):37-8. doi: https://doi.org/10.13175/swjpcc006-17 PDF 

Medical Image of the Week: The Luftsichel Sign

Figure 1. Anteroposterior chest radiograph demonstrating partial opacification of the left hemithorax, with preservation of the diaphragmatic border. A central mass is seen (thin arrow), as well as a radiolucent stripe bordering the aorta (thick arrows). Tracheal deviation to the left, a right-sided chest tube and a small right-sided pneumothorax are also noted.

Figure 2. Axial computed tomographic of the chest at the level of the carina (A) and left upper lobe bronchus (B) demonstrate opacification and volume loss of the left upper lobe with occlusion of the left upper lobe bronchus. The superior segment of the left lower lobe is interposed between the aorta and the atelectatic upper lobe (arrows). The right-sided pneumothorax is demonstrated and ground glass opacities are noted in the left lower lobe (arrowheads).

A 59-year old woman with recently diagnosed small cell carcinoma with metastases to liver and spine presented after a fall presented with lower extremity weakness and incontinence. She was diagnosed with intertrochanteric femoral fracture and prior to planned transfer to our hospital for neurosurgical evaluation she underwent operative fixation of the fracture. An indwelling venous access port was also placed on the same day which was complicated by a pneumothorax requiring chest tube placement

Upon arrival to our institution, she had normal vital signs and was in no distress. On respiratory examination, breath sounds were clear bilaterally on auscultation of the posterior chest but reduced on the left side on anterior auscultation. A chest tube was in place in the right mid-axillary line with no evidence of an air leak.

Chest x-ray demonstrated the right-sided chest tube and partial opacification of the left hemithorax, with a left hilar mass (Figure 1). The radiographic findings of left tracheal deviation, preservation of the left hemidiaphragm, and identification of the luftsichel sign suggested collapse of the left upper lobe. Computed tomography (CT) scan of the chest confirmed left upper lobar collapse due to extrinsic compression of the left upper lobar bronchus by a left upper lobe lung mass (Figure 2).

The luftsichel sign, a long-described marker of left upper lobe collapse on chest radiography, is a para-aortic stripe of radiolucency so-named for its course along the straight proximal descending aorta and curved aortic knob (in the German, luft for air, sichel for sickle) (1). Once theorized to be a result of herniation of the right lung into the left hemithorax after left-sided volume loss, CT correlation studies of radiographic signs in the 1980s verified the superior segment of the left lower lobe as the source of the lucency (2). Collapse of the left upper lobe displaces the major fissure anteriorly; the consequent movement of the left lower lobe results in expansion and interposition of its superior segment between the aorta and the atelectatic lung, as demonstrated in the correlate CT images in our patient.

Luke Gabe MD and Linda Snyder MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson, AZ USA

References

1. Blankenbaker DG. The luftsichel sign. Radiology. 1998 Aug;208:319-20. [CrossRef] [PubMed]
2. Khoury MB, Godwin JD, Halvorsen RA Jr, Putman CE.CT of obstructive lobar collapse. Invest Radiol. 1985 Oct;20(7):708-16. [CrossRef] [PubMed]

Cite as: Gabe L, Snyder L. Medical image of the week: the luftsichel sign. Southwest J Pulm Crit Care. 2017;14(1):26-7. doi: https://doi.org/10.13175/swjpcc003-17 PDF