Medical Image of the Week: Medical Administrative Growth

Figure 1. Growth of administrators compared to physicians 1970-2010 (used with permission of David Himmelstein).

It is generally agreed that healthcare costs are too high in the US. Although there has been considerable finger pointing, there is little doubt that administrative costs are far outpacing other healthcare costs. In ground-breaking work published in 1991, Woolhandler and Himmelstein (1) found that US administrative health care costs increased 37% between 1983 and 1987. They estimated these costs accounted for nearly a quarter of all health care expenditures. They followed their 83-87 report by examining data from 1999 (2). US administrative costs had risen to 31% of US health care expenditures. Himmelstein now estimates that administrative costs may now account for up to 40% of healthcare costs (Robbins RA, personal communication). The trend is perhaps best illustrated by Figure 1 showing growth of administrators compared to physicians from 1970-2010 (3).

Richard A. Robbins MD¹ and Bhupinder Natt MD²

¹Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ USA

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

References

1. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of the US health care system. N Engl J Med. 1991;324(18):1253-8. [CrossRef] [PubMed]
2. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349(8):768-75. [CrossRef] [PubMed]
3. Bureau of Labor Statistics. NCHS. Himmelstein and Woolhandler analysis of current population survey. Available at: http://www.pnhp.org/ (accessed 7/9/18).

Cite as: Robbins RA, Natt B. Medical image of the week: Medical administrative growth. Southwest J Pulm Crit Care. 2018;17(1):35. doi: https://doi.org/10.13175/swjpcc087-18 PDF 

Medical Image of the Week: Malposition of Central Venous Catheter

Figure 1. Portable anterior-posterior chest x-ray showing the tip of the catheter projecting on the left lung filed instead of crossing the midline.

Figure 2. Coronal images of computed tomography of head, neck, and upper chest. Yellow arrows showing the anatomical course of the left internal jugular catheter. Left upper image showing the catheter entering the internal jugular vein. Right lower image showing the tip of the catheter in the left inferior pulmonary vein.

A 66-year-old man a with history of systolic heart failure and end-stage renal disease on hemodialysis was admitted to the intensive care unit due to cardiogenic shock requiring inotropes. As left arm fistula was clotted, left internal jugular vein triple-lumen catheter (IJC) was placed to obtain a hemodialysis access. Central line placement was performed under ultrasound guidance with no complications. A confirmatory chest x-ray revealed central venous catheter malposition; the catheter tip did not cross the midline; instead, it projected over the left lung field which was concerning for arterial puncture of the carotid artery (Figure 1). Bedside ultrasonography showed an appropriate catheter placement in the left internal jugular vein, but the final catheter tip location was unclear. The transduced pressure was low; approximately 5mmHg. A blood gas sample from the catheter was compatible with arterial blood; pH 7.42, pCO2 34, and pO2 92. Computed tomography scan of the head and neck showed the IJC entering the left jugular vein, coursing within an anomalous left pulmonary vein, and terminating within the left inferior pulmonary vein (Figure 2). The catheter was not used and was withdrawn without complications.

One of the notable complications of central venous catheter (CVC) placement is malposition, with an approximate rate of 6,7 % (1). Catheter malposition indicates that the catheter tip lies outside the recommended position (within the mid lower part of the superior vein cava (SVC) above its junction with the right atrium and parallel to the vessel walls). Possible sites of central catheter malposition include the carotid artery, azygos vein, persistent left‑sided SVC, internal mammary vein, vertebral vein, pericardium, pleural space, thoracic duct and mediastinum (2). As artery puncture in the carotid artery can lead to serious complications, malposition of the catheter should be addressed in a stepwise approach. Initially bedside ultrasound should be performed to determine the anatomical catheter course and the position of the tip. A pressure transducer is also helpful in differentiating venous versus arterial waveform and measuring the transduced pressure, obtaining arterial blood gases and eventually confirming the catheter position with CT scan or CT angiography. Malposition of the jugular catheterization incidentally revealing partial anomalous of pulmonary venous return was described in a very few cases in literature, the catheter was used for seven days for continuous veno-venous hemofiltration in one of these cases (3). At this time there is insufficient literature to determine the safety of using CVC inserted in an anomalous pulmonary vein.

Mohamad Muhailan, MD and Muhamad Alhaj Moustafa, MD

Department of Internal Medicine

MedStar Washington Hospital Center

Washington, DC USA

References

1. Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG. Mechanical complications and malposition of central venous cannulations by experienced operators. A prospective study of 1794 catheterizations in critically ill patients. Intensive Care Med. 2007 Jun;33(6):1055-9. [CrossRef] [PubMed]
2. Wang L, Liu ZS, Wang CA. Malposition of central venous catheter: Presentation and management. Chin Med J (Engl). 2016 Jan 20;129(2):227-34. [CrossRef] [PubMed]
3. Grillot N, Figueiredo S, Aubry A, Leblanc PE, Duranteau J. Unusual dialysis catheter position due to partial anomalous pulmonary venous return: Diagnosis and management. Anaesth Crit Care Pain Med. 2016 Jun;35(3):233-5. [CrossRef] [PubMed]

Cite as: Muhailan M, Moustafa MA. Medical image of the week: Malposition of central venous catheter. Southwest J Pulm Crit Care. 2018;17(1):30-1. doi: https://doi.org/10.13175/swjpcc084-18 PDF 

Medical Image of the Week: Fournier’s Gangrene with a Twist

Figure 1. A: Coronal view of abdominal CT scan showing extensive gas formation from the site of trauma (scrotum) ascending along fascial planes, encompassing abdominal wall and chest wall (arrows). B: Close up view of the scrotum and perineum showing tissue necrosis with gas formation. C: Sagittal view of the thoracic CT scan showing gas formation tracking along the chest wall and superior mediastinum (arrows).

Figure 2. Status post incision and debridement of scrotum and perineum.

A 37-year-old man presented with worsening left testicular pain, swelling and redness within 3 days of being poked by a safety-pin during foreplay. Over 24 hours, his left scrotum doubled in size with significant erythema, edema, crepitus and induration. Imaging of scrotum and legs revealed extensive gas formation extending to the retroperitoneum and ascending along fascial planes. Subcutaneous emphysema of abdominal wall, chest wall with mediastinal gas was noted. Investigation showed a shite blood cell count of 22,000 cells/mcL with 12% bands and HIV testing was negative. Intravenous vancomycin and ertapenem were administered on presentation followed by emergent bilateral debridement of the scrotum. Wound/tissue cultures grew methicillin sensitive Staphylococcus aureus, group B Streptococcus and anaerobic Bacteroides. Antibiotics were de-escalated to ciprofloxacin and metronidazole and the patient showed adequate recovery at 30 days of follow up.

Improved survival of Fournier’s gangrene can only be achieved by prompt diagnosis, early debridement by an experienced surgical team and microbiology guided use of antibiotics.

Our case brings forward the act of piquerism, a paraphilia which led to rapidly progressive perineal tissue necrosis with bacterial synergism of non-clostridial micro-organisms causing extensive gas formation.

Padmastuti Akella, MD¹, Himmat Grewal MD¹, Imola Daniel MD²

¹Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA

²Division of Infectious Diseases, Saint Vincent Hospital, Worcester, MA

References 

1. Archer CB, Rosenberg WM, Scott GW, MacDonald DM. Progressive bacterial synergistic gangrene in patient with diabetes mellitus. J R Soc Med. 1984;77 Suppl 4:1-3. [PubMed]
2. Yasuda K, Hayashi M, Takeda N, Goshima E, Miura K. A survived case of diabetic nonclostridial gas gangrene and the review of the literatures on microbiological findings. Jpn J Med. 1986 May;25(2):171-4. [CrossRef] [PubMed]
3. Takazawa K, Otsuka H, Nakagawa Y, Inokuchi S. Clinical features of non-clostridial gas gangrene and risk factors for in-hospital mortality. Tokai J Exp Clin Med. 2015 Sep 20;40(3):124-9. [PubMed]
4. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-65. [CrossRef] [PubMed]

Cite as: Akella P, Grewal H, Daniel I. Medical image of the week: Fournier's gangrene with a twist. Southwest J Pulm Crit Care. 2018;17(1):28-9. doi: https://doi.org/10.13175/swjpcc083-18 PDF

July 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

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: 0.75 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 completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options 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, 2017-December 31, 2018

Clinical History: An 81–year old non-smoking woman presented with complaints of shortness of breath for one month, more so when laying down. The patient had a history of Sjögren syndrome established 13 years earlier. She notes a history of dryness of the eyes and upper airways. Her medications included 5 mg prednisone daily as well as various vitamins and supplements. While she complained of several medication “allergies,” none were serious and most appeared to represent side effects or untoward reactions to medications as opposed to true allergic reactions. Her past medical history included arthritis, possible obstructive sleep apnea, kidney stones, and orthostatic hypotension, the latter thought to be related to her Sjögren syndrome. Her surgical history included a sternotomy for thymoma resection years earlier.

Her physical examination was unremarkable except for diminished breath sounds at the left base; her vital signs were within normal limits.

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

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

Which of the following represents the most accurate assessment of the chest radiographic findings? (click on the correct answer to be directed to the second of eleven pages)

1. Chest radiography shows an elevated left hemidiaphragm
2. Chest radiography shows bibasilar fibrotic-appearing opacities
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows multifocal bronchiectasis
5. Chest radiography shows small pulmonary nodules

Cite as: Gotway MB. July 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;17(1):15-27. doi: https://doi.org/10.13175/swjpcc086-18 PDF 

Medical Image of the Week: Intracavitary View of Mycetoma

Figure 1. Thoracic CT scan shows Monod’s sign, a mycetoma within an existing cavity, in the left upper lobe.

Figure 2. A: Current thoracic CT scan. B: thoracic CT scan 8 months earlier.

Figure 3. Bronchoscopic views of the cavity with intracavitary mycetoma in the left upper lobe.

A 46-year-old Hispanic man with no medical history presents to the pulmonary service for a second opinion regarding his unresolved pneumonia that initially presented as fever and cough; he did not have hemoptysis. He was found to have left upper lobe cavitary lesion and had been diagnosed with Aspergillus multiple times, with the initial diagnosis one year prior to presentation. He was seen by an outside pulmonologist and was placed on voriconazole 200 mg/day. Since being on the voriconazole he has not been feeling better. He continued to note symptoms of productive cough, fatigue, and weakness. Monod’s sign (Figure 1) is appreciated on CT imaging during initial encounter at an outside facility. Comparison of parenchymal damage is seen in Figure 2 comparing CT scans 8 months apart. Patient’s fungal cavity was appreciated on bronchoscopic exam (Figure 3). Ultimately, he was evaluated by cardiothoracic surgery and underwent a left upper lobectomy which he tolerated well.

Aspergillomas present as a mycetoma within an existing cavity. Monod’s sign is the radiographic finding of a mycetoma within the existing cavity as evidenced in the CT scan. This is not to be confused with the air-crescent sign which is seen more often with invasive aspergillosis, a separate clinical entity. This case is unique given its unique radiographic sign along with the visualization of fungal cavity from within through the bronchoscope.

Steve Tseng, DO and Raed Alalawi, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

References

1. Pesle GD, Monod O. Bronchiectasis due to aspergilloma. Dis Chest. 1954;25(2):172-183. [PubMed]
2. Thompson BH, Stanford W, Galvin JR, Kurihara Y. Varied radiologic appearances of pulmonary aspergillosis. Radiographics. 1995 Nov;15(6):1273-84. [CrossRef] [PubMed]

Cite as: Tseng S, Alalawi R. Medical image of the week: Intracavitary view of mycetoma. Southwest J Pulm Crit Care. 2018;16(6):360-1. doi: https://doi.org/10.13175/swjpcc082-18 PDF 

Medical Image of the Week: Neuromyelitis Optica and Sarcoidosis

Figure 1. Magnetic resonance imaging (MRI) showing enhancement of the left optic nerve (circle) consistent with optic neuritis.

Figure 2. Thoracic CT scan showing mediastinal lymphadenopathy (arrow).

A 33-year old woman presented to the emergency room with progressive vision loss of the left eye. A diagnosis of optic neuritis was made clinically and on magnetic resonance imaging MRI (Figure 1). With high anti-aquaporin 4 antibody titers, and compatible lesions on the MRI of the spinal cord, she was diagnosed with neuromyelitis optica (NMO). After dialysis catheter placement for plasmapheresis, an enlarged mediastinal shadow was seen. Fearing a complication of the catheter placement, a CT scan of the chest was obtained, confirming mediastinal lymphadenopathy (Figure 2).

An endobronchial ultrasound (EBUS) guided transbronchial needle aspiration of the mediastinal lymph nodes showed non-caseating granulomas, consistent with sarcoidosis in the absence of infectious work up and no known beryllium exposure.

NMO, also known as Devic's disease or Devic's syndrome, is a heterogeneous condition consisting of the inflammation and demyelination of the optic nerve (optic neuritis) and the spinal cord (myelitis). NMO and sarcoidosis can be difficult to differentiate (1). Our patient had a rarely described co-existing disease.

Tammer El-Aini MD and Bhupinder Natt MD

Division on Pulmonary, Allergy, Critical Care and Sleep

University of Arizona College of Medicine

Tucson AZ USA

Reference

1. Flanagan EP, Kaufmann TJ, Krecke KN, et al. Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol. 2016 Mar;79(3):437-47. [CrossRef] [PubMed]

Cite as: El-Aini T, Natt B. Medical image of the week: neuromyelitis optica and sarcoidosis. Southwest J Pulm Crit Care. 2018;16(6):341-2. doi: https://doi.org/10.13175/swjpcc081-18 PDF

Medical Image of the Week: Pulmonary Amyloidosis in Primary Sjogren’s Syndrome

Figure 1. Thoracic CT scan showing multiple pulmonary nodules and lung cysts. The lung cysts were located apart from the pulmonary nodules.

Figure 2. Follow up CT scan in one year revealing worsening of the widespread lung cysts.

A 69-year-old woman with past medical history of Sjögren's syndrome presented with pleuritic chest pain and shortness of breath for a month. Review of systems revealed worsening dysphagia and dryness of eyes over the last one year. Physical exam was significant for a palpable left axillary node and mild rhonchi bilaterally in the lower lung bases. Laboratory work was positive for Sjogren’s Syndrome antibodies. Chest x-ray revealed multiple nodules in bilateral lung fields. HRCT showed interlobular septal thickening and multiple cystic areas throughout the lung parenchyma which had progressed over 1 year (Figure 1). Wedge resection and thorough lymph node dissection were performed via video-assisted thoracic surgery (VATS). Biopsy of the lung nodules revealed thickened alveolar septate with acellular eosinophilic homogenous materials, which took up Congo Red stain. Based on these pathological findings, the final diagnosis was - diffuse septal alveolar pulmonary amyloidosis secondary to Sjogren’s Syndrome. bortezomib. However, patient did not want to undergo chemotherapy. She preferred the ‘wait and watch approach’ and wished to be treated with only prednisone, with the intention to switch to azathioprine in future. However, after one year thoracic CT showed worsening of the cysts (Figure 2).

Pulmonary amyloidosis of the lower respiratory tract may represent a significant clinical problem in systemic and organ-limited amyloidosis and can contribute to cardiopulmonary failure. Pulmonary amyloidosis may present as a nodular localized type, diffuse septal alveolar amyloidosis, tracheobronchial amyloidosis and even pleural amyloidosis (1). Each patient requires complete assessment and unequivocal amyloid typing to determine their optimal treatment. Diffuse alveolar-septal amyloidosis is treated according to the underlying systemic amyloidosis, with most chemotherapeutic regimes similar to that of multiple myeloma (2). Patients should be monitored very closely and physicians should frequently asses the efficacy of the chemotherapeutic regime.

Payal Sen, MD and Betty Chang, MDCM, PhD

University of New Mexico

Albuquerque, NM USA

References

1. Milani P, Basset M, Russo F, Foli A, Palladini G, Merlini G. The lung in amyloidosis. Eur Respir Rev. 2017 Sep 6;26(145). [CrossRef] [PubMed]
2. Dispenzieri A, Seenithamby K, Lacy MQ, et al. Patients with immunoglobulin light chain amyloidosis undergoing autologous stem cell transplantation have superior outcomes compared with patients with multiple myeloma: a retrospective review from a tertiary referral center. Bone Marrow Transplant. 2013 Oct;48(10):1302-7. [CrossRef] [PubMed]

Cite as: Sen P, Chang B. Medical image of the week: Pulmonary amyloidosis in primary Sjogren’s syndrome. Southwest J Pulm Crit Care. 2018;16(6):336-7. doi: https://doi.org/10.13175/swjpcc072-18 PDF 

Medical Image of the Week: Post Pneumonectomy Syndrome

Figure 1.Computed tomography of the chest. Panel A: lung windows reveal hyperexpansion of right lung with extreme shift of mediastinum to the left hemithorax. Panel B: mediastinal windows reveals rotation of the heart toward midline.

A 73 year-old woman with a history of left pneumonectomy in 2012 for Stage IB adenocarcinoma of the lung presented to the outpatient pulmonary clinic with dyspnea on exertion and fatigue. Computed tomography of the chest reveals hyperexpansion of the right lung with complete shift of the heart and mediastinal structures into the left hemithorax, (Figure  1). There is tethering of the right mainstem bronchus and right-sided vessels with a stretched configuration of the trachea, esophagus and right-sided vasculature.  The heart is rotated toward the midline. The central airways are patent, however, the tethering and rotation of the mediastinal structures are concerning for post-pneumonectomy syndrome (PPS).

PPS is a rare and late complication after pneumonectomy and results from extreme shift and rotation of the mediastinum. Symptoms can include progressive dyspnea, cough, inspiratory stridor and recurrent pneumonia (1). Dyspnea can be caused by bronchial compression or by compression of the pulmonary vein (2). Dysphagia and acid reflux can result from esophageal compression (3). PPS is more common after right pneumonectomy, however cases following left pneumonectomy are well described. Treatment options include surgical correction using saline‐filled tissue expanders to restore normal mediastinal position (4).

Billie Bixby MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona

University Medical Center Tucson

Tucson, AZ USA

References

1. Valii, AM, Maziak DE, Shamii FM, Matzinger RF. Postpneumonectomy syndrome: recognition and management. Chest. 1998; 114:1766. [CrossRef] [PubMed]
2. Partington SL, Graham A, Weeks SG. Pulmonary vein stenosis following left pneumonectomy: a variant contributor to postpneumonectomy syndrome. Chest. 2010;137(1):205-6. [CrossRef] [PubMed]
3. Soll C, Hahnloser D, Frauenfelder T, Russi EW, Weder W, Kestenholz PB. The postpneumonectomy syndrome: Clinical presentation and treatment. Eur J Cardiothorac Surg. 2009; 35: 319-24. [CrossRef] [PubMed]
4. Jung JJ, Cho JH, Kim HK, et al. Management of post‐pneumonectomy syndrome using tissue expanders. Thoracic Cancer. 2016;7(1):88-93. [CrossRef] [PubMed]

Cite as: Bixby B, Knepler J. Medical image of the week: post pneumonectomy syndrome. Southwest J Pulm Crit Care. 2018;16(6):332-3. doi: https://doi.org/10.13175/swjpcc071-18 PDF 

June 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

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: 0.75 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 completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options 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, 2017-December 31, 2018

Clinical History: A 63-year-old non-smoking woman presented with complaints of nausea, vomiting and abdominal pain, which prompted CT of the abdomen and pelvis (images not shown). The CT of the abdomen and pelvis disclosed several small basilar nodules, for which dedicated thoracic CT (Figure 1) was performed. 

 

Figure 1. Panels A-H: Representative images from unenhanced axial thoracic CT displayed in lung windows. Lower panel: video of thoracic CT in lung windows.

Which of the following represents the most accurate assessment of the thoracic CT findings? (click on the correct answer to be directed to the second of nine pages)

1. Thoracic CT shows bibasilar fibrotic-appearing opacities
2. Thoracic CT shows cavitary pulmonary lesions
3. Thoracic CT shows multifocal bronchiectasis
4. Thoracic CT shows multifocal ground-glass opacity
5. Thoracic CT shows small pulmonary nodules

Cite as: Gotway MB. June 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(6):311-23. doi: https://doi.org/10.13175/swjpcc069-18 PDF 

Medical Image of the Week: Elemental Mercury Poisoning

Figure 1. Panel A: Abdominal x-ray showing radiopaque matter. Panel B: Repeat x-ray after colonoscopy.

A 34-year-old woman presented to the Emergency department with abdominal pain after ingestion of an unknown liquid that family felt might be poisonous. The patient had a past history of prior suicide attempts, as well as a history of polysubstance and alcohol abuse. The patient was confused, tangential and a difficult historian. The patient had a heart rate of 72, was normotensive, and had an oxygen saturation of 100% on room air.  She was confused and answered questions intermittently. The remainder of her physical examination including her neurological exam was normal. The initial serum chemistry, anion gap, lactate, liver function tests were normal. Urine drug screen was positive for benzodiazepines, for which the patient was prescribed. An abdominal x-ray was performed showing a radiopaque substance in the abdomen (Figure 1A). It was eventually determined she ingested elemental mercury. Blood levels were elevated, and she did eventually have hematochezia. Colonoscopy was performed which removed some of the metallic liquid mercury (Figure 1B).

Mercury in any form is poisonous, with mercury toxicity most commonly affecting the neurologic, gastrointestinal (GI) and renal organ systems (1). Poisoning can result from mercury vapor inhalation, mercury ingestion, mercury injection, and absorption of mercury through the skin.

Elemental mercury is poorly absorbed after ingestion but easily vaporizes at room temperature and is well absorbed (80%) through inhalation. Once absorbed elemental mercury is mostly converted to an inorganic divalent or mercuric form by catalase in the erythrocytes. This inorganic form has similar properties to inorganic mercury (e.g., poor lipid solubility, limited permeability to the blood-brain barrier, and excretion in feces).

Treatment of mercury toxicity consists of removal of the patient from the source of exposure, supportive care, and chelation therapy. Our patient had limited symptoms, and for this reason, chelation therapy was not performed. She made an uneventful recovery after discharge to psychiatry. Her blood levels eventually returned to normal in a few months.

Michel A. Boivin, MD

Pulmonary/Critical Care/Sleep Medicine

Department of Internal Medicine

University of New Mexico

Albuquerque, NM USA

Reference

1. Olson DA. Mercury poisoning. Medscape. August 14, 2017. Available at: https://emedicine.medscape.com/article/1175560-overview (accessed 5/22/18).

Cite as: Boivin M. Medical image of the week: Elemental mercury poisoning. Southwest J Pulm Crit Care. 2018;16(5):287-8. doi: https://doi.org/10.13175/swjpcc067-18 PDF 

Medical Image of the Week: Thoracic Splenosis

Figure 1. A: Axial CT of the chest without intravenous contrast demonstrates a cluster of soft tissue nodules adjacent to the left posterior hemi-diaphragm (blue arrows). B: Axial CT of the chest without intravenous contrast demonstrates absence of the spleen and a surgical clip (blue arrow) consistent with a prior splenectomy.

Figure 2. Fused technetium 99m-label sulfur colloid uptake study and axial CT of the chest without intravenous contrast demonstrates uptake of radiotracer in the previously seen soft tissue nodules adjacent to the posterior aspect of the left hemi-diaphragm (red arrows) which confirms the diagnosis of thoracic splenosis.

A 38-year-old man with a history of a motor vehicle collision about 20 years prior to presentation which resulted in multiple left-sided rib fractures, a left-sided pneumothorax requiring chest tube placement, and a high-grade splenic laceration necessitating an emergent splenectomy that presents to outpatient pulmonary clinic for evaluation of pulmonary nodules at the request of his primary care physician. He is asymptomatic. He has a 20-pack-year of smoking history and currently smokes 6 cigarettes per day. He denies any significant exposures or recent infections. He has a family history significant for heart disease and depression, but no history of malignancy. His vital signs and physical examination are normal. He had a CT of the chest performed with representative images from the study shown in Figure 1.

A nuclear medicine scan was subsequently requested which demonstrated uptake of the technetium 99m-labeled sulfur colloid in the soft tissue nodules adjacent to left hemi-diaphragm (Figure 2) confirming the diagnosis of thoracic splenosis. No further treatment or diagnostic work up was required.

Splenosis is defined as auto-transplantation of splenic tissue following traumatic or surgical disruption of the spleen. Splenosis usually occurs in the abdomen, most commonly in the left upper quadrant (1,2). However, with disruption of the diaphragm in the setting of trauma, splenic tissue can migrate into the thoracic cavity, and most often settles in the inferior, posterior left pleural space (as in our patient).  The diagnosis of thoracic splenosis should be suspected when one sees left basilar pleural nodules/masses in the setting of a previous trauma necessitating a splenectomy. A technetium 99m-labeled sulfur colloid study will demonstrate uptake of the radiotracer in the auto-transplanted splenic tissue as this radiotracer has a strong affinity for tissue arising from the reticuloendothelial system.

Gregory Gardner MD¹, Kevin Breen¹, Tammer Elaini MD², and Tiffany Ynosencio MD²

¹Department of Internal Medicine

²Division of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Khosravi MR, Margulies DR, Alsabeh R, Nissen N, Phillips EH, Morgenstern L. Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury. Am Surg. 2004 Nov;70(11):967-70. [PubMed]
2. Rosado-de-Christenson ML, Abbott GF. Diagnostic Imaging: Chest. 2^nd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 30-1.

Cite as: Gardner G, Breen K, Elaini T, Ynosencio T. Medical image of the week: thoracic splenosis. Southwest J Pulm Crit Care. 2018;16(5):285-6. doi: https://doi.org/10.13175/swjpcc066-18 PDF

Medical Image of the Week: Valley Fever Cavity with Fungus Ball

Figure 1. Chest x-ray taken in 2004 showing pulmonary nodule (arrows).

Figure 2. A: Thoracic CT scan in lung windows from 2004 showing the pulmonary nodule with cavitation. B: CT scan from 2007 showing thin-walled cavity. C: CT scan from 2008 showing fungus ball inside the cavity.  D: CT scan from 2010 showing the continued presence of the fungus ball inside the cavity.

A 72-year-old man was seen in 2010 because of hemoptysis. In 2004 a routine chest x-ray discovered a new pulmonary nodule (Figure 1, Figure 2A). Coccioidomycosis by complement fixation and IgM were negative but IgG was elevated at 0.203 (upper limit of normal 0.150).  A transthoracic needle biopsy revealed a granuloma without malignancy and no growth of any organisms. He was followed because he was asymptomatic. He remained asymptomatic but developed a thin-walled cavity (Figure 2B). However, beginning in 2008 he developed a cough with occasional hemoptysis. His thoracic CT scan was repeated and was interpreted as showing findings consistent with a fungus ball (Figure 2C). He was treated with fluconazole for about 6 months but his hemoptysis persisted and therapy was switched to itraconazole. His hemoptysis persisted although it was somewhat improved. A repeat CT scan performed in 2010 (Figure 2D) continued to show the fungus ball. He was referred to pulmonary and bronchoscopy revealed no other source of the hemoptysis; stains and cultures were negative; and he was referred to thoracic surgery for resection.

Hemoptysis from coccioidomycosis is unusual and should prompt a search for other causes (1). These could include bronchitis, malignancy, or rarely, a fungus ball as in our case. When hemoptysis is present with a fungus ball, treatment with fluconazole, itraconazole or amphotericin B is often advised although descriptions are limited to case reports. When hemoptysis persists despite drug therapy, resection of the cavity has been performed (2).

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Reference

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):238-49. [CrossRef]
2. Thadepalli H, Salem FA, Mandal AK, Rambhatla K, Einstein HE.Pulmonary mycetoma due to Coccidioides immitis. Chest. 1977 Mar;71(3):429-30. [PubMed]

Cite as: Robbins RA. Medical image of the week: valley fever cavity with fungus ball. Southwest J Pulm Crit Care. 2018;16(5):281-2. doi: https://doi.org/10.13175/swjpcc064-18 PDF 

Medical Image of the Week: Recurrent Sarcoidosis Resembling Malignancy

Figure 1. CT scan showing multiple splenic masses.

The patient is a 64-year-old, non-smoking, woman who presented with a dry cough for a year and had a history of sarcoidosis. Five years ago, she presented with cough, bilateral pulmonary nodules and mediastinal adenopathy. At that time by a fine needle aspiration (FNA) under endobronchial ultrasound biopsy (EBUS), revealing non caseating granulomatous inflammation. She had complete remission after she was treated with a course of steroids. Follow up chest CT showed remission of her disease. On this presentation, she was found to have incidental multiple splenic masses on a CT scan of the chest (Figure 1). Physical examination was normal, CBC and chemistry were normal, and she had negative tests for tuberculosis, rheumatologic disease, systemic sclerosis, and mixed connective tissue disease. 

Pulmonary function tests were consistent with restrictive impairment and mild decrease in diffusion capacity for carbon monoxide. Positron Emission Tomography (PET scan) showed increased uptake corresponding to these lesions with no other areas of abnormal uptake in the body. CT-guided biopsy of splenic lesion showed non-caseating granulomas consistent with sarcoidosis. She was retreated with a course of steroids and a follow up CT scan of the abdomen showed resolution of the splenic masses.

Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by non-caseating granulomas. It is thought to result from an exaggerated host cellular immune response to an unknown antigen. Although the lungs are involved in 90 % of patients, other organs can be affected with the lungs or in isolation. Visceral involvement is usually asymptomatic and presents as hepatosplenomegaly on physical exam, or less often as isolated nodular splenic lesions suspicious of lymphoma. Rarely patients can have elevated liver enzymes from liver involvement or cytopenias from splenic enlargement (1).

Other differential diagnoses include infectious, neoplastic or benign conditions that may have similar morphology, such as tuberculosis, histoplasmosis, and lymphomas, hemangiomas and hamartomas. Diagnosis is usually confirmed by a biopsy and the disease responds to steroid treatment in over 70% of patients (2). Splenectomy is a therapeutic option in cases of steroids failure, severe hypersplenism, inability to exclude malignancy, or if risk of splenic rupture is high (3).

Isolated splenic sarcoidosis is a rare condition that can be the first presentation of sarcoidosis or a site of disease recurrence. It can mimic a variety of infectious, benign or malignant conditions especially when it presents with cytopenias due to hypersplenism, making biopsy necessary. Fortunately, splenic sarcoidosis responds to steroid treatment in most patients. Splenectomy can be considered in refractory cases.

Fuad Zeid MD¹, Hasan S. Yamin MD¹, Ahmed Amro MD², Fadi Alkhankan MD³, and Hani Alkhankan MD⁴

¹Pulmonary and Critical Care and ²Internal Medicine

Marshall University

Huntington, WV USA

³Pulmonary and Critical Care

Mercy hospital/ St. Louis University

St. Louis, MO USA

⁴McLaren Oakland Pulmonary/Critical Care,

Pontiac, MI USA

References

1. Vakil A, MD, Upadhyay H, Sherani K, Cervellione K, Fein A. A case of splenic sarcoidosis: initial diagnosis and one-year symptom follow-up. Chest. 2014;145(3):210A [Abstract].
2. Calik M, Aygun M, Yesildag M, et al. Nodular splenic sarcoidosis: a rare case report and review of the literature. Chest. 2014;146(4):399A [Abstract].
3. Sharma OP, Vucinic V, James DG. Splenectomy in sarcoidosis: indications, complications, and long-term follow-up. Sarcoidosis Vasc Diffuse Lung Dis. 2002 Mar;19(1):66-70. [PubMed]

Cite as: Zeid F, Yamin HS, Amro A, Alkhankan F, Alkhankan H. Medical image of the week: recurrent sarcoidosis resembling malignancy. Southwest J Pulm Crit Care. 2018;18(5):279-80. doi: https://doi.org/10.13175/swjpcc057-18 PDF 

May 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 79-year-old man with a past medical history significant for mild, intermittent asthma since childhood and mild aortic stenosis presents to the Emergency Room with fevers and chills for 5 days, associated with dry cough and dyspnea on exertion. His past medical history was otherwise relatively unremarkable, with coronary artery disease as evidenced by coronary artery calcium at a calcium scoring CT, hypothyroidism, and dyslipidemia. The patient has allergies to dust and penicillin, and his only medications included thyroid replacement, aspirin, and an albuterol inhaler as needed. He was a 15-pack-year smoker, quitting 30 years ago. His past surgical history was remarkable only for tonsillectomy, inguinal hernia repair, meniscal repair, and sigmoid colon resection for diverticular abscess 14 years earlier. The patient was afebrile, his heart rate was 96 beats / minute and regular, decreased breath sounds at the lung bases was noted, and the white blood cell count was normal. Electrocardiography showed no abnormalities. Oxygen saturation was 92% on room air. Frontal chest radiography (Figures 1A and B) was performed.

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

Which of the following represents the most accurate assessment of the frontal chest imaging findings? (Click on the correct answer to proceed to the second of nineteen pages)

1. Chest frontal imaging shows bilateral pleural fluid collections
2. Chest radiography shows bilateral lower lobe bronchial wall thickening and patchy consolidation
3. Chest radiography shows cavitary lung disease
4. Chest radiography shows numerous small nodules
5. Chest radiography shows peribronchial and mediastinal lymphadenopathy

Cite as: Gotway MB. May 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(5):254-78. doi: https://doi.org/10.13175/swjpcc062-18 PDF 

Medical Image of the Week: Cardiac Magnetic Resonance Imaging Findings of Severe RV Failure

  

Figure 1. Transthoracic echocardiography, short-axis view (1A) and four-chamber view (1B) demonstrating leftward deviation with flattening of interventricular septum (“D-sign”) due to increased right ventricular pressure and volume overload from severe pulmonary arterial hypertension (PAH). RV=right ventricle. RA=right atrium. LV=left ventricle.

Figure 2. Cardiac Magnetic Resonance Imaging, sagittal view (2A), and cross-sectional view (2B) show the same signs of massive right ventricular (RV) pressure and volume overload with severe RV dysfunction. RV ejection fraction of 13%. RV=right ventricle. RA=right atrium. LV=left ventricle. LA=left atrium.

A 56-year-old man with history a of alcohol abuse presents with progressive shortness of breath on exertion, bilateral lower extremity swelling and 12-pound weight gain over two weeks.

His transthoracic echocardiography (Figure 1) demonstrated severely increased global right ventricle (RV) size, severely dilated right atrium (RA), severe pulmonary artery (PA) dilation, moderate tricuspid regurgitation (TR) and right ventricular systolic pressure (RVSP) estimated at 85 + central venous pressure (CVP) in the context of severely reduced RV systolic function.  Right heart catheterization (RHC) showed PA pressure (systolic/diastolic, mean) of 94/28, 51 mmHg with a PA occlusion pressure of 12 mmHg. After extensive evaluation, our patient’s presentation of right heart failure seemed to be a manifestation of idiopathic pulmonary arterial hypertension.

Our patient subsequently had cardiac MRI (cMRI) with findings shown above (Figure 2). CMRI is a valuable, three-dimensional imaging modality that provides detailed morphology of the cardiac chambers along with accurate quantification of chamber volumes, myocardial mass and transvalvular flow (1). Cardiac MRI is an accurate tool to estimate the RV function at baseline and to follow up response to treatment. RV function at presentation and after treatment are very important determinants of prognosis independent of other hemodynamic indices (2).  

Kelly Wickstrom, DO¹, Huthayfa Ateeli, MBBS², Sachin Chaudhary, MD²

¹Internal Medicine Department and ²Pulmonary and Critical Care Division

Banner University Medical Center

Tucson, AZ USA

References

1. Grünig E, Peacock AJ. Imaging the heart in pulmonary hypertension: an update. Eur Respir Rev. 2015 Dec;24(138):653-64. [CrossRef] [PubMed]
2. Swift AJ, Wild JM, Nagle SK, et al. Quantitative magnetic resonance imaging of pulmonary hypertension: a practical approach to the current state of the art. J Thorac Imaging. 2014 Mar;29(2):68-79. [CrossRef] [PubMed]

Cite as: Wickstrom K, Ateeli H, Chaudhary S. Medical image of the week: cardiac magnetic resonance imaging findings of severe RV failure. Southwest J Pulm Crit Care. 2018;16(5):252-3. doi: https://doi.org/10.13175/swjpcc047-18 PDF

Medical Image of the Week: Mediastinal Lipomatosis

Figure 1. Chest X-ray showing right sided mediastinal mass.

Figure 2. Coronal (A) and axial (B) CT Images showing a right paratracheal homogenously fat-enhancing mass.

A 61-year-old man presented to the pulmonary clinic for evaluation of a chronic cough of 6 months’ duration.  Other medical problems included class three obesity, obstructive sleep apnea on CPAP therapy, and hypertension.  Chest X-Ray (Figure 1) revealed a right mediastinal mass which then prompted a chest CT to be performed. The chest CT (Figure 2) demonstrated a homogenously enhancing, well circumscribed and fat-attenuating 8 x 5 cm mass in the right paratracheal region without invasion or compression into surrounding structures.

Mediastinal lipomatosis was diagnosed.  This is a benign soft tissue tumor made of mature adipocytes that can be seen with obesity, chronic corticosteroid use, and Cushing’s syndrome.  They are thought to represent up to 2.3% of all primary mediastinal tumors (1).  They are occasionally associated with compression of surrounding structures which can cause superior vena cava syndrome, dry cough, dysphagia, and occasionally arrhythmias (2).  Management is typically conservative with weight loss encouraged unless mass effect is present that significantly affects quality of life, in which case surgical options may be explored. 

Although this patient’s cough could be due to this lipoma, he also had symptoms of cough possibly exacerbated by severe gastroesophageal reflux disease which was not yet managed.  A trial of a proton pump inhibitor was pursued with follow-up arranged to determine if further intervention is necessary.

Bryan Borg MD and James Knepler MD

Department of Medicine

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

University of Arizona

Tucson, AZ USA

References

1. Gaerte SC, Meyer CA, Winer-Muram HT. Fat-containing lesions of the chest. Radiographics. 2002;22:61-78. [CrossRef] [PubMed]
2. Cutilli T, Schietroma M, Marcelli VA, Ascani G, Corbacelli A. Giant cervico-mediastinal lipoma. A clinical case. Minerva Stomatol. 1999 Jan-Feb;48(1-2):23-8. [PubMed]

Cite as: Borg B, Knepler J. Medical image of the week: mediastinal lipomasosis. Southwest J Pulm Crit Care. 2018;16:228-9. doi: https://doi.org/10.13175/swjpcc046-18 PDF 

Medical Image of the Week: Dobhoff Tube Placement with Roux-En-Y Gastric Bypass

Figure 1. Abdominal X-ray after Dobhoff tube (DHT) placement to confirm accurate positioning. The distal tip of the feeding tube is in a loop of jejunum in patient status post gastrojejunostomy.

Figure 2. Gastrointestinal anatomy before and after Roux-en-Y gastric bypass procedure.

Roux-en-Y gastric bypass is one of the most commonly performed bariatric operations in the United States.  It involves partitioning a small gastric pouch off the proximal stomach and attaching that pouch directly to the intestine, thereby bypassing the large remainder of the stomach (1,2). Placing a Dobhoff tube (DHT) and confirming its placement can be challenging due to the change in anatomy after the procedure. Here, we have a 65-year-old woman who presented to the hospital with acute encephalopathy and acute hypoxic respiratory failure due to multifocal pneumonia requiring intubation and prolonged ICU stay. A DHT was inserted after intubation for feeding purposes. An abdominal X-ray was obtained to confirm placement of the DHT (Figure 1).  Normally the DHT tip should be placed in the 2^nd to 3^rd portion of the duodenum and would create a C-shaped tracing on the X-ray. However, in our patient who had history of Roux-en-Y, the DHT bypassed the duodenum and went straight down from the stomach to the jejunum as illustrated in Figure 1. It is important to be aware of this change in anatomy in patients who had a Roux-en-Y gastric bypass surgery in order to confirm accurate placement of DHT.

Hasan Ali¹ MD, Huthayfa Ateeli² MBBS, Bhupinder Natt²  MD FACP, and Sachin Chaudhary² MD.

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

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Smoot TM, Xu P, Hilsenrath P, Kuppersmith NC, Singh KP. Gastric bypass surgery in the United States, 1998–2002. Am J Public Health. 2006;96(7):1187–9. [CrossRef] [PubMed]
2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909–17. [CrossRef] [PubMed]

Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: Dobhoff tube placement with Roux-en-Y gastric bypass. Southwest J Pulm Crit Care. 2018;16(4):226-7. doi: https://doi.org/10.13175/swjpcc045-18 PDF 

Medical Image of the Week: Atypical Deep Sulcus Sign

Figure 1.  Chest X-ray showing hyper inflated lungs with no clear evidence of pneumothorax.

Figure 2. Atypical deep sulcus sign on the left side.

Figure 3. Complete resolution of left sided pneumothorax after chest tube placement.

The deep sulcus sign is a radiolucent lateral sulcus where the chest wall meets the diaphragm. The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign (1). Here, we present a 42-year-old man with a history of asthma who was admitted with status asthmaticus requiring intubation. On hospital day 3, the patient developed subcutaneous emphysema surrounding his entire neck and extending into left side of the chest wall. Chest X-ray after this episode showed an atypical deep sulcus sign (Figure 2) concerning for left sided pneumothorax that was also confirmed by bedside ultrasound. A surgical chest tube was placed immediately and a repeat chest X-ray (Figure 3) showed complete resolution of the pneumothorax and the deep sulcus sign. In critically ill patients where it is difficult to obtain an upright film, it is important to pay attention to the costophrenic angles when concern for pneumothorax arises. In a supine film, a deep sulcus sign may be the only indication of a pneumothorax because air collects anteriorly and basally within the nondependent portions of the pleural space, as opposed to the apex when the patient is upright (2).

Hasan Ali MD¹, Huthayfa Ateeli MBBS², Bhupinder Natt MD FACP², Sachin Chaudhary MD².

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

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Kim HK, Park CY, Cho HM. Deep sulcus sign. Trauma Image & Procedure. 2016;1(1):12-3. [CrossRef]
2. Liu SY, Tsai IT, Yang PJ. Pneumothorax and deep sulcus sign. QJM. 2016;109(9):621-2. [CrossRef] [PubMed]  

Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: atypical deep sulcus sign. Southwest J Pulm Crit Care. 2018;16(4):224-5. doi: https://doi.org/10.13175/swjpcc044-18 PDF 

April 2018 Imaging Case of the Month

Robert W. Viggiano, MD*

Michael B. Gotway, MD**

*Pulmonary Department and **Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 65-year-old non-smoking man with a past medical history significant for hyperlipidemia, hypertension, coronary artery disease, and pacemaker placement, presented for a routine medical evaluation.

The patient was allergic to penicillin, and his list of medications included aspirin, a diuretic, an ACE inhibitor, and a statin, in addition to over-the-counter vitamin supplements. Laboratory evaluation showed a normal complete blood count, electrolyte panel, and liver function tests. Frontal and chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography performed at presentation (A) and three years earlier (B).

Which of the following represents the most accurate assessment of the frontal chest imaging findings? (Click on the correct answer to proceed to the second of ten pages)

1. Chest frontal imaging shows a mediastinal mass
2. Chest frontal imaging shows bilateral peribronchial and mediastinal lymph node enlargement
3. Chest frontal imaging shows bilateral pleural fluid collections
4. Chest frontal imaging shows focal masses
5. Chest frontal imaging shows reduced lung volumes with basilar fibrotic changes

Cite as: Viggiano RW, Gotway MB. April 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(4):194-205. doi: https://doi.org/10.13175/swjpcc056-18 PDF

Medical Image of the Week: Headcheese Sign

Figure 1. Representative image from thoracic CT scan showing ground glass opacities, most prominent in the lower lung fields bilaterally with air trapping.

A 95-year-old woman with a past medical history of breast cancer and mastectomy presented with fevers, cough productive of sputum and progressive dyspnea for 2 weeks. She denies any recent travel or sick contacts but has bird at home since last 10 years. She was afebrile but tachypneic with respiratory rate of 25 and sPO2 of 86% on room air. Her initial chest examination reveals coarse rhonchi in both lungs. Labs were significant for a sodium of 118 mEq/L, leukocytosis to 18,000 cells/mcL without peripheral eosinophilia. Arterial blood gas showed pO2 of 55 mm Hg, pCO2 of 48 mm Hg and pH of 7.44. An initial chest X-ray was positive for extensive bilateral pulmonary infiltrates predominantly in the mid and lower lungs with areas of airspace consolidation. Her urine Streptococcus pneumoniae antigen was negative as well as rapid influenza and a respiratory syncytial virus panel. The high resolution thoracic CT showed scattered ground glass opacities, most prominent in the lower lung fields bilaterally (Figure 1). Small more focal consolidative opacities are seen in the right upper lobe. As there was a juxtaposition of low, normal and high-attenuated area of CT scan, characteristic of the headcheese sign.

The head cheese sign is indicative of a mixed obstructive and infiltrative process (1). The low attenuated regions reflect air trapping suggestive of obstructive small airway disease and vasoconstriction due to hypoxia (2). Expiration CT may be needed to enhance low attenuation areas. This airway pathology leads to mosaic attenuation on HRCT. The most common cause of this radiological sign is hypersensitivity pneumonitis (3). As our patient had a long exposure to bird, it was probably the cause of her lung pathology. Other causes of the headcheese sign such as sarcoidosis, bronchiolitis, mycoplasma pneumonia or desquamative interstitial pneumonitis should be considered.

Learning Points:

1. Headcheese is a radiological sign suggestive of hypersensitivity pneumonitis as most common cause.
2. Occupation or any animal exposure history will be most useful in this scenario.
3. The clinician should rule out other causes such as an infectious etiology or sarcoidosis.

Ajay Adial MD, Danial Arshed MD, Lourdes Sanso MD, and Asma Iftikhar MD

Pulmonary/Critical Care Medicine

New York-Presbyterian/Queens

New York, NY USA

References

1. Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the image--the 2004 Fleischner lecture. Radiology. 2006 May;239(2):322-38. [CrossRef] [PubMed]
2. Hirschmann JV, Pipavath SN, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics. 2009 Nov;29(7):1921-38. [CrossRef] [PubMed]
3. Patel RA, Sellami D, Gotway MB, Golden JA, Webb WR. Hypersensitivity pneumonitis: patterns on high-resolution CT. J Comput Assist Tomogr. 2000 Nov-Dec;24(6):965-70. [CrossRef] [PubMed]

Cite as: Adial A, Arshed D, Sanso L, Iftikhar A. Medical image of the week: headcheese sign. Southwest J Pulm Crit Care. 2018;16(4):192-3. doi: https://doi.org/10.13175/swjpcc040-18 PDF