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: Achalasia with Lung Abscess

Figure 1. CT coronal view showing a left lower lobe lung abscess measuring approximately 8 x 5 cm.

Figure 2. Barium swallow study showed dilated esophagus with tapering off at the lower esophageal sphincter junction, demonstrating the classic bird-beak like appearance.

Figure 3. Upper endoscopy showing diffuse whitish plaque suggestive of candidiasis likely due to chronic stasis of food.

An 80-year old woman with past medical history of high grade serous fallopian tube carcinoma presented with 2 months history of productive cough. This was associated with shortness of breath and subjective fever, chills and weight loss of 5 pounds over 2 months. She was treated with outpatient antibiotics without improvement of symptoms. Patient was afebrile on presentation, hemodynamically stable, and saturating at 99% on room air. Lung examinations revealed dullness on percussion of left lower lung field and reduced breath sounds on the same area.

Computed tomographic imaging revealed a large lung abscess on left lower lobe (Figure 1) and moderately dilated esophagus and fluid filled to the level of gastro-esophagus junction. Barium swallow study showed a classic bird-beak like appearance (Figure 2). There was no contrast that passed through the gastro-esophagus junction during the entire course of the barium study. Upper endoscopy was performed to rule out intraluminal pathology that may contribute to the obstruction which revealed a large amount of barium and retained food in the entire esophagus with diffuse whitish plaque suggestive of candidiasis and a benign appearing intrinsic mild stenosis at lower third of esophagus (Figure 3). Pneumatic dilation and botulinum toxin injection were performed and she was started on pantoprazole. She was also started on broad-spectrum antibiotics (vancomycin, cefepime, metronidazole) for the lung abscess. A chest tube was inserted under computed tomography (CT) guidance. Subsequently, cultures from the chest tube drainage grew Streptococcus intermedius. She was discharged to a skilled nursing facility with additional 3-weeks of ampicillin-sulbactam. Repeat imaging at 3-weeks showed improvement of the lung abscess.

Achalasia is a rare primary esophageal motor disorder, with incidence of approximately 1 in 100,000 people annually and prevalence of 10 in 100,000 (1). Common presentations of achalasia includes gradual dysphagia to solid and liquids, heartburn symptoms unrelieved by adequate proton pump inhibitor therapy and weight loss. Achalasia presenting with respiratory symptoms without dysphagia is rare as this disease entity is gradual and patient will normally present with different degrees of dysphagia or regurgitation of food. This case report is a good reminder that aspiration should be considered as a cause for pneumonia in the elderly. Our patient could have been aspirating for a period of time, leading to the development of a large lung abscess. Kikuchi et al. (2) demonstrated the high incidence of silent aspiration in the elderly population. A more detailed assessment by trained swallowing therapist may aid in detecting dysphagia.

Kai Rou Tey MD¹ and Naser Mahmoud MD²

¹Department of Internal Medicine University of Arizona College of Medicine- South Campus

²Department of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona College of Medicine

Tucson, AZ USA

References

1. Francis DL, Katzka DA. Achalasia: update on the disease and its treatment. Gastroenterology. 2010 Aug;139(2):369-74. [CrossRef] [PubMed]
2. Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med. 1994 Jul;150(1):251-3. [CrossRef] [PubMed]

Cite as: Tey KR, Mahmoud N. Medical image of the week: achalasia with lung abscess. Southwest J Pulm Crit Care. 2016 May;12(5):194-6. doi: http://dx.doi.org/10.13175/swjpcc025-16 PDF

Medical Image of the Week: Killian-Jamieson Diverticulum

Figure 1. Chest x-ray showing worsening consolidation in both lungs.

Figure 2. Anterior (panel A) and lateral (panel B) fluoroscopic images showing retained contrast material in the anterior esophageal diverticulum in the hypopharynx.

An 89 year old female nursing home resident with a past medical history of hypertension and coronary artery disease was admitted with generalized weakness and vomiting for two days. Chest x-ray revealed consolidation in the left lung suggestive of pneumonia and she was started on broad spectrum antibiotics. Due to worsening consolidation in both lung fields (Figure 1) a video swallow was done for possible aspiration, which revealed contrast retained within the proximal esophagus within a diverticula in the anterior aspect (Figure 2). After excision of the diverticulum her pneumonia resolved and she was discharged back to the nursing home.

Killian-Jamieson diverticulum is a mucosal protrusion through a muscular gap in the anterolateral wall of the cervical esophagus; inferior to the cricopharyngeus and lateral to the longitudinal muscle of the esophagus just below its insertion on the posterior lamina of cricoid cartilage (gap also known as Killian-Jamieson space). This differentiates it from the Zenker’s diverticulum which arises from the muscular gap in the posterior portion of cricopharyngeus muscle (also known as Killian’s dehiscence). Killian-Jamieson diverticulum causes more non-specific symptoms than Zenker's diverticulum. Because these diverticula occur in close proximity to the recurrent laryngeal nerve, it should be carefully preserved during surgical resection.

Chandramohan Meenakshisundaram, MD and Nanditha Malakkla, MD

Medical Education

Saint Francis Hospital

Evanston, IL

References

1. Kim DC, Hwang JJ, Lee WS, Lee SA, Kim YH, Chee HK. Surgical treatment of killian-jamieson diverticulum. Korean J Thorac Cardiovasc Surg. 2012;45(4):272-4. [CrossRef] [PubMed]
2. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J. 2001;77:506-11. [CrossRef] [PubMed]
3. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781765188

Reference as: Meenakshisundaram C, Malakkla N. Medical image of the week: killian-jamieson diverticulum. Southwest J Pulm Crit Care. 2014;9(5):287-8. doi: http://dx.doi.org/10.13175/swjpcc134-14 PDF

Medical Image of the Week: Massive Esophagus

Figure 1. Chest x-ray taken 10 years prior to admission showing mild thickening of the right paratracheal stripe (arrow).

Figure 2. Admission chest x-ray showing a mass with mixed density silhouetting the right pulmonary artery and right paraspinal stripe.

Figure 3. Coronal view of the thoracic CT scan showing the mass is a massive esophagus.

A 34 year-old male inmate presents with chest pain 10 years prior to admission. His prior chest x-ray shows only mild thickening of the right paraspinal stripe (Figure 1). Chest x-ray on admission 10 years later shows a large right mixed density paramediastinal mass silhouetting the right pulmonary artery and right paratracheal stripe (Figure 2). This was confirmed to be a massive esophagus on thoracic CT scan (Figure 3). The patient was eventually diagnosed with achalasia.

A number of disorders can present with a massive esophagus including achalasia, esophagectomy with colonic interposition, scleroderma, esophageal carcinoma with stricture, and esophagitis with stricture (1). Diagnostic imaging findings using fluroscopy, CT and X-ray can help differentiate these disorders.  A massive esophagus due to achalasia is smooth walled with symmetric tapering to a "bird-beak" deformity and a chest x-ray may initially be normal.  Colonic interposition is evident by colonic haustra.  A dilated esophagus due to scleroderma is normal above aortic arch (striated muscle) but atonic below the aortic arch (smooth muscle).  On an upper GI series there is dilated jejunum with thin, crowded folds that are pathognomonic (Hidebound sign) for scleroderma.  Esophageal carcinoma shows a fixed irregularity with disruption of normal mucosal pattern.  Esophagitis has fine nodularity with an ulcerated mucosa on fluroscopy.

Jason R. Young MD, David L. August MD

Department of Radiology

Maricopa Integrated Health System

Phoenix, AZ

Reference

1. Cole TJ, Turner MA. Manifestations of gastrointestinal disease on chest radiographs. Radiographics. 1993;13(5):1013-34. [PubMed] 

Reference as: Young JR, August DL. Medical image of the week: massive esophagus. Southwest J Pulm Crit Care. 2013;7(4):265-6. doi: http://dx.doi.org/10.13175/swjpcc142-13 PDF