Imaging

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.

The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

Rick Robbins, M.D. Rick Robbins, M.D.

September 2023 Medical Image of the Month: Aspergillus Presenting as a Pulmonary Nodule in an Immunocompetent Patient

Figure 1. Chest CT showing 11 x10 mm nodule in the anterior segment of the left upper lobe in the background of emphysematous and basal sub segmental atelectatic changes.

 

Figure 2. Lung biopsy low power (A) showing chronic inflammatory infiltrate in the interstitium along with a collection of fungus (arrow) (H&E: x40). Fungus with an area of necrosis (B) (H&E: x100). Numerous thin, narrow-angle, and branching hyphae with septa morphologically consistent with Aspergillus (C) (H&E: x400). Collection of Aspergillus (D). (Periodic acid–Schiff stain: x400).

 

A 32-year-old nonsmoking woman presented with complaints of recurrent hemoptysis for 5 months and dyspnea on exertion for 1 month. She denied any history of fever, cough, or COVID infection. She has hypothyroidism controlled on thyroxine 25mcg. During the evaluation, she was found to have an enhancing solitary pulmonary nodule (11 x 10 x 9mm) in the anterior segment of the left upper lobe (Figure 1). The patient was given a course of oral antibiotics (amoxicillin /clavulanic acid) and supportive treatment for hemoptysis. Sputum for Ziehl–Neelsen stain and cartridge based nucleic acid amplification test (CBNAAT) was negative. CT- guided biopsy of the nodule was performed. Histopathology showed fungal organisms which were thin, septate with acute angle branching and focal necrotic areas, morphologically consistent with Aspergillus (Figure 2). Serum-specific IgG against aspergillus antigen was normal. The patient was started on oral itraconazole 200mg BID. Follow-up after 1 month showed both symptomatic and radiological improvement. Repeat chest CT showed a significant decrease in size of the nodule.

There is a large spectrum of pulmonary aspergillosis. From this spectrum, pulmonary nodules are a less common manifestation of chronic pulmonary aspergillosis (CPA), especially in immunocompetent individuals. Aspergillus nodules are defined as small, round, discrete, and focal opacities on chest imaging. It can be further classified on basis of internal cavitation (i.e., non-cavitary nodules and cavitary nodules). Differentiating these nodules from other lung pathology may be difficult on CT findings alone and may demand further investigation like image-guided needle aspiration cytology or biopsy, blood investigations like serum Aspergillus precipitin IgG antibody and/or serum Aspergillus galactomannan. Delay in diagnoses may lead to persistence of pulmonary symptoms, and cavitation of the nodule. This entity has a favorable prognosis if managed accordingly. Although there is data regarding surgical management of aspergillus nodules, but data regarding the benefits of anti-fungal therapy in the same is limited.

Diagnosing aspergillus nodules in an immunocompetent individual is a challenge to all pulmonologists. Literature shows limited case reports and small case series on CPA presenting as non-cavitating SPN on radiology. Usually, in such cases, the diagnosis is made following removal or biopsy of the nodule(s), presuming it to be malignant. Patients diagnosed with Aspergillus nodules can’t be differentiated from lung malignant conditions based on demographics, which are usually similar. In the largest case series of Aspergillus nodules done by Muldoon EG et al. (6), 33 patients were reviewed constituting less than 10 % of the cohort of patients with CPA.  In a study done by Kang et al. (4) 77% of patients with aspergillus nodules were symptomatic and the most common symptom reported was hemoptysis. Similarly in our case hemoptysis was the chief complaint of the patient. Our patient is a woman and non-smoker similar to previous case reports and series.

In the current guidelines, the detection of serum Aspergillus precipitin IgG antibody is a key diagnostic criterion for CPA. Literature is unclear if the presence of Aspergillus IgG antibody could be considered a supportive finding in the making the diagnosis of Aspergillus nodules. Similarly, in our case also serum specific IgG against Aspergillus fumigatus was negative. Azoles are the primary treatment option in all subtypes of CPA including aspergillus nodule. Our patient also showed disease regression during itraconazole treatment. Another option for management is surgical, though it is associated with significant postoperative complications and recurrence of disease at other sites and must be reserved for selected patients.

Dr. Deependra Kumar Rai, Dr. Priya Sharma, Dr. Vatsal Bhushan Gupta

Department of Pulmonary, Critical Care, and Sleep Medicine

AIIMS Patna, Bihar, India

References

  1. Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015 Mar;70(3):270-7. [CrossRef] [PubMed]
  2. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008 Mar;246(3):697-722. [CrossRef] [PubMed]
  3. Lee SH, Lee BJ, Jung DY, Kim JH, Sohn DS, Shin JW, Kim JY, Park IW, Choi BW. Clinical manifestations and treatment outcomes of pulmonary aspergilloma. Korean J Intern Med. 2004 Mar;19(1):38-42. [CrossRef] [PubMed]
  4. Kang N, Park J, Jhun BW. Clinical Characteristics and Treatment Outcomes of Pathologically Confirmed Aspergillus Nodules. J Clin Med. 2020 Jul 10;9(7):2185. [CrossRef] [PubMed]
  5. Yasuda M, Nagashima A, Haro A, Saitoh G. Aspergilloma mimicking a lung cancer. Int J Surg Case Rep. 2013;4(8):690-2. [CrossRef] [PubMed]
  6. Muldoon EG, Sharman A, Page I, Bishop P, Denning DW. Aspergillus nodules; another presentation of Chronic Pulmonary Aspergillosis. BMC Pulm Med. 2016 Aug 18;16(1):123. [CrossRef] [PubMed]
  7. Denning DW, Cadranel J, Beigelman-Aubry C, et al. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J. 2016 Jan;47(1):45-68. [CrossRef] [PubMed]
  8. Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128. [CrossRef] [PubMed]
  9. Godet C, Philippe B, Laurent F, Cadranel J. Chronic pulmonary aspergillosis: an update on diagnosis and treatment. Respiration. 2014;88(2):162-74. [CrossRef] [PubMed]
  10. Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011 Sep 1;20(121):156-74. [CrossRef] [PubMed]
Cite as: Rai DK, Sharma P, Gupta VB. September 2023 Medical Image of the Month: Aspergillus Presenting as a Pulmonary Nodule in an Immunocompetent Patient. Southwest J Pulm Crit Care Sleep;27(3):30-32. doi: https://doi.org/10.13175/swjpccs035-23 PDF
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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Month: Idiopathic Pulmonary Hemosiderosis

Figure 1. A-C: T1W 3D GRE post contrast multilevel axial images. D-F: CT axial images in a lung window (obtained three years before) both demonstrate innumerable centrilobular nodules consistent with the diagnosis of IPH.

The patient is a 36-year-old woman with a complex medical history including multiple venous thromboembolic events, miscarriages, heterozygous state for factor V Leiden deficiency, and Systemic Lupus Erythematosus. These images have been obtained during multiple admissions for shortness of breath during which she has been diagnosed with pulmonary embolism, anti-coagulation failure, pulmonary hypertension, and intracardiac right to left shunting. Images A-C are T1 weighted MRI axial sections showing centrilobular micronodules which are unchanged when compared to images D-F obtained during a CT scan of the chest three years prior. These findings are consistent with pulmonary hemosiderosis.

Idiopathic pulmonary hemosiderosis (IPH) is a rare condition that occurs with recurrent diffuse alveolar hemorrhage (1). Hemosiderin, a heme byproduct, gradually accumulates within the lung tissue, and can lead to fibrosis (2). IPH has a characteristic triad of hemoptysis, iron deficiency anemia, and pulmonary infiltrates on imaging (2) - although clinical presentation may be highly variable. The gold standard for diagnosis is lung biopsy, although bronchoalveolar lavage has 92% sensitivity of finding hemosiderin-laden macrophages in IPH (2). Classically, the disorder is found in children, but there have been more cases recorded in adults in recent years (3).

Radiographic findings: On chest x ray, areas of air-space consolidation or ground-glass opacities may be seen, usually with a perihilar or lower lung predominance. Consolidations typically clear within 3 days and are replaced by a reticular pattern (4). This may initially resolve but may progress to fibrosis after multiple occurrences - appearing as permanent reticulation or miliary stippling (1). On CT, the subacute phase demonstrates diffuse nodules and patchy areas of ground glass opacification. During an exacerbation, CT shows diffuse, homogenous areas of ground glass attenuation (4). On MRI, T1 images may show diffusely increased parenchymal signal intensity, whereas T2 images may show markedly reduced signal intensity due to the hemosiderin (4). The 3D gradient echo higher resolution MRI sequences in our patient, allowed for the recognition of the chronic micronodular pattern displayed.

Long term, low-dose, glucocorticoids are the main treatment for IPH, with immunosuppressants added on for severe cases. Tapering or reduction of glucocorticoids usually led to recurrence of pulmonary hemorrhage in patients (2). A large number of IPH cases coexist with Celiac disease (known as Lane-Hamilton Syndrome) and a gluten free diet may lead to remission (3).

On imaging, the differential diagnosis is broad, particularly if no remote imaging is available. In our patient’s case, the micronodular pattern may be seen with miliary infections, hypersensitivity pneumonitis, some forms of bronchiolitis (particularly smoking related or inhalational diseases). Microangiopathies are also to be considered, such as capillary hemangiomatosis.  IPH is a diagnosis of exclusion, and all other causes of diffuse alveolar hemorrhage must first be investigated, such as bronchiectasis, interstitial pneumonia, infections, connective tissue disease, coagulation disorders, systemic vasculitis, and/or anti-GBM disease (3).

Cynthia Ha, MS IV1 and Diana Palacio, MD2

1Lake Erie College of Osteopathic Medicine, Erie, PA

2Department of Medical Imaging, University of Arizona College of Medicine – Tucson, AZ

References

  1. Repetto G, Lisboa C, Emparanza E, et al. Idiopathic pulmonary hemosiderosis. Clinical, radiological, and respiratory function studies. Pediatrics. 1967;40(1):2432. [PubMed]
  2. Zhang Y, Luo F, Wang N, Song Y, Tao Y. Clinical characteristics and prognosis of idiopathic pulmonary hemosiderosis in pediatric patients. J Int Med Res. 2019;47(1):293‐302. [CrossRef] [PubMed]
  3. Chen XY, Sun JM, Huang XJ. Idiopathic pulmonary hemosiderosis in adults: review of cases reported in the latest 15 years. Clin Respir J. 2017;11(6):677681. [CrossRef] [PubMed]
  4. Primack SL, Miller RR, Müller NL. Diffuse pulmonary hemorrhage: clinical, pathologic, and imaging features. AJR Am J Roentgenol. 1995;164(2):295300. [CrossRef] [PubMed] 

Cite as: Ha C, Palacio D. Medical image of the month: idiopathic pulmonary hemosiderosis. Southwest J Pulm Crit Care. 2020;20(6):190-1. doi: https://doi.org/10.13175/swjpcc033-20 PDF 

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Month: Aspergilloma – Monod’s Sign

Figure 1 (A) Contrast-enhanced CT of chest showing irregular shape, thick wall cavity with oval heterogeneous soft tissue lesion (black arrow) at the posterior inferior aspect of this cavity. Figure 1 (B) Computed tomography of the chest in the prone position showing the mass moving to dependent region of the cavity (black arrow), known as Monod sign.

A 58-year-old man with a history of human immunodeficiency virus on antiretroviral therapy, bullous emphysematous lung with right upper lobe cavity presented with hemoptysis for three days. On presentation, he was afebrile, with normal oxygen saturation on room air and reduced bilateral breath sounds. Computed tomography (CT) of the chest showed a thick wall cavity at the right upper lobe, with a 3 cm heterogeneous mass at the posterior aspect of the cavity (Figure 1 A). When the patient was placed in the prone position, the soft tissue lesion displaced anteriorly (Figure 1B) showing gravity-dependency (Monod's sign). His serum Aspergillus fumigatus antibodies were also positive. The patient was diagnosed with aspergilloma and started on voriconazole initially. However, because of recurrent hemoptysis, the patient was scheduled to undergo surgical excision. Saprophytic aspergillosis is the causative organism for the development of an aspergilloma (1). It results from colonization of fungus in a preexisting pulmonary cavity which can lead to the formation of a fungus ball within the cavity (1,2). Hemoptysis is the most common presentation. CT scan should be performed in the supine as well as in the prone position to help differentiate from other conditions. In the case of recurrent or life-threatening hemoptysis, surgical excision remains the gold standard option (1).  

Kulothungan Gunasekaran MD, Nageshwari Palanisamy MBBS, Sandra Patrucco Reyes MD, Safal Shetty MD

Division of Pulmonary Diseases and Critical Care

Yale New Haven Health Bridgeport Hospital

Bridgeport, CT USA

References

  1. Sharma S, Dubey S, Kumar N, Sundriyal D. 'Monod' and 'air crescent' sign in aspergilloma. BMJ Case Rep. 2013 Sep 13;2013:bcr2013200936. [CrossRef] [PubMed]
  2. Grech R. Images in clinical medicine. Aspergilloma. N Engl J Med. 2010 Mar 18;362(11):1030. [CrossRef] [PubMed]

Cite as: Gunasekaran K, Palanisamy N, Patrucco Reyes S, Shetty S. Medical image of the month: aspergilloma – Monod’s sign. Southwest J Pulm Crit Care. 2020;20(6):188-9. doi: https://doi.org/10.13175/swjpcc032-20 PDF 

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Month: Coccidioidal Pneumatocele Complicated by Pulmonary Hemorrhage

Figure 1. Axial CT of the chest without contrast 12 years prior to this hospitalization demonstrates an irregularly-marginated right upper lobe cyst measuring 1.5 x 1.6 cm (red arrow).

 

Figure 2. Axial CT of the chest without contrast obtained 4 months prior to this admission demonstrated a cavitary lesion now measuring 6.3 x 8.2 cm, thin-walled, with small internal air-fluid level and adjacent small pleural effusion without any internal debris (red arrow).

 

Figure 3. An axial CT angiogram of the chest in lung windows demonstrated a right upper lobe pulmonary cavitary lesion increased in size to 10.5 cm in largest dimension with almost complete opacification (red star) concerning for a superimposed infection.

 

A 77-year-old man with emphysema, hypertension, hypothyroidism, and diabetes mellitus presented with two days of worsening cough that progressed to massive hemoptysis. His hemoptysis included clots the size of golf balls and multiple episodes of frank blood, measuring half a cup each. His symptoms included dyspnea at rest, fatigue, and a 15-20-pound weight loss in three weeks. He denied fevers, night sweats, chest pain, hematemesis, and prior hemoptysis. Additionally, he had a history of coccidioidomycosis complicated by a cavitary lung lesion. Per chart review, 12 years prior to this hospitalization the patient had an irregularly-marginated right upper lobe cyst measuring 1.5 x 1.6 cm (Figure 1). A CT scan obtained 4 months prior to admission showed the cavity to be 6.3 x 8.2 cm thin-walled and clear of debris (Figure 2) – consistent with a pneumatocele. The patient was referred to thoracic surgery for possible resection at that time but was lost to follow up.

Admission labs showed a decrease in hemoglobin to 13.4 from a baseline of 15.1 g/dL and white blood cells of 10,300 cells/µL. Blood cultures were negative. CT angiography now demonstrated an increase in the right upper lobe pulmonary cavitary lesion to 10.5 cm in largest dimension with almost complete opacification of the lesion - concerning for a superimposed infection. Imaging also showed tree-in-bud nodules in right middle and lower lobes without evidence of a pulmonary embolism (Figure 3). Coccidioidomycosis serologies by EIA showed a non-reactive IgM with reactive IgG. Acid fast bacilli staining of the sputum was negative. Bronchoscopy performed in the hospital showed fresh blood present in the trachea and in the visualized tracheobronchial tree. Active bleeding was noted only from the posterior segment of the right upper lobe. A bronchoalveolar lavage was performed confirming alveolar hemorrhage centered in the right upper lobe. Lidocaine with epinephrine was instilled to stop bleeding. No endobronchial lesion was seen.

The case was evaluated by an interventional radiologist and cardiothoracic surgeon at our institution. They both felt the patient would benefit from transfer to a larger medical center for definitive management of his hemorrhage. He was transferred to a tertiary academic center for a right upper lobectomy, which he tolerated well.  Surgical pathology and bronchoscopy cultures ultimately grew coccidioides immitis and the patient was discharge on a treatment course of oral fluconazole.

Pulmonary pneumatoceles are thin-walled, air-filled cystic structures. Most pneumatoceles are encountered in infancy; however, they can appear at any age (1). Pneumatoceles are known sequelae of pneumonia but can also occur due to blunt thoracic injury or as a rare side effect of chemotherapy (2,3). While the mechanism of pneumatocele formation is unclear, several theories have been postulated including check-valve bronchial obstruction and narrowing or from parenchymal necrosis with accompanying focal collections of air within the interstitial tissue (5). Such cases are typically asymptomatic and do not require intervention as they resolve within weeks to months (6). While many pneumatocele resolve on their own without additional intervention, complex pneumatoceles may result in uncontrolled hemorrhage, as portrayed in this case, or infected lesions unresponsive to antibiotics - necessitating surgical intervention (7). Other complications of pneumatoceles are rare and may include a tension pneumatocele with cardiorespiratory compromise or pneumothorax (8). 

Staphylococcal pneumonia is frequently complicated by pneumatocele development, with pneumatoceles thought to occur in 61% of cases of staphylococcal pneumonia (9). However, the literature of pneumatocele development following cocci infection is scant. In immunocompetent hosts, infections from coccidiosis are transient, with pulmonary complications (often nodules and self-limited thin-walled cavities) occurring in less than 10% of patients (10).  Complications from coccidiosis infection are usually brief fatigue, dyspnea, cough, and arthritis, with chronic infection or severe complication being rare. Here, we report a case of a gradually enlarging pneumatocele in the setting of cocci infection that eventually eroded into the pulmonary vasculature. The resulting massive hemoptysis was refractory to epinephrine injection and not amenable to catheter embolization. Upper lobectomy was required for definite treatment of the pulmonary hemorrhage.

Sylvester Moses MD, Gregory Gardner MD, Ella Starobinska MD, and Arthur Wolff MD

Department of Internal Medicine

University of Arizona

Tucson, AZ USA

References

  1. Flaherty RA, Keegan JM, Sturtevant HN. Post-pneumonic pulmonary pneumatoceles. Radiology. 1960;74:50-3. [CrossRef] [PubMed]
  2. Aissaoui O, Alharrar R. Traumatic pulmonary pseudocyst: a rare complication of blunt thoracic injury. Pan Afr Med J. 2019 Apr 11;32:180. [CrossRef] [PubMed]
  3. Sangro P, Bilbao I, Fernández-Ros N, Iñarrairaegui M, Zulueta J, Bilbao JI, Sangro B. Pneumatocele during sorafenib therapy: first report of an unusual complication. Oncotarget. 2017 Dec 22;9(5):6652-6. [CrossRef] [PubMed]
  4. Quigley MJ, Fraser RS. Pulmonary pneumatocele: pathology and pathogenesis. AJR Am J Roentgenol. 1988 Jun;150(6):1275-7. [CrossRef] [PubMed]
  5. Zuhdi MK, Spear RM, Worthen HM, Peterson BM. Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. Crit Care Med. 1996 Feb;24(2):330-3. [CrossRef] [PubMed]
  6. Kaira K, Ishizuka T, Yanagitani N, Sunaga N, Hisada T, Mori M. Pulmonary traumatic pneumatocele and hematoma. Jpn J Radiol. 2009 Feb;27(2):100-2. [CrossRef] [PubMed]
  7. Kesieme EB, Kesieme CN, Akpede GO, Okonta KE, Dongo AE, Gbolagade AM, Eluehike SU. Tension pneumatocele due to Enterobacter gergoviae pneumonia: a case report. Case Rep Med. 2012;2012:808630. [CrossRef] [PubMed]
  8. Dines DE. Diagnostic significance of pneumatocele of the lung. JAMA. 1968 Jun 24;204(13):1169-72. [CrossRef] [PubMed]
  9. Nayeemuddin M, Jankowich MD, Noska A, Gartman EJ. A strange case of coccidioidomycosis: utilization of bronchoscopy to diagnose a chronic cavitary lesion. Am J Resp Crit Care Med. 2018;197:A5427 [Abstract].

Cite as: Moses S, Gardner G, Starobinska E, Wolff A. Medical image of the month: coccidioidal pneumatocele complicated by pulmonary hemorrhage. Southwest J Pulm Crit Care. 2020;20(3):84-6. doi: https://doi.org/10.13175/swjpcc008-20 PDF 

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Rick Robbins, M.D. Rick Robbins, M.D.

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 

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Chemotherapy-Induced Diffuse Alveolar Hemorrhage

Figure 1. Panel A: Chest X-ray on admission consistent showing some pulmonary edema and effusions at the bases. Panel B: Chest X-ray after initiation of chemotherapy showing diffuse bilateral infiltrates and consolidation.

 

Figure 2. CT scan of the chest after initiation of chemotherapy showing patchy ground glass consolidation throughout the lung fields bilaterally. Large bilateral pleural effusions can also be seen.

 

A 65-year-old man presented with relapse of his acute myeloid leukemia (AML). On admission he was seen to have a reduced ejection fraction at 40-50%. His chest X-ray showing pulmonary edema and bilateral pleural effusions (Figure 1A). He was diuresed to his dry weight to improve his clinical status. The decision was made to re-induce him for his AML with fludarabine and cytarabine without idarubicin (due to his reduced ejection fraction). After 2 doses of each the fludarabine and cytarabine the patient showed worsening respiratory distress, had increasing oxygen requirements and started having hemoptysis. Repeat imaging of his chest showed bilateral infiltrates in his lungs on both chest x-ray (Figure 1B) and chest CT (Figure 2). Infectious causes for the changes were sought and ruled out. He was transferred to the ICU where he was put on high flow oxygen and received methylprednisolone 1000 mg IV daily for 3 days. During this period his blood hemoglobin also dropped from 8.2 g/dl to 6.8 g/dl requiring transfusion of 1 unit of packed red blood cells. After 3 days of supportive care he was transferred back out of the ICU on oxygen by nasal cannula with progressive improvement in his lung function. Pulmonary toxicity is a known side effect resulting from both fludarabine and cytarabine and can present in a variety of forms. Their prompt recognition is important due to the steroid responsive nature of many of these once infectious causes have been ruled out.

Saud Khan, MD and Huzaifa A. Jaliawala, MD

Department of Internal Medicine

University of Oklahoma Health Sciences Center

Oklahoma City, OK USA

References

  1. Helman DL Jr, Byrd JC, Ales NC, Shorr AF. Fludarabine-related pulmonary toxicity: a distinct clinical entity in chronic lymphoproliferative syndromes. Chest. 2002 Sep;122(3):785-90. [CrossRef] [PubMed]
  2. Rudzianskiene M, Griniute R, Juozaityte E, Inciura A, Rudzianskas V, Emilia Kiavialaitis G. Corticosteroid-responsive pulmonary toxicity associated with fludarabine monophosphate: a case report. Turk J Haematol. 2012 Dec;29(4):392-6. [CrossRef] [PubMed]
  3. Forghieri F, Luppi M, Morselli M, Potenza L.Cytarabine-related lung infiltrates on high resolution computerized tomography: a possible complication with benign outcome in leukemic patients. Haematologica. 2007 Sep;92(9):e85-90. [CrossRef] [PubMed]

Cite as: Khan S, Jaliawala HA. Medical image of the week: chemotherapy-induced diffuse alveolar hemorrhage. Southwest J Pulm Crit Care. 2017;15(5):219-20. doi: https://doi.org/10.13175/swjpcc131-17 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

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

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Bronchial Artery Embolization

Figure 1. Thoracic CT with contrast demonstrating right upper and lower lobe tree-in-bud and ground glass opacities (arrows) consistent with progressing pulmonary coccidioidomycosis.

 

Figure 2. Chest radiograph demonstrates the ethylene vinyl alcohol polymer retained in the bronchial arteries after the embolization procedure (arrows).

 

A 25-year-old woman with a past medical history significant for pulmonary coccidioidomycosis and poorly controlled type I diabetes mellitus presented to the emergency department with a chief complaint of 4 days of progressively worsening shortness of breath and 3-4 days of intermittent hemoptysis. Initial CT scan demonstrated progressive tree-in-bud and ground glass opacities in the right upper and lower lung lobes suggesting worsening of her ongoing coccidiomycosis (Figure 1). On hospital day 3 she began to have worsening hypoxemia and hemoptysis requiring transfer to the intensive care unit. Interventional radiology was consulted who performed an emergent right sided bronchial artery embolization with the ethylene vinyl alcohol polymer, Onyxtm. After embolization her chest radiographs demonstrated evidence of the embolization material in the pulmonary vasculature (Figure 2).

Ethylene vinyl alcohol polymer, Onyxtm is a liquid embolic substance which solidifies after contact with ionic materials (1). This results in a rapid, irreversible and permanent embolization of the bleeding target vessel (2). It was initially approved for use in the embolization of cerebral arteriovenous malformations, however has been used for rapid embolization of other hemorrhagic conditions such has hemoptysis from bleeding bronchial arteries (3). The most common complication after embolization is chest pain that is self-limiting. Transverse myelitis from spinal cord ischemia is the most serious complication associated with bronchial artery embolization however the occurrence is significantly decreased by spinal arterial identification during initial angiography (4). This patient’s embolization was without complications. She was successfully extubated on hospital day 15 without evidence of ongoing hemoptysis and will continue to follow up in the pulmonary and infectious disease clinics for ongoing treatment of her Coccidiodes pulmonary disease.

Benjamin J. Jarrett MD, MPH and Sachin Chaudhary, MD

Department of Medicine

University of Arizona

Tucson, AZ USA

References

  1. Lubarsky M, Ray C, Funaki B. Embolization agents-which one should be used when? Part 2: small-vessel embolization. Semin Intervent Radiol. 2010 Mar;27(1):99-104. [CrossRef] [PubMed]
  2. Yamashita K, Taki W, Iwata H, Nakahara I, Nishi S, Sadato A, Matsumoto K, Kikuchi H. Characteristics of ethylene vinyl alcohol copolymer (EVAL) mixtures. AJNR Am J Neuroradiol. 1994 Jun;15(6):1103-5. [PubMed]
  3. Guimaraes M, Wooster M. Onyx (Ethylene-vinyl Alcohol Copolymer) in Peripheral Applications. Semin Intervent Radiol. 2011 Sep;28(3):350-6. [CrossRef] [PubMed]
  4. Sopko DR, Smith TP. Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 2011 Mar;28(1):48-62. [CrossRef] [PubMed]

Cite as: Jarrett BJ, Chaudhary S. Medical image of the week: bronchial artery embolization. Southwest J Pulm Crit Care. 2016;13(1):32-3. doi: http://dx.doi.org/10.13175/swjpcc053-16 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Mediastinal Metastases Causing Right Ventricular Outflow Obstruction

Figure 1. Computed tomography (CT) of chest showed large right mediastinal mass (arrow) causing mass effect on the heart.

Figure 2.  Echocardiography showing large extra-cardiac mass (white arrow) compressing on right ventricle and its outflow tract (black arrow).

A 36-year-old man with a history of testicular choriocarcinoma with metastases to the lung presented with a 2-days history of hemoptysis. Initial diagnosis of the malignancy was made about 5 months earlier and he was treated with platinum based chemotherapy with a partial response.

He reported two days of significant hemoptysis, associated with shortness of breath and pleuritic chest pain and rapidly developed acute hypoxic respiratory failure requiring emergent intubation and mechanical ventilation. Computed tomography (CT) of chest showed large right mediastinal mass with diffuse reticular and nodular opacities predominantly in the left lung (Figure 1).

A pulmonary angiogram was performed that showed multiple active bleeding sites in the bronchial arterial system. These were treated with embolization. He developed shock and during investigations the echocardiogram showed a significant compression of the superior vena cava, right atrium and right ventricle by the malignant mass (Figure 2). Despite aggressive therapy and resuscitative therapies he continued to deteriorate and did not survive the hospital stay.

Mediastinal tumors are a rare cause of extrinsic right ventricular outflow tract (RVOT) obstruction. Echocardiography is an important tool in the assessment of hemodynamic effects caused due to such pathology including degree of compression and pressure gradients.

Kai Rou Tey MD1, Bhupinder Natt MD2

1Department of Internal Medicine, University of Arizona College of Medicine- South Campus, Tucson, AZ USA

2Division of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona Medical Center, Tucson, AZ USA

Cite as: Tey KR, Natt B. Medical image of the week: mediastinal metastases causing right ventricular outflow obstruction. Southwest J Pulm Crit Care. 2016:12(1):22-3. doi: http://dx.doi.org/10.13175/swjpcc145-15 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

September 2015 Imaging Case of the Month

Philip W. Ho, M.D.

Clinton Jokerst, M.D.

 

Department of Medical Imaging

Banner University Medical Center

Tucson, AZ

 

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

Figure 1. Frontal chest radiography.

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

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

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Bilateral Atrial Appendage Thrombi

Figure 1. Panel A: Right atrial appendage (RAA) thrombus (red arrow) on chest computerized tomorgraphy angiogram (CTA). Panel B: Left atrial appendage (LAA) thrombus (yellow arrow) on chest CTA. Panel C: RAA thrombus (red arrow) on transesophageal echocardiography (TEE). Panel D: LAA thrombus (yellow arrow) on TEE.

A 63-year-old man with a past history significant for hypertension, low back pain and polysubstance abuse (tobacco and marijuana) presented with shortness of breath and hemoptysis for the last 8 days prior to admission. His initial exam showed elevated jugular venous pressure and bilateral basal crackles with reduced air entry on the right lower lung zone.

The patient was found to be in atrial fibrillation with a rapid ventricular response. His initial chest X-ray showed a moderate right-sided pleural effusion. Immediate bedside echo was concerning for bilateral ventricular dysfunction with concerns of right-sided heart pressure and volume overload. A chest CT angiogram was obtained and showed acute lower lobe pulmonary embolism, with possible distal infarct, moderate right sided pleural effusion, and filling defects in both atrial appendages concerning for thrombi (Figure 1, Panels A & B).

The patient was started on therapeutic anticoagulation and underwent therapeutic thoracentesis, gentle diuresis, and rate control for his atrial fibrillation. A few days later, a trans-esophageal echo confirmed the bilateral atrial thrombi (Figure 1, Panels C & D).

Huthayfa Ateeli MBBS1, Andrew Kovoor MD1, Hem Desai MBBS1, Alana Stubbs MD2, Tam Nguyen MD3

1Department of Medicine, 2Radiology Department, and 3Cardiology Division

University of Arizona and Southern Arizona VA Health Care System

Tucson, AZ

References

  1. Kim YY, Klein AL, Halliburton SS, Popovic ZB, Kuzmiak SA, Sola S, Garcia MJ, Schoenhagen P, Natale A, Desai MY. Left atrial appendage filling defects identified by multidetector computed tomography in patients undergoing radiofrequency pulmonary vein antral isolation: a comparison with transesophageal echocardiography. Am Heart J. 2007;154(6):1199-205. [CrossRef] [PubMed]
  2. Shapiro MD, Neilan TG, Jassal DS, Samy B, Nasir K, Hoffmann U, Sarwar A, Butler J, Brady TJ, Cury RC. Multidetector computed tomography for the detection of left atrial appendage thrombus: a comparative study with transesophageal echocardiography. J Comput Assist Tomogr. 2007;31(6):905-9. [CrossRef] [PubMed] 

Reference as: Ateeli H, Kovoor A, Desai H, Stubbs A, Nguyen T. Medical image of the week: bilateral atrial appendange thrombi. Southwest J Pulm Crit Care. 2015;10(1):54-5. doi: http://dx.doi.org/10.13175/swjpcc006-15 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image Of The Week: Secondary Pneumonia Presenting as Hemoptysis

Figure 1. A-C: Axial images of the chest demonstrating bilateral consolidation of the lung with air bronchograms. D: Chest radiograph on presentation. E: BAL findings. F: Bronchoscopic images of diffuse airway sloughing; this is the main carina.

A 44 year-old man with a history of asthma presented to the hospital with encephalopathy, severe hypoxia and what was reported to be hematemesis. The patient was intubated in the Emergency Department and mechanical ventilation was instituted. Upper endoscopy was performed but source of bleeding could not be identified. Imaging of the chest showed pulmonary consolidation on both plain radiograph (D) and computed tomography (A-C). Bronchoscopy revealed a very friable mucosa with sloughing of the respiratory epithelium from the main carina (F) to at least the subsegmental level. Bronchoalveolar lavage (BAL) returned bloody fluid (E) but without any increase in blood with subsequent aliquots of fluid. The patient had progressively worsening hypoxia consistent with the acute respiratory distress syndrome (ARDS) requiring rescue maneuvers including paralysis, airway pressure release ventilation, and inhaled nitric oxide but we were unable to implement proning or transfer for extracorporeal life support due to profound cardiovascular collapse refractory to treatment. Ultimately, he succumbed from multiorgan failure. On laboratory evaluation of the BAL both Staphylococcus aureus and Influenza B virus were detected.

Bacterial pneumonia is a common complication of influenza infection. Historically, patients at the extremes of age have been most susceptible to secondary pneumonia. However, during the recent 2009 influenza pandemic an unusually high rate of secondary pneumonia among young adults was observed (1). The most common bacterial pathogens isolated following influenza infection include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus mitis, Streptococcus pyogenes and Haemophilus influenzae (2). A number of pathogenic mechanisms for synergies between influenza and bacteria have been proposed including disruption of the respiratory epithelium leading to enhanced bacterial adhesion (3).

Cameron Hypes MD MPH1,2, Christian Bime MD MSc1, Kevin Sun MD3, and Elizabeth Ulliman MD3

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

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

3 Department of Medicine, University of Arizona Medical Center; Tucson, AZ

References

  1. Chowell G, Bertozzi SM, Colchero MA, Lopez-Gatell H, Alpuche-Aranda C, Hernandez M, et al. Severe respiratory disease concurrent with the circulation of H1N1 influenza. New Engl J Med. 2009;361(7):674-9. [CrossRef] [PubMed]
  2. Centers for Disease Control and Prevention (CDC). Bacterial coinfections in lung tissue specimens from fatal cases of 2009 pandemic influenza A (H1N1) - United States, May-August 2009. MMWR Morb Mortal Wkly Rep. 2009;58(38):1071-4. [PubMed]
  3. Metersky ML, Masterton RG, Lode H, File Jr TM, Babinchak T. Epidemiology, microbiology, and treatment considerations for bacterial pneumonia complicating influenza. Int J Infect Dis. 2012;16(5):e321-e31. [CrossRef] [PubMed]

Reference as: Hypes C, Bime C, Sun K, Ulliman E. Medical image of the week: secondary pneumonia presenting as hemoptysis. Southwest J Pulm Crit Care. 2014;9(3):177-8. doi: http://dx.doi.org/10.13175/swjpcc116-14 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Idiopathic Pulmonary Hemosiderosis

Figure 1. Representative axial high-resolution CT (HRCT) scan sections demonstrating increased attenuation of the lungs due to diffuse groundglass opacification with subpleural and scattered clustered cysts most evident in the upper lung zones.

The patient is a 40 year-old man who was diagnosed with Idiopathic Pulmonary Hemosiderosis (IPH) at the age of three. He has recurrent episodes of hemoptysis several times a year that are controlled with increased doses of prednisone. He is chronically on 10 mg daily which usually control his symptoms. A HRCT scan of the chest shows predominantly upper lung cystic changes both subpleural and clustered with a honeycomb appearance superimposed on a background of diffuse ground glass opacification.

Typical HRCT findings include patchy scattered areas of ground glass opacity and consolidation that usually involve the perihilar and lower aspects of the lungs. However, case reports of rare findings of multiple honeycomb cystic changes have been reported that are thought to be a result of progressive fibrotic changes from hemosiderin deposition in the interstitium (1). These honeycomb cysts may represent sites of more severe and recurrent alveolar hemorrhage in adults with IPH and are probably related to a traction phenomenon secondary to interstitial fibrosis following recurrent episodes of alveolar hemorrhage.

Nathaniel Reyes MD*, Linda Snyder MD*, Veronica Arteaga MD+
Department of Medicine, Division of Pulmonary and Critical Care Medicine*
Department of Radiology+

University of Arizona, Tucson, Arizona

Reference

  1. Harte S, McNicholas WT, Donnelly SC, Dodd JD. Honeycomb cysts in idiopathic pulmonary haemosiderosis: high-resolution CT appearances in two adults. Br J Radiol. 2008;81(972):e295-8. [CrossRef] [PubMed] 

Reference as: Reyes N, Snyder L, Arteaga V. Medical image of teh week: idiopathic pulmonary hemosiderosis. Southwest J Pulm Crit Care. 2014;9(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc092-14 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Aspergilloma

Figure 1.  Axial thoracic computed tomography (CT) image showing emphysematous disease throughout with prominent bullous disease in the upper lobes.  Areas of consolidation were concerning for infection.  Large cavitation with particulate matter (arrow) was seen in the left upper lobe. 

A 69-year-old woman, a current smoker, with very severe chronic obstructive pulmonary disease and prior atypical mycobacterium, was found unresponsive by her family and intubated in the field by emergency medical services for respiratory distress.  Her CT thorax showed severe emphysematous disease, apical bullous disease, and a large left upper lobe cavitation with debris (Figure 1).  She was treated with broad-spectrum antibiotics and anti-fungal medications.  Hemoptysis was never seen.  Sputum cultures over a span of two weeks repeatedly showed Aspergillus fumigatus and outside medical records confirmed the patient had a known history of stable aspergilloma not requiring therapy. 

Aspergillomas usually arises in cavitary areas of the lung damaged by previous infections.  The fungus ball is a combination of colonization by Aspergillus hyphae and cellular debris.  Individuals with aspergillomas are usually asymptomatic or have mild symptoms (chronic cough) and do not require treatment unless it begins to invade into the cavity wall.  When bleeding complications arise, surgical resection is curative but in high-risk patients, embolization may be considered as a stabilizing measure. 

Wendy Hsu, MD, Carmen Luraschi-Monjagatta, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

University of Arizona 

Tucson, AZ 

Reference 

Kousha M1, Tadi R, Soubani AO. Pulmonary aspergillosis: a clinical review. Eur Respir Rev. 2011;20(121):156-74. [CrossRef] [PubMed]

Reference as: Hsu W, Luraschi-Monjagatta C, Carr G. Medical image of the week: aspergilloma. Southwest J Pulm Crit Care. 2014;8(5):282-3. doi: http://dx.doi.org/10.13175/swjpcc044-14 PDF 

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Fontan Procedure

Figure 1. Thoracic CT scan showing Fontan anatomy, with the superior vena cava (SVC) connected to the pulmonary arteries (yellow arrow) and a single atrium and ventricle (red arrow).

 

Figure 2. SVC venography shows SVC connected to the pulmonary artery.

A 25-year-old man with a history of transposition of the great vessels (L-TGA) was admitted for persistent hemoptysis. He had a history of a double inlet left ventricle, pulmonary hypertension and was postoperative for a Fontan procedure completed at age of 2. No anatomical source for the hemoptysis was found.  A thoracic CT showed the Fontan anatomy: SVC connected to the pulmonary artery as per the Glenn connection (IVC drained to right pulmonary artery through the Fontan pathway) and a single ventricle and atrium (Figure 1). SVC venography showed the SVC connected to the pulmonary artery (Figure 2). The hemoptysis resolved after started sidenafil and bosentan for pulmonary hypertension.

Mohammed Alzoubaidi MD, Carmen Luraschi Monjagatta MD, Maria Tumanik DO, Naomi Jean Young MD

University of Arizona

Department of Pulmonary and Critical Care Medicine

Internal Medicine, South Campus.

Family Medicine, South Campus

Tucson, AZ

Reference as: Alzoubaidi M, Monjagatta CL, Tumanik M, Young NJ. Medical image of the week: Fontan procedure. Southwest J Pulm Crit Care. 2013;7(2):112-3. doi: http://dx.doi.org/10.13175/swjpcc114-13 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Metastatic Melanoma with Hemorrhage

Figure 1. Axial image of CT Chest with contrast showing pulmonary metastatic masses and alveolar opacities consistent with pulmonary hemorrhage.

 

Figure 2. Coronal image of CT Chest with contrast showing innumerable pulmonary nodules and masses along with ground-glass alveolar opacities representing alveolar hemorrhage.

A 62 year-old gentleman presented with right leg swelling due to an extensive DVT in the right femoral vein.  He was found to have a right groin mass attributed to metastatic malignant melanoma.  Chest X-ray and CT revealed multiple bilateral pulmonary nodules.  He was started on warfarin 3mg daily for acute DVT and referred to Oncology.  2 weeks later he developed hemoptysis and was found to be hypoxemic.  He was admitted to our MICU.  His INR upon admission was 8.2 and hemoglobin 6.4.  CT Chest showed innumerable bilateral pulmonary nodules and ground-glass alveolar opacities with thickening and nodularity of intra-lobular septa adjacent to the nodules.  Warfarin was held and packed RBC and FFP transfusions were given with progressive improvement in hemoptysis and pulmonary status.

Tauseef Afaq Siddiqi, MD; Abdulmajid Eddib, MD; Phillip Factor, DO; and Steven Knoper, MD

Department of Medicine

Section of Pulmonary, Allergy, Critical Care and Sleep Medicine

The University of Arizona

Tucson, AZ 85724, USA

Reference as: Siddiqi TA, Eddib A, Factor P, Knoper S. Medical image of the week: metastatic melanoma with hemorrhage. Southwest J Pulm Crit Care. 2013;6(6):287-8. http://dx.doi.org/10.13175/swjpcc079-13 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Osler-Weber-Rendu Syndrome

A 44 year-old woman with Osler-Weber-Rendu syndrome (commonly known as Hereditary Hemorrhagic Telangiectasia [HHT]) presented with hemoptysis. Her past history was notable for hemoptysis treated with hemostatic coil placement in multiple areas of arteriovenous (AV) malformations.  Her last episode of hemoptysis was 15 years prior to this admission and she had not been seen by a physician for almost 2 years.  Her CT Chest revealed multiple previous hemostatic coils and new AV malformations.

Figure 1. Chest X-Ray: Multiple hemostatic metallic coils throughout both lungs.

 

Figure 2. Axial images of CT Chest: Metallic foreign bodies are seen within the lungs. Several areas are enhancing and somewhat serpentine, possibly representing small residual or new areas of arteriovenous abnormality with dilated veins (arrows).

Tauseef Afaq Siddiqi MD, Toral Parikh MD and Phillip Factor DO

Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ 85724, United States

Reference as: Siddiqi TA, Parikh T, Factor P. Medical image of the week: Osler-Weber-Rendu syndrome. Southwest J Pulm Crit Care. 2013;6(5):241-2. PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Eisenmenger Syndrome and Hemoptysis

A 26 year-old female with Eisenmenger syndrome presented with hemoptysis. An echocardiogram showed an enlarged right ventricle and two large mid-muscular ventricular septal defects (VSD) with right to left shunting (Figures 1 and 2).

 

Figure 1. Apical four-chamber view of the heart as seen on a transthoracic echocardiogram demonstrating an enlarged right ventricle (RV) and two large mid muscular ventricular septal defects (*).  RA - right atrium, LA - left atrium, LV - left ventricle.

 

Figure 2.  Apical four-chamber view on a transthoracic echocardiogram.  Color Doppler jets (blue color) demonstrate right-to-left shunt through the two mid-muscular ventricular septal defects seen in Figure 1.

 

A contrast enhanced CT of the chest showed an enlarged pulmonary artery, no evidence of pulmonary embolism and the VSDs (Figure 3 and 4).

 

Figure 3. Contrast enhanced CT of chest demonstrating markedly enlarged main pulmonary artery (arrow), approximately twice the size of the ascending aorta (straight arrow).

 

Figure 4. Contrast enhanced CT of chest showing ventricular septal defects (arrows).

 

Eisenmenger syndrome is a condition in which increased pulmonary blood flow secondary to a left to right intracardiac shunt leads to irreversible pulmonary vascular obstructive disease.  The resultant high pulmonary vascular resistance causes reversal and right to left intracardiac shunt.  Hemoptysis is a common complication of Eisenmenger syndrome and has been reported as the cause of death in 11-29% of patients. It can be caused by pulmonary artery thrombosis, pulmonary embolism, rupture of aortopulmonary collaterals, pulmonary artery dissection and hemorrhage due to an aneurysm or thin-walled arterioles, infectious sources or a bleeding diathesis.  Treatment of hemoptysis in patients with Eisenmenger syndrome is challenging because they are at increased risk for bleeding and thrombotic complications. Hemoptysis in patients with Eisenmenger syndrome is often self-limited; however, it can be severe and life threatening. It is estimated that nearly 90% of patients with congenital heart disease survive into adulthood therefore adult pulmonologists may encounter this clinical scenario.  Our patient’s hemoptysis resolved spontaneously and she remains clinically stable.

Jamie Nicole Colombo DO*, Linda Snyder MD, and Daniela Lax MD§

Department of Pediatrics*, Division of Pediatric Cardiology§

Division of Pulmonary, Critical Care, Allergy and Sleep Medicine

University of Arizona

 

Reference as: Colombo JN, Snyder L, Lax D. Medical image of the week: Eisenmenger syndrome and hemoptysis. Southwest J Pulm Crit Care. 2013;6(5):231-3. PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Bronchial Clot

This patient was admitted from oncology clinic for ten days of hemoptysis on Coumadin.  Her laboratory data on admission showed a platelet count of 14,000/μL and an INR of 4.5.  She was found on bronchoscopy with her right mainstem completely occluded by a clot.  A cryoprobe was used and the clot was removed in one piece as seen above in a 4 x 4 container.  The clot was notable to have the cast of the right mainstem bronchial rings as well as impressions of the right upper, right middle, and right lower lobe bronchus.  The entire length of the clot was approximately four centimeters. 

Wendy Hsu, MD and Yuval Raz, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Reference as: Hsu W, Raz Y. Medical image of the week: bronchial clot. Southwest J Pulm Crit Care 2012;5:296. PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

June 2012 Imaging Case of the Month

Michael B. Gotway, MD

Associate Editor, Imaging

Clinical History: A 46 -year-old man presents to the emergency room with hemoptysis. Frontal and lateral chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal and lateral chest radiography shows a lobulated, circumscribed lesion within the left hilum. The right hilum appears normal, no lung consolidation is present, and no pleural abnormalities are seen. There is no evidence of mediastinal lymph node enlargement. There is relative lucency involving the left lung, particularly the left upper lobe, compared with the right side.

Which of the differential diagnostic considerations listed below is the least likely consideration for the appearance of the lesion on the chest radiograph?

 Reference as: Gotway MB. June 2012 imaging case of the month. Southwest J Pulm Crit Care 2012;4:214-21. (click here for a PDF version of the manuscript)

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