October 2017 Imaging Case of the Month

Paul J. Conomos, MD¹

Michael B. Gotway, MD²

¹Arizona Pulmonary Specialists

Phoenix, AZ USA

²Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: An 18-year-old man with no known previous medical history presented with complaints of intermittent cough persisting several months. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 99% on room air. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Frontal and lateral chest radiography (Figure 1) was performed.

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

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

1. The chest radiograph shows asymmetric reticulation and interlobular septal thickening
2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes
3. The chest radiograph shows focal consolidation
4. The chest radiograph shows large lung volumes
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Conomos PJ, Gotway MB. October 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(4):138-46. doi: https://doi.org/10.13175/swjpcc119-17 PDF

August 2017 Imaging Case of the Month

Brandon T. Larsen, MD, PhD¹

Michael B. Gotway, MD²

Departments of Pathology¹ and Radiology²

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 67-year-old man with a 23 pack-year history of smoking, stopping 6 years earlier, presented with a year-long history of intermittent hemoptysis consisting of small specs of blood particularly in the morning after he awoke. No sputum discoloration was reported and the patient denied shortness of breath, fever, shortness of breath, and chills. The patient also denied rash, joint pain, and night sweats. His past surgical history was remarkable only for an appendectomy, tonsillectomy, and repair of an ankle fracture, all as a young man. The patient did report some asbestos exposure in the past. He takes a multivitamin and occasional over-the counter pain relievers, but was not taking prescription medications.

Physical examination: unremarkable and the patient’s oxygen saturation was 98% on room air.

Laboratory evaluation: largely unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative. An outside otolaryngology examination was reported to show no abnormalities. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

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

1. The chest radiograph shows a mediastinal mass
2. The chest radiograph shows multifocal consolidation and pleural effusion
3. The chest radiograph shows multifocal smooth interlobular septal thickening
4. The chest radiograph shows a possible focal air space opacity
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Larsen BT, Gotway MB. August 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(2):69-79. doi: https://doi.org/10.13175/swjpcc098-17 PDF

Medical Image of the Week: Idiopathic Subglottic Stenosis

Figure 1. Flow-loop demonstrating fixed large airway obstruction.

Figure 2. Subglottic stenosis.

A 40 year-old previously healthy woman presented with a three-month history of exercise-induced shortness of breath. Clinical exam revealed inspiratory stridor. Spirometry was remarkable for flattening of the inspiratory and expiratory limbs of the flow-volume loop (Figure 1). Fiberoptic bronchoscopy revealed subglottic tracheal stenosis (Figure 2). The patient subsequently underwent successful balloon dilation of the involved segment and has remained symptom free.

Tracheal stenosis may be related to previous airway trauma, collagen vascular disease, sarcoidosis, or vasculitis. The clinical presentation is characterized by exertional dyspnea with stridor.  The flow-volume loop classically demonstrates a pattern of fixed upper airway obstruction, with flattening of both the inspiratory and expiratory limbs of the curve. CAT scanning is usually supportive of the diagnosis, and bronchoscopy is confirmatory. In the absence of an identifiable etiology, the condition is termed idiopathic tracheal stenosis. Idiopathic subglottic stenosis is a subgroup of tracheal stenosis that occurs in young women, and that is limited to the first two rings of the proximal trachea (1). Bronchoscopic tools, including balloon dilation, laser, and electrocautery have all been used with safety and efficacy for the treatment of idiopathic subglottic stenosis (2).

Charles J. Van Hook MD and Britt Warner PA

Longmont United Hospital

Longmont, CO USA

References

1. Nussbaumer-Ochsner Y, Thurnheer R. Images in clinical medicine: subglottic stenosis. N Engl J Med. 2015 Jul 2;373(1):73. [CrossRef] [PubMed]
2. Solly WR, O'Connell RJ, Lee HJ, Sterman DH, Haas AR. Diagnosis of idiopathic tracheal stenosis and treatment with papillotome electrocautery and balloon bronchoplasty. Respir Care. 2011 Oct;56(10):1617-20. [CrossRef] [PubMed]

Cite as: Van Hook CJ, Warner B. Medical image of the week: idiopathic subglottic stenosis. Southwest J Pulm Crit Care. 2017;15(1):39-40. doi: https://doi.org/10.13175/swjpcc076-17 PDF 

Medical Image of the Week: Saber Sheath Trachea

Figure 1. A: Narrowing in the mid and lower parts of the trachea on the scout film (arrow). B: Cross sectional image from chest computed tomography (CT) showing coronal narrowing of the trachea (arrow).  C: Cross sectional images from chest computed tomography (CT) showing sagittal widening of the trachea (arrow).  No mass or external compression seen.

Figure 2. Bronchoscopy image that shows the coronal narrowing and sagittal widening of the (A) proximal trachea, (b) mid trachea and (C) distal trachea.

A 79-year-old man with chronic obstructive pulmonary disease (COPD) and an active smoker was transferred for evaluation of tracheal narrowing and concerns of malignant external compression versus tracheobronchomalacia for possible stenting.

The patient underwent both chest computed tomography (Figure 1) and bronchoscopy (Figure 2) that confirmed the diagnosis of saber-sheath trachea and ruled out external compression. The airway was still adequately patent during inspiration and expiration with no clear dynamic collapse.

Saber-sheath trachea is commonly described as intra-thoracic coronal narrowing and sagittal widening of the trachea (like a sword sheath). Repetitive cartilaginous injury from excessive coughing and elevated intra-thoracic pressure causes degeneration and calcification of the trachea cartilage, leading to remodeling and bending of the tracheal cartilage (1). Presence of saber-sheath trachea is highly associated with obstructive lung disease, which is present in our patient (2). There is no known specific treatment for saber-sheath trachea, however if patient with saber-sheath trachea were to require intubation, air leak can be a concern due to the rigid deformity of the trachea (3).

See-Wei Low, MD¹; Huthayfa Ateeli, MD²; James Knepler, MD²

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

Banner University Medical Center Tucson

Tucson, AZ, USA

References

1. Ismail SA, Mehta AC. "Saber-sheath" trachea. J Bronchol Intervent Pulmonol 2003;10:296-7. [CrossRef]
2. Greene R. Saber-sheath trachea: relation to chronic obstructive pulmonary disease. AJR Am J Roentgenol. 1978;130:441-5. [CrossRef] [PubMed]
3. Wallace E, Chung F. General anesthesia in a patient with an enlarged saber-sheath trachea. Anesthesiology. 1998;88:527-9. [CrossRef] [PubMed] 

Cite as: Low S-W, Ateeli H, Knepler J. Medical image of the week: saber sheath trachea. Southwest J Pulm Crit Care. 2017;14(6):283-4. doi: https://doi.org/10.13175/swjpcc056-17 PDF 

Medical Image of the Week: Pulmonary Metastases of Rectal Cancer

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

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

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

Michael Insel MD, Naser Mahmoud MD and Afshin Sam MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center Tucson

Tucson, AZ USA

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

Medical Image of the Week: Bronchial Clot Removal via Cryotherapy

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

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

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

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

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

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

²The Department of Anesthesia

University of Arizona

Tucson, AZ USA

Reference

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

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

Medical Image of the Week: Tracheobronchial Foreign Body Aspiration

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

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

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

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

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

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

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

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

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

References

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

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

Medical Image of the Week: Tracheobronchopathia Osteochondroplastica

Figure 1: Panels (A and B) show the lumpy, bumpy nodules of tracheobronchopathia osteochondroplastica affecting the anterior tracheal wall with sparing of the posterior membrane. In this patient, copious amounts of white secretions can be seen in the distal trachea and the posterior membrane from her current MRSA pneumonia. 

Tracheobronchopathia osteochondroplastica (TO) is a rare, idiopathic tracheobronchial abnormality that is seen during 0.7% of bronchscopies. It is usually diagnosed in the 5th to 6th decades of life with a male preponderance (1,2)^. Here, we present the case of a 62-year-old woman with history of bronchial asthma with recurrent exacerbations who was admitted with pneumonia and a new mass-like consolidation on imaging. She underwent bronchoscopy for further work up and was found to have methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Incidental nodules were found in her trachea during the bronchoscopy (Figure 1). Most patients with TO are asymptomatic but can rarely present with cough, shortness of breath, and even non-massive hemoptysis due to ulceration of nodular mucosa. Secondary airway narrowing has also been reported. The lumpy, bumpy nodules typically are 3-8 mm in size, localize in the sub-mucosa of the trachea, and are difficult to biopsy due to their cartilaginous or osseous nature. Diagnosis can be made by chest CT or bronchoscopy. A very important distinctive feature is sparing of the posterior membranous wall of the trachea, differentiating it from other nodular airway diseases. TO is a benign disease that generally doesn’t need any specific treatment or intervention (1,2).

Huthayfa Ateeli, MBBS, Elaine Cristan, MD, and Afshin Sam, MD.

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

University of Arizona, Tucson, AZ USA

References

1. Lundgren R, Stjernberg NL. Tracheobronchopathia osteochondroplastica. A clinical bronchoscopic and spirometric study. Chest. 1981 Dec;80(6):706-9. [CrossRef] [PubMed]
2. Prince JS, Duhamel DR, Levin DL, Harrell JH, Friedman PJ. Nonneoplastic lesions of the tracheobronchial wall: radiologic findings with bronchoscopic correlation. Radiographics. 2002 Oct;22 Spec No:S215-30. [CrossRef] [PubMed] 

Cite as: Ateeli H, Cristan E, Sam A. Medical image of the week: tracheobronchopathia osteochondroplastica. Southwest J Pulm Crit Care. 2016;13(3):131-2. doi: http://dx.doi.org/10.13175/swjpcc067-16 PDF

Medical Image of the week: Endobronchial Valves

Figure 1. Bronchoscopic view of the endobronchial valves in the right upper lobe sub-segments.

Figure 2. Post procedural chest x-ray shows the valves (encircled). Other findings on this chest x-ray include a tracheostomy tube, right sided chest tube, left sided PICC line. Bilateral pneumatoceles are also seen (arrows).

A 39 year-old woman was referred to our hospital for evaluation of persistent broncho-pleural fistula after severe necrotizing streptococcal pneumonia. She had undergone a segmentectomy for the necrosis resulting in the broncho-pleural fistula. Her overall medical condition and malnutrition precluded another major surgery such as a muscle flap for the persistent air leak. Endobronchial valve placement was attempted to minimize the gradient and leak across the parenchymal defect to promote healing.

A sequential balloon occlusion technique was used to localize the leak to the right upper lobe, which was the site of the previous surgery. The sub-segments were measured and three endobronchial valves (Spiration®, Olympus Respiratory, USA) (1). Valves of 5 mm, 6 mm and 7 mm – were placed in the three sub-segments of the right upper lobe (Figure 1) with a flexible bronchoscope. Near elimination of the air leak was seen post procedure. Figure 2 shows post procedure chest x-ray showing the three valves.

Removable endobronchial valves have been shown to be safe and effective in cases of persistent post-operative air leaks (2).

Bhupinder Natt MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner University Medical Center-Tucson

Tucson, AZ USA

References

1. Olympus Corporation. Spiration® valve system. Available at: http://www.spiration.com/us/product-overview (accessed 6/21/16).
2. Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski RA, Musani AI, Kucharczuk JC, Gonzalez HX, Springmeyer SC. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011 Jan;91(1):270-3. [CrossRef] [PubMed]

Cite as: Natt B, Knepler J. Medical image of the week: endobronchial valves. Southwest J Pulm Crit Care. 2016;13(1):34-5. doi: http://dx.doi.org/10.13175/swjpcc057-16 PDF

April 2016 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  

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

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

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

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

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

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

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

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

Financial Support Received: None.

Clinical History: A 19 year-old man with no previous medical history was vacationing when he was found down, intoxicated, surrounded by vomit. He went into cardiac arrest, and, after several minutes, cardiopulmonary resuscitation was initiated. He was intubated in the field, and epinephrine was administered.

Once at the hospital, frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate?

1. The frontal chest radiograph shows central venous catheter malposition
2. The frontal chest radiograph shows focal consideration
3. The frontal chest radiograph shows pleural fluid loculated within the major fissures
4. The frontal chest radiograph shows pneumomediastinum
5. The frontal chest radiograph shows pneumothorax

Cite as: Gotway MB. April 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4):137-46. doi: http://dx.doi.org/10.13175/swjpcc035-16 PDF

December 2015 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: An 80-year-old woman with a history of polycythemia vera (12 years), migraines, hypertension, and gastroesophageal reflux disease presented with complaints of declining functional status due to worsening shortness of breath over 3-4 weeks’ duration. She also complained of occasional palpitations. No history of fever, cough, chest pain, or hemoptysis was elicited. A frontal chest radiograph (Figure 1) was performed.

Figure 1.  Panel A: Frontal chest radiograph obtained at presentation, when the patient complained of worsening shortness of breath. Panel B: 3 years earlier.

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

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows fairly diffuse, bilateral, increased opacity
3. The frontal chest radiograph shows layering pleural effusions bilaterally
4. The frontal chest radiograph shows multifocal consolidation
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. December 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(6):254-9. doi: http://dx.doi.org/10.13175/swjpcc150-15 PDF 

Medical Image of the Week: Virtual Anatomical Dissociation During Electromagnetic Navigation Bronchoscopy

Figure 1. During the first navigation virtual bronchoscope image and 3D map (top left and bottom left) show the tip of the locatable guide in the posterior segment of the right upper lobe matching live video bronchoscope image.

Figure 2. Second navigation: the virtual bronchoscope image and 3D map (top left and bottom left) show the tip of the bronchoscope in the right main bronchus whereas the video bronchoscope shows the tip in the posterior segment of the right upper lobe.

A 59 year-old woman with a 40 pack-year smoking history was referred to our practice with a 2.5 cm spiculated right upper lobe lung nodule for a diagnostic bronchoscopy.

We performed electromagnetic navigation bronchoscopy under general anesthesia in the operating room. After successfully navigating to the lesion and obtaining 3 needle biopsy samples and two cytology brush samples we lost target alignment. After attempting to rotate and reposition the catheter several times it was decided to re-navigate from the trachea. Two images comparing virtual navigation to real anatomy during the first and second navigation attempts are provided bellow (Figures 1 and 2).

Why are the virtual images different? (Click on the correct answer for a discussion)

1. It is an artifact from respiratory movements
2. The locatable guide is outside the sensing volume
3. You should suspect a pneumothorax
4. Your registration procedure was suboptimal, you should repeat it.

Cite as: Vazquez-Guillamet R, Horn E, Sarver R, Melendres L. Medical image of the week: virtual anatomical dissociation during electromagnetic navigation bronchoscopy. Southwest J Pulm Crit Care. 2015;11(5):238-9. doi: http://dx.doi.org/10.13175/swjpcc111-15 PDF

Medical Image of the Week: Healthcare-associated Pneumonia Secondary to Aspiration

Figure 1. Panel A: Axial computed-tomography image demonstrating a foreign body within the right main-stem bronchus, with consolidation and volume loss of right lung. Panel B: Coronal view.

Figure 2. Panel A: bronchoscopy revealing an ingested foreign body in the right main-stem bronchus. Panel B: forceps retrieval yielded a large piece of broccoli.

A 57 year-old bedbound paraplegic man developed a worsening productive cough after being hospitalized for several days. He was brought to the radiology suite for a CT scan of the chest, revealing a soft tissue density within his right main-stem bronchus, with volume loss of his right lung (Figure 1). Bronchoscopy was performed, yielding a 2 cm piece of broccoli, successfully removed with forceps (Figure 2). Culture from the bronchial aspirate was positive for Pseudomonas aeruginosa. The patient’s respiratory status dramatically improved after removal of the foreign body and commencement of pathogen-directed antibiotics. This study illustrates a dramatic example of healthcare-associated pneumonia (HCAP) secondary to aspiration, as described by the American Thoracic Society / Infectious Diseases Society of America (1).

Lavi Nissim MD, Sam Alnajjar MD and Edward Vivio RT

Phoenix Baptist Hospital

2000 W. Bethany Home Road

Phoenix, AZ 85015

Reference

1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]

Reference as: Nissim L, Alnajjar S, Vivio E. Medical image of the week: healthcare-associated pneumonia secondary to aspiration. Southwest J Pulm Crit Care. 2015;11(1):1-2. doi: http://dx.doi.org/10.13175/swjpcc065-15 PDF

Medical Image of the Week: Carcinoid at the Carina

Figure 1. Flow-volume loop showing flattening of expiratory loop suggesting variable intra-thoracic obstruction.

Figure 2. CT of the chest showing pedunculated tracheal lesion at the level of main carina.

Figure 3. Bronchoscopic view of endobronchial tumor before (Panel A) and after removal (Panel B).

A 74-year-old woman with history of 30 pack-year smoking, allergic rhinitis and asthma presented to pulmonary clinic with cough and dyspnea on exertion. She was placed on inhaled corticosteroids and long-acting beta-agonist. Pulmonary function test showed moderate obstructive ventilator defect and flow volume loop suggested variable intra-thoracic obstruction (Figure 1). In the meantime, she was hospitalized with complaint of dyspnea and possible COPD exacerbation. Het CT chest revealed an endobronchial 12 mm pedunculated lesion at anterior aspect of main carina (Figure 2). She underwent flexible bronchoscopy and lesion was removed using electro-surgical snare and cryoprobe (Figure 3). Her symptoms improved post-procedure. Pathologic examination of lesion revealed a carcinoid tumor.

Endobronchial tumors are masses confined within the bronchus, and may be associated with atelectasis or pneumonia of the distal parenchyma. These tracheobronchial tumors are classified as malignant or benign. Malignant tumors arising from surface epithelium include squamous cell carcinoma and neuro-endocrine tumors; and those arising from mesenchyme include sarcoma and malignant lymphoma. On the other hand, benign tumors arising from surface epithelium include squamous cell papilloma and mucus gland adenoma; and those arising from mesenchyme include hamartoma, lipoma, fibroma, leiomyoma, and neurogenic tumor. Hamartomas may present as a fatty mass, nodules with calcification, or as soft-tissue-density nodules on CT scans. The lipomas manifested as fat density on CT scans. The other benign tumors were low-attenuating, soft-tissue-density masses without characteristic findings on CT scans.

Tauseef Afaq Siddiqi, MD; Muhammad Alzoubaidi, MD; James Knepler, MD and Kenneth Knox, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona, Tucson, AZ

Reference

1. Ko JM, Jung JI, Park SH, Lee KY, Chung MH, Ahn MI, Kim KJ, Choi YW, Hahn ST. Benign tumors of the tracheobronchial tree: CT-pathologic correlation. AJR Am J Roentgenol. 2006;186(5):1304-13. [CrossRef] [PubMed] 

Reference as: Siddiqi TA, lzoubaidi M, Knepler J, Knox KS. Medical image of the week: carcinoid at the carina. Southwest J Pulm Crit Care. 2015;10(6):341-2. doi: http://dx.doi.org/10.13175/swjpcc052-15 PDF 

Medical Image of the Week: Actinomycosis

Figure 1. Thoracic CT scan showing right-sided necrotizing pneumonia, lung abscess and empyema (arrows).

Figure 2. Cytospin and cell block of right lower lobe bronchoalveolar lavage fluid stained with Grocott-Gomori's (or Gömöri) methenamine silver (GMS) stain showing positive filamentous organisms consistent with Actinomyces species within a background of inflammatory cells.

Figure 3. Low (Panel A) and high power view (Panel B) of the lung showing alveolar septa filled with predominantly acute (neutrophilic) infiltrate.

A 55-year-old man with history of tobacco and alcohol abuse, presented with unresolving pneumonia despite treatment with moxifloxacin. It was thought to be possible coccidioidomycosis and an azole was started. However, he returned with increasing dyspnea and hypoxemia. He had leukocytosis with a thoracic CT revealing a loculated empyema, multifocal necrotizing infection and a large intrapulmonary abscess (Figure 1). He was admitted to MICU, intubated and ventilated. He was in septic shock requiring fluid resuscitation, vasopressors, and broad antibiotics. Bronchoscopy revealed erythematous and edematous airways, with drainage of over one liter of purulent fluid. A chest tube was placed to drain pleural fluid with removal of around two liters of blood-tinged, purulent fluid. His condition worsened with development of disseminated intravascular coagulation leading to hemorrhagic shock. He arrested and died. Gram stain on bronchoalveolar lavage fluid showed mixed gram negative and gram variable rods, and cultures grew lactobacillus species. GMS stain revealed filamentous organisms consistent with Actinomyces (Figure 2).

Necrotizing pneumonia is usually secondary to aspiration of oral bacterial flora, and is usually associated with severe sepsis and acute respiratory failure. The obstruction of the bronchus and blood vessels corresponding to a lung segment leads to decreased perfusion that is often shown on contrast enhanced CT scan. Hence, systemic antibiotic treatment alone is usually not effective. The management of necrotizing pneumonia is multidisciplinary; including adequate antibiotic therapy, mechanical ventilation, closed pleural drainage and supportive care. Despite the serious morbidity, massive parenchymal damage and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is good with multidisciplinary care. If initial medical therapy fails, surgery is a reasonable option. Resection of gangrenous lung parenchyma and drainage of pleural empyema can lead to recovery in up to 80% of patients. Rarely, lobectomy can be a salvage operation. Outcome is affected by the severity of disease and underlying comorbidities. It should be considered once operative risk is acceptable.

Tauseef Afaq Siddiqi MD^1,2, Tracy Lundberg MD³, Jennifer Thorn MD³, and Dena L’heureux MD^1,2

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

²Department of Medicine, Southern Arizona Veterans Administration Health Sciences Center, Tucson, AZ

³Department of Pathology, The University of Arizona Medical Center, Tucson, AZ

References

1. Alifano M, Lorut C, Lefebvre A, Khattar L, Damotte D, Huchon G, Regnard JF, Rabbat A. Necrotizing pneumonia in adults: multidisciplinary management. Intensive Care Med. 2011;37(11):1888-9. [CrossRef] [PubMed]
2. Schweigert M, Dubecz A, Beron M, Ofner D, Stein HJ. Surgical Therapy for Necrotizing Pneumonia and Lung Gangrene. Thorac Cardiovasc Surg. 2013;61(7):636-41. [CrossRef] [PubMed]
3. Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med. 2012;18(3):246-52. [CrossRef] [PubMed]

Reference as: Siddiqi TA, Lundberg T, Thorn J, L’heureux D. Medical image of the week: actinomycosis. Southwest J Pulm Crit Care. 2015;10(5):302-3. doi: http://dx.doi.org/10.13175/swjpcc050-15 PDF

April 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 73-year-old woman with a history of ovarian malignancy in remission for several years and treated with hysterectomy and oopherectomy, hypothyroidism, and hypertension, presented with rather abrupt onset cough, chest pain, dyspnea and low-grade fever (99.6°F). Her past medical history was otherwise unremarkable. Her medications included thyroid replacement, amlodipine, benazepril, and, recently, calcium and magnesium supplementation. Chest radiography was performed (Figure 1).

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

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

1. Chest radiography shows a large right pleural effusion
2. Chest radiography shows focal lung opacity
3. Chest radiography shows mediastinal widening
4. Chest radiography shows pneumomediastinum
5. Chest radiography shows pneumothorax

Reference as: Gotway MB. April 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;10(4):171-81. doi: http://dx.doi.org/10.13175/swjpcc048-15 PDF

November 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 38-year-old non-smoking woman presented with complaints of intermittent dry cough, occasional vomiting, and dyspnea, occasionally with fever and chills. She indicated that she has suffered recurrent bouts of bronchitis and pneumonia annually over the previous 10 years. The patient had a history of upper arm localized melanoma resection 10 years earlier. She had smoked for 10 years, but quit one year prior to presentation. Her past medical and surgical histories were otherwise unremarkable.

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

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

Which of the following statements regarding the chest radiograph is most accurate? (click on the correct answer to proceed to the next panel)

1. The chest radiograph shows asymmetric pulmonary vascularity
2. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
3. The chest radiograph shows mild, bilateral, streaky central opacities, possibly reflecting airway thickening
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows volume loss involving the right thorax with a mass-like opacity projected over the right hilum

Reference as: Gotway MB. November 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;9(5):264-77. doi: http://dx.doi.org/10.13175/swjpcc147-14 PDF

Medical Image of the Week: Bronchus Sui

Figure 1. Panel A: Coronal view of the thoracic CT scan showing the right upper lobe superior subsegment bronchus taking off from the trachea (arrow). Panel B: Bronchoscopy confirming the tracheal origin of the superior subsegment bronchus.

A 65 year-old man presented to the outpatient clinic for evaluation of a chronic cough. The patient underwent CT Chest (Figure 1A) that shows a right upper lobe (RUL) infiltrate with an incidental right-sided tracheal bronchus. The incidence of right-sided tracheal bronchus is 0.1-2% and has different subtypes. This patient has the most common subtype called a displaced tracheal bronchus as the aberrant, superior segment has normal RUL branching, which coexists with normal right-sided anatomy except that the one branch of the upper lobe bronchus is missing. A true “bronchus sui” (pig bronchus) is when the RUL takes off from the trachea and the right main bronchus acts as the bronchus intermedius feeding the right middle and lower lobes. A tracheal bronchus is usually asymptomatic but can be associated with recurrent pneumonia, chronic bronchitis and bronchiectasis. Bronchoscopy (Figure 1B) was performed for the purpose of RUL bronchoalveolar lavage and endobronchial ultrasound of the mediastinal lymphadenopathy. 

Nathaniel Reyes MD, Bhupinder Natt MD, Janet Campion MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, AZ

Reference

Findik S. Tracheal bronchus in the adult population. J Bronchology Interv Pulmonol. 2011;18(2):149-52. [CrossRef] [PubMed] 

Reference as: Reyes N, Natt B, Campion J. Medical image of the week: bronchus sui. Southwest J Pulm Crit Care. 2014;8(5):281. doi: http://dx.doi.org/10.13175/swjpcc043-14 PDF

Medical Image of the Week: Granulation Tissue

Figure 1. Subglottic space showing the presence of granulation tissue (arrows).

Figure 2. Argon Plasma Coagulation of the granulation tissue

A 57 year old woman presented with a tickling sensation in the back of throat and intermittent bleeding from the healing stoma one month after decannulation of her tracheostomy tube. On bronchoscopy a granuloma with surrounding granulation tissue was present in the subglottic space (Figure 1). Argon plasma coagulation (APC) was performed to cauterize the granulation tissue (Figure 2).

Formation of granulation tissue after tracheostomy is a common complication which can result in tracheal stenosis. APC and electrocautery using flexible bronchoscopy has been shown to safely and effectively remove the granulation tissue.

Aarthi Ganesh, MBBS and  James Knepler, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona

Tucson, AZ

Reference

1. Epstein SK. Late complications of tracheostomy. Respir Care. 2005;50(4):542-9. [PubMed] 

Reference as: Ganesh A, Knepler J. Medical image of the week: granulation tissue. Southwest J Pulm Crit Care. 2014;8(3):192-3. doi: http://dx.doi.org/10.13175/swjpcc029-14 PDF

February 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man presented with a history of weight loss and dysphagia for about 2 weeks duration. There was a possible history of asthma accompanied by ongoing shortness of breath first noticed nearly 2 years ago. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Choose the correct answer to move to the next panel)

1. The chest radiograph shows a mass
2. The chest radiograph shows hilar and mediastinal lymph node enlargement
3. The chest radiograph shows multifocal consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities suggesting fibrosis
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. February 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(2):88-95. doi: http://dx.doi.org/10.13175/swjpcc010-14 PDF