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WWWTP #23 (What’s Wrong With This Picture?) Answer

March 12, 2015

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Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235639/

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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Student Corner: A Cavitary Lesion

January 6, 2015

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Cavitary lesions in the lungs are gas or fluid filled compartments in an area of pathology, such as a consolidation or a mass. Interestingly, a specific set of pathologies are known to cause this specific finding. Cavitary lesions can be detected on a chest x-ray, as is shown below.

cavitary-mass with IDCavitary masscavitary mass lateral with IDCavitary mass 2

Legend: Red Ellipse–cavity (with margins), Blue Ellipse–air-fluid level

The lesion practically jumps out of the picture on the AP view, but the colored circles are there just to point out the entire area of pathology (blue) and the cavity within (red). The pathology is a bit harder to see on lateral view, but the cavity has an air-fluid level that is easily identified as a vertical line separating a lighter fluid filled portion from an air filled portion. This air-fluid interface is often called a meniscus. You might remember being in chemistry class and measuring water out of tall beakers where the water stuck to the sides of the glass creating a concave meniscus. The surface tension of water allows it to stick to both itself and surrounding surfaces. If you look close enough, you’ll notice that the air-fluid level in the image above, best visualized in the AP view, has a slightly concave shape because the liquid at the bottom is sticking to the solid sides of the cavity.

The underlying pathophysiology is an interesting concept to understand when discussing cavitary lesions. A cavity can form in lung tissue for various reasons, but infection is the major underlying cause. Abscesses are localized collections of pathogens, fluid and immune system components that are walled off from the surrounding tissue, therefore creating a fluid-filled cavity. Tuberculosis is a disease process that involves caseous necrosis, which results in coagulation of cell proteins and liquefaction of cellular components. Eventually, the liquid portion drains out through the lymph system or through the bronchi, leaving air pockets behind. Necrotizing pneumonia and non-infectious processes such as ischemia and neoplasm can also cause a similar picture. Rheumatologic diseases such as granulomatosis with polyangitis and sarcoidosis also cause cavitary lesions by causing localized inflammation, which in turn leads to an area of increased mass, which then in turn can cavitate once the inflammatory reaction recruits fluid to the area. In other words, most of these processes, even if they aren’t inherently related to one another, all converge on the same mechanism of causing a localized area of inflammation.

With such a wide array of categories to choose from, it is perhaps more important than usual to contextualize the radiographic image with information about the patient.

This particular patient is a 30 year old male who presents with a cough.  He has been traveling around the world to multiple continents including Sub-Saharan Africa.  The extensive travel history, including to continents with rare infectious diseases leaves infection at the top of the differential. Things like Staphylococcal pneumonia, fungal infections and even amebiasis are possible because of the patient’s travel history. For a complete list of the infectious causes of a cavitary lesion, check the first two references at the bottom of the page.

References/resources:

Gadkowski LB, Stout JE. Cavitary Pulmonary Disease. Clinical Microbiology Reviews 2008;21(2):305-333. doi:10.1128/CMR.00060-07. (LINK)

Ryu, Jay H. et al. Cystic and Cavitary Lung Diseases: Focal and Diffuse. Mayo Clinic Proceedings , Volume 78 , Issue 6 , 744 – 752. (LINK)

Good pathologic image of caseous necrosis with resulting cavitation

Image Contributor:  James Luz, MD

Author:  Jaymin Patel

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Multifocal opacities…

May 12, 2014

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A patient presented to the ED with flu-like symptoms in the height of flu season:

multifocal opacities

Chest CT:

Multifocal opacities CT 2 Multifocal opacities CT

The CT demonstrates multifocal opacities with some cavitation on the larger lesions.  There seems to be a peripheral and lower-lobe predominence.  This could represent atypical pneumonia (legionella, mycoplasma, chlamydia), fungal pneumonia (cocciodomycosis, histoplasmosis, aspergillosis), miliary tuberculosis, metastatic lesions or carcinomatosis, septic emboli, or viral pneumonia.

After a significant inpatient workup the final diagnosis was Human Metapneumovirus.  All others were ruled out and viral testing revealed this culprit.

Image contributors:  David Barnes, MD and Julie Phan, MD

Author:  Russell Jones, MD

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Multiple masses chest..

April 3, 2014

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Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

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19 month old with pneumonia…

November 3, 2013

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Peds PNA

This is an interesting pediatric chest Xray.  Immediately you notice that the right lung is diffusely more dense than the left.  This is because the patient is supine and a pleural effusion is layering behind the right lung in a dependent fashion.  Also notice the hyperinflation of the left side compared to the right.  This patient ended up having a post-obstructive pneumonia due to aspiration!

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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Answer AIDS PNA…

October 22, 2013

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On a previous post I posed a question on the differential diagnosis of pneumonia in an AIDS patient with this chest Xray:

AIDS CXR PNA

This is a multilobar pneumonia vs. ARDS (Acute Respiratory Distress Syndrome).  AIDS patients can have the same bacterial causes of multilobar pneumonia that is present in other patient populations (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus Influenza, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumoniae, etc.).  If they are healthcare associated or hospital-acquired further drug-resistant bugs such as Pseudomonas aeruginosa and MRSA could be implicated.  Infectious organisms specifically involved in immunocompromised hosts could include (among others):

  • Pneumocystis Jiroveci (PCP pneumonia)
  • Coccidioides species
  • Cytomegalovirus (CMV)
  • Tuberculosis (TB)
  • Histoplasma species
  • Aspergillus species
  • Mycobacterium avium complex (MAC)
  • Influenza
  • Herpes simplex virus (HSV)
  • Varicella-zoster virus (VZV)
  • Legionella species
  • Nocardia species
  • Cryptococcus neoformans
  • Mucoraceae species
  • Strongyloides species
  • Toxoplasma species
  • Capnocytophaga species

Non-infectious causes of multilobar infiltrates such as this could include diffuse alveolar hemorrhage, cardiogenic pulmonary edema, ARDS, among others. The multilobar involvement of the Xray above could implicate certain pathogens in favor of others (for example, Pneumocystis Jiroveci is usually multilobar as opposed to Streptococcus pneumonia which usually will cause a dense, lobar pneumonia).  The other interesting feature of the Xray is that it appears multi-nodular.  This can implicate entities such as CMV rather than a bat-wing ground-glass appearance of Pneumocystis Jiroveci.  For further discussion on pneumonia radiographic findings in AIDS, please see radiopaedia.org discussion below:

http://radiopaedia.org/articles/pulmonary-manifestations-of-hiv-aids

Incidentally, the endotracheal tube should be pulled back about 2 cm.

Author:  Russell Jones, MD

References

1.  Jones J, Stanislavski A, et al.  Pulmonary Manifestations of HIV/AIDS.  http://radiopaedia.org/articles/pulmonary-manifestations-of-hiv-aids.  Accessed 10/2013.

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COPD and dyspnea…

October 18, 2013

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This patient has a history of COPD (Chronic Obstructive Pulmonary Disease) and presented with acute shortness of breath:

COPD and PTXCOPD and PTX 2

One of the complications of COPD are pulmonary bullae.  Bullae are thin-walled, air-filled spaces that enlarge over months to years.  Sometimes they can burst, causing pneumothoracies.  This Xray demonstrates a pneumothorax on the left side in which a chest tube was placed for reexpansion.  On the right side the patient has multiple large apical bullae which are also at risk of rupture.  The chest tube is in good position with the side-port visualized inside the thoracic cavity and reexpansion of the lung is demonstrated.

Author:  Russell Jones, MD

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Pneumonia in AIDS patient…

October 14, 2013

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This patient has a history of AIDS with very low CD4 count and came in with respiratory distress:

AIDS CXR PNA

This Xray shows a diffuse pulmonary infiltrates, bilateral pleural effusions.  There is an endotracheal tube near the carina, it could come back a couple centimeters.  He also has a nasogastric tube coursing below the diaphragm. 

What is the differential diagnosis of a multilobar pneumonia such as this in an AIDS patient?  Comments appreciated!

Author:  Russell Jones, M.D.

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Lung Mets…

August 16, 2013

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This patient has a history of recently diagnosed uterine cancer and came in with dyspnea:

Mets

Just a simple CXR showing multiple lesions highly suspect of secondary lung neoplasms (metastasized uterine cancer).

The most common type of uterine malignancy is endometrial carcinoma.  It commonly metastasizes to lung, liver, brain, vagina, bone, and abdominal and pelvic lymph nodes (1).  Almost any malignancy can metastasize to the lung due to its rich blood flow, however here is a list of some of the more common primary sites that metastasize to the lungs:

  • Bladder
  • Colon
  • Breast
  • Prostate
  • Wilm’s Tumor
  • Neuroblastoma

Author:  Russell Jones, MD

References

1.  Endometrial Cancer Treatment.  National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page1.  Accessed 8/2013.

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“Doc I’m a little short of breath…”

July 9, 2013

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I had a man present the other day with dyspnea, mostly on exertion, minimal pleuritic chest pain.  He was hemodynamically stable while sitting in the gurney but would desaturate to the high 80s and become tachycardic with walking several feet.  He had a history of recently diagnosed multiple myeloma and was awaiting treatment initiation.  Here’s what we found on Chest CT:

Central PE 2Central PE 1

 

The chest CT shows a “saddle embolus.”  This is a pulmonary embolus that is very large and located in the proximal pulmonary artery before it bifurcates into the right and left pulmonary arterial tree.  This type of pulmonary embolus represents a large clot burden that can easily lead to hemodynamic instability and sudden death.  In fact, it was very suprising that this patient was so stable sitting in the gurney.  Initially he was reading a book on his tablet which I usually associate with no emergent pathology! 

This is a good time to review the indications for thrombolysis in pulmonary embolus:

  • Severe hypoxemia
  • Intractable hypotension
  • Large perfusion defect on ventilation-perfusion scans
  • Extensive embolic burden on computed tomography
  • Right ventricular dysfunction
  • Free-floating right atrial or ventricular thrombus
  • Patent foramen ovale
  • Cardiopulmonary resuscitation

These are all relative indications and it is important to weigh the risks of thrombolytics on a case-by-case basis.  There are no true indications for thrombolytics.  There are many widely accepted contraindications…I’ll leave it up to the reader to search for these. 

Author:  Russell Jones, MD

References:

1.  Tapson, VF.  Fibrinolytic (thrombolytic) therapy in acute pulmonary embolus and deep venous thrombosis.  www.uptodate.com.  Accessed 7/2013.

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