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Imaging

Last 50 Imaging Postings

(Click on title to be directed to posting, most recent listed first, CME offerings in bold)

Medical Image of the Week: Lemierre Syndrome
Medical Image of the Week: Chemotherapy-Induced Diffuse Alveolar 
   Hemorrhage
November 2017 Imaging Case of the Month
Medical Image of the Week: Erythema Nodosum
Medical Image of the Week: Pulmonary Mycetoma
Medical Image of the Week: Pulmonary Infarction- the “Reverse Halo Sign”
Medical Image of the Week: Pulmonary Artery Sling
Medical Image of the Week: Hypertensive Emergencies
October 2017 Imaging Case of the Month
Medical Image of the Week: Typical Pulmonary CT Findings Following 
   Radiotherapy
Medical Image of the Week: Pembrolizumab-induced Pneumonitis
Medical Image of the Week: Asbestos Related Pleural Disease
Medical Image of the Week: Fast-growing Primary Malignant Mediastinal 
   Mixed Germ Cell Tumor
September 2017 Imaging Case of the Month
Medical Image of the Week: The Atoll Sign in Cryptogenic Organizing 
   Pneumonia
Medical Image of the Week: Cannon V Waves
Medical Image of the Week: Bilateral Vocal Cord Paralysis
Medical Image of the Week: Tortuosity of Thoracic Aorta Mimicking a Lung
   Mass
August 2017 Imaging Case of the Month
Medical Image of the Week: Portal Vein Thrombosis in a Patient with
   Polycythemia Vera
Medical Image of the Week: Coral Reef Aorta
Medical Image of the Week: Hematopneumatoceles from Pulmonary 
   Lacerations
Medical Image of the Week: Idiopathic Subglottic Stenosis
July 2017 Imaging Case of the Month
Medical Image of the Week: Zenker’s Diverticulum
Medical Image of the Week: Superior Sulcus Tumor with Neural Invasion
Medical Image of The Week: Urothelial Carcinoma with Pulmonary
   Metastases Presenting with Shoulder Pain
Medical Image of the Week: Spontaneous Pneumothorax in End Stage
   Fibrotic Lung Disease
Medical Image of the Week: Saber Sheath Trachea
June 2017 Imaging Case of the Month
Medical Image of the Week: Coronary Artery Ectasia
Medical Image of the Week: Lymphangitic Carcinomatosis
Medical Image of the Week: Type A Aortic Dissection Extending Into Main 
   Coronary Artery 
The “Hidden Attraction” of Cardiac Magnetic Resonance Imaging for 
   Diagnosing Pulmonary Embolism
Medical Image of the Week: Pulmonary Vein Thrombosis
May 2017 Imaging Case of the Month
Medical Image of the Week: A Positive Sniff Test
Medical Image of the Week: Staphylococcal Pneumonia in a Patient with
   Influenza
Medical Image of the Week: Bronchopulmonary Sequestration
Medical Image of the Week: Wolff-Parkinson-White Syndrome
Medical Image of the Week: DISH with OPLL and C3 Fracture
April 2017 Imaging Case of the Month
Medical Image of the Week: Artery of Percheron Infarction
Medical Image of the Week: Papillomatosis
Medical Image of the Week: VA Shunt Remnant Fibrosing into Right Atrium
March 2017 Imaging Case of the Month
Medical Image of the Week: Evolution of Low Grade Adenocarcinoma
Medical Image of the week: Chronic Pulmonary Histoplasmosis
Medical Image of the Week: Endovascular Intervention for Life-
   threatening Hemoptysis 
Medical Image of the Week: Fibrosing Mediastinitis
February 2017 Imaging Case of the Month
Medical Image of the Week: Disseminated Coccidioidomycosis
Medical Image of the Week: Pulmonary Metastases of Rectal Cancer

 

For complete imaging listings click here.

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 and Critical Care 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 and Critical Care 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.

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Wednesday
Nov152017

Medical Image of the Week: Lemierre Syndrome

Figure 1. CT scan of chest (axial image) demonstrating peripheral cavitating lesion (arrow) with multifocal ground glass opacities and bilateral pleural effusions.

 

Figure 2. CT scan of neck, soft tissue (coronal [A], axial [B] image) demonstrating a partially occlusive thrombus in the left internal jugular vein (coronal red arrows, axial green arrow).

 

A previously healthy 18-year-old girl was evaluated at an urgent care center for a three day history of sore throat, fever, nausea, vomiting, diarrhea, and myalgias; the diagnosis of influenza was made at that time. Four days later, she presented to our Emergency Department with sore throat, left sided neck pain and swelling, productive cough, fever, worsening dyspnea, and pleuritic chest pain. On examination her temperature was 36.9 °C, heart rate was 142 beats per minute, and respiratory rate was 18 breaths per minute. She had enlarged tonsils without exudates, cervical and submandibular lymphadenopathy, and tenderness of her left lateral neck. Lung examination showed increased work of breathing with decreased breath sounds at the bases. Laboratory evaluation revealed an elevated white count (17,000 cells/µL) with 91% neutrophils, elevated blood urea nitrogen (21 mg/dL), creatinine (1.6 mg/dL), and venous lactate (4.0 mMol/L). Initial chest radiograph showed no evidence for acute cardiopulmonary process.  She was admitted, blood cultures were drawn, and treatment for sepsis with vancomycin, xeftriaxone, and azithromycin was initiated. Subsequent chest radiograph demonstrated an ill-defined airspace opacification in the right lower lobe.

Computed tomographic (CT) imaging of the chest showed multifocal ground glass opacities and areas of consolidation with cavitation, consistent with septic embolic disease (Figure 1). Blood cultures grew Streptococcus anginosus and Fusobacterium necrophorum. CT imaging of the neck showed a partially occlusive thrombus in the left internal jugular vein (Figure 2).  The diagnosis of Lemierre’s syndrome was made. The patient required chest tube drainage for bilateral empyema and was treated with 3 weeks of ampicillin followed by 3 weeks of high dose amoxicillin-clavulanate; she recovered completely.

Lemierre's syndrome, or anaerobic postanginal sepsis, was first described by Andre Lemierre in 1936. It is characterized by thrombophlebitis of the internal jugular vein and bacteremia caused by organisms of the normal oropharyngeal bacterial flora, classically Fusobacterium necrophorum. Lemierre’s syndrome is most commonly preceded by pharyngitis or tonsillitis, but can also be associated with odontogenic infections or otitis media. The primary infection progresses from the oropharynx and invades the lateral pharyngeal space, eventually leading to thrombophlebitis of the internal jugular vein. A majority of patients develop septic emboli, as seen in our patient, with the lungs and large joints being the most common sites of metastasis. Lemierre’s syndrome predominantly affects previously healthy children, adolescents, and young adults with most cases presenting in the second decade of life. Common physical findings include severe pharyngitis, cough/hemoptysis, dyspnea, and tenderness and swelling over the internal jugular vein. Diagnosis is confirmed by the presence of thrombophlebitis of the internal jugular vein and anaerobic organisms such as F. necrophorum in the bloodstream.

Elisa Phillips BA, BS*, Ziad Shehab MD**, and Daniela Lax MD***

*The University of Arizona College of Medicine; **Department of Pediatrics, Division of Infectious Disease; and ***Banner – University Medical Group, Pediatric Cardiology

University of Arizona

Tucson, AZ USA

References

  1. Bliss SJ, Flanders SA, Saint S. Clinical problem-solving. A pain in the neck. N Engl J Med. 2004 Mar 4;350(10):1037-42. [CrossRef] [PubMed]
  2. Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012 Oct;12(10):808-15. [CrossRef] [PubMed]
  3. Eilbert W, Singla N. Lemierre's syndrome. Int J Emerg Med. 2013 Oct 23;6(1):40. [CrossRef] [PubMed]

Cite as: Phillips E, Shehab Z, Lax D. Medical image of the week: Lemierre syndrome. Southwest J Pulm Crit Care. 2017;15(5):223-4. doi: https://doi.org/10.13175/swjpcc135-17 PDF 

Monday
Nov062017

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