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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 Month: Double Aortic Arch
May 2019 Imaging Case of the Month: Asymptomatic Pulmonary
   Nodules and Cysts in a 47-Year-Old Woman
Medical Image of the Month: Ludwig’s Angina
Medical Image of the Month: Incarcerated Morgagni Hernia
Medical Image of the Month: Pectus Excavatum
February 2019 Imaging Case of the Month: Recurrent Bronchitis and 
   Pneumonia in a 66-Year-Old Woman
Medical Image of the Month: Massive Right Atrial Dilation After Mitral Valve
   Replacement
Medical Image of the Month: Chronic Ogilvie’s Syndrome
Medical Image of the Month: Malignant Pleural and Pericardial Effusions
November 2018 Imaging Case of the Month: Respiratory Failure in a 
   36-Year-Old Woman
Medical Image of the Month: Superior Vena Cava Syndrome
Medical Image of the Month: Hot Tub Lung
Medical Image of the Week: Chylothorax
August 2018 Imaging Case of the Month: Dyspnea in a 55-Year-Old 
   Smoker
Medical Image of the Week: Tracheobronchopathia Osteochondroplastica
Medical Image of the Week: Plastic Bronchitis in an Adult Lung Transplant
   Patient
Medical Image of the Week: Medical Administrative Growth
Medical Image of the Week: Malposition of Central Venous Catheter
Medical Image of the Week: Fournier’s Gangrene with a Twist
July 2018 Imaging Case of the Month
Medical Image of the Week: Intracavitary View of Mycetoma
Medical Image of the Week: Neuromyelitis Optica and Sarcoidosis
Medical Image of the Week: Pulmonary Amyloidosis in Primary Sjogren’s
   Syndrome
Medical Image of the Week: Post Pneumonectomy Syndrome
June 2018 Imaging Case of the Month
Medical Image of the Week: Elemental Mercury Poisoning
Medical Image of the Week: Thoracic Splenosis
Medical Image of the Week: Valley Fever Cavity with Fungus Ball
Medical Image of the Week: Recurrent Sarcoidosis Resembling Malignancy
May 2018 Imaging Case of the Month
Medical Image of the Week: Cardiac Magnetic Resonance Imaging Findings
   of Severe RV Failure
Medical Image of the Week: Mediastinal Lipomatosis
Medical Image of the Week: Dobhoff Tube Placement with Roux-En-Y
   Gastric Bypass
Medical Image of the Week: Atypical Deep Sulcus Sign
April 2018 Imaging Case of the Month
Medical Image of the Week: Headcheese Sign
Medical Image of the Week: Chronic Bilateral Fibrocavitary Pulmonary
   Coccidioidomycosis
Medical Image of the Week: Paget-Schroetter Syndrome
A Finger-Like Projection in the Carotid Artery: A Rare Source of Embolic 
   Stroke Requiring Carotid Endarterectomy
Medical Image of the Week: Post-Traumatic Diaphragmatic Rupture
Medical Image of the Week: Bronchogenic Cysts
March 2018 Imaging Case of the Month
Medical Image of the Week: Acute Pneumonitis Secondary to Boric Acid 
   Exposure
Medical Image of the Week: Traumatic Aortic Dissection
Medical Image of the Week: Blue-Green Urine and the Serotonin 
   Syndrome
Medical Image of the Week: Acute Encephalopathy in a Multiple
   Myeloma Patient
February 2018 Imaging Case of the Month
Medical Image of the Week: Stomach Rupture
Medical Image of the Week: Methemoglobinemia
Medical Image of the Week: Pulmonary Artery Dilation
Medical Image of the Week: Plastic Bronchitis
January 2018 Imaging Case of the Month
Medical Image of the Week: Pulmonary Alveolar Proteinosis
Medical Image of the Week: Fat Embolism
Medical Image of the Week: Central Venous Access with Dextrocardia

 

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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Tuesday
Apr022019

Medical Image of the Month: Ludwig’s Angina

Figure 1.  A coronal reconstruction of the patient’s initial post-contrast maxillofacial CT demonstrates swelling of the soft tissues of the floor of the mouth consistent with phlegmonous changes and early abscess formation (blue arrows).  There is also swelling in the region of the vallecula and epiglottis (red arrow).

 

Figure 2.  A coronal reconstruction of the patient’s follow-up post-contrast maxillofacial CT after placement of a tracheostomy tube demonstrates marked progression of the swelling of the soft tissues of the floor of the mouth with development of a large, ill-defined abscess in the floor of the mouth (blue circle). Note the marked, progressive narrowing of the oropharynx (red arrow) over a period of approximately 24 hours.

 

Case Presentation: A 65-year-old gentleman with a history of insulin-dependent diabetes mellitus presented to the emergency room with a chief complaint of two days of difficulty swallowing and jaw pain.  Four days prior to presentation, he had extensive dental work performed to address multiple dental caries.  On arrival to the emergency room, he was noted to be tachycardic with difficulty swallowing his saliva and liquids.  On physical examination, he had difficulty opening his mouth with marked swelling of his tongue.  He also had marked swelling of the soft tissues of the floor of the mouth with palpable adenopathy.  A maxillofacial CT with contrast (Figure 1) was performed which demonstrated extensive edema and early abscess formation in the floor of the mouth.  He was initially admitted to the general medicine floor and started on broad-spectrum antibiotics.  Over the course of the next 12 hours, he began to have increased difficulty breathing and was unable to swallow his own secretions.  He was promptly transferred to the ICU where a fiberoptic nasotracheal intubation was attempted at bedside but was unable to be performed given the extensive soft tissue swelling in the posterior oropharynx.  An emergent awake tracheostomy was subsequently performed by ENT.  A repeat maxillofacial CT with contrast (Figure 2) demonstrated marked progression of the inflammatory changes and abscess formation in the floor of the mouth consistent with progressive Ludwig's angina.  The combination of prompt surgical drainage and broad-spectrum antibiotics resulted in marked clinical improvement over the next 72 hours. The patient's final tissue cultures grew Streptococcus viridans.

Ludwig's angina is a potentially life-threatening gangrenous cellulitis of the neck and floor of the mouth which is characterized by progressive submandibular swelling with elevation and posterior displacement of the tongue. Odontogenic infections are the cause for most cases. Pre-existing medical conditions which predispose patients to the development of Ludwig's angina include diabetes mellitus, malnutrition, alcoholism, and immunocompromised states (i.e. AIDS and organ transplantation).

In the early stages of the disease, patients may be managed with observation and intravenous antibiotics to cover for β-hemolytic streptococcus and anaerobic organisms. The most life-threatening complication of Ludwig's angina is airway obstruction.  Immediate involvement of an anesthesiologist and ENT are crucial in the management of this condition.  Blind nasotracheal intubation should not be attempted in these patients given the potential for bleeding and abscess rupture.  Flexible nasotracheal intubation requires skill and experience.  If flexible nasotracheal intubation is not possible, a cricothyrotomy and tracheostomy under local anesthesia can be performed in the emergent setting.  An elective awake tracheostomy is a safer and more logical method of airway management in patients with fully developed Ludwig's angina.

Lauren Estep, MD and Tammer El-Aini, MD

Department of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

  1. Hasan W, Leonard D, Russell J. Ludwig's Angina-A Controversial Surgical Emergency: How We Do It. Int J Otolaryngol. 2011;2011:231816. [CrossRef] [PubMed]
  2. Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig's Angina - An emergency: A case report with literature review. J Nat Sci Biol Med. 2012 Jul;3(2):206-8. [CrossRef] [PubMed]

Cite as: Estep L, El-Aini T. Medical image of the month: Ludwig’s angina. Southwest J Pulm Crit Care. 2019:18(4):74-5. doi: https://doi.org/10.13175/swjpcc013-19 PDF 

Saturday
Mar022019

Medical Image of the Month: Incarcerated Morgagni Hernia

Figure 1. Lateral view of abdominal-thoracic CT in soft tissue windows.

 

Figure 2. Coronal view of thoracic CT scan in lung windows.

 

A Morgagni hernia is a congenital diaphragmatic hernia in which abdominal viscera herniate into the thorax via a defect within an anterior attachment of the diaphragm. As with any bowel-containing hernia, the most feared complication is strangulation with subsequent bowel necrosis. In the present case, a 67-year-old woman presented with a five-day history of acute onset and progressively worsening upper abdominal pain and inability to tolerate oral intake, associated with nausea, vomiting, and mild shortness of breath. A CT revealed a large defect in the right hemidiaphragm consistent with a Morgagni hernia with herniation of the omentum, vessels, and a segment of transverse colon (Figure 1). Findings of bowel ischemia were observed, including (a) pneumatosis intestinalis, seen as cystic foci of air lining the bowel wall, and (b) fluid and fat-stranding adjacent to the affected bowel (Figure 2). Evidence of bowel wall perforation include large volume free air adjacent to the bowel in the right hemithorax and within the abdomen (Figures 1 and 2). Bowel ischemia and necrosis can occur with any hernia and requires prompt diagnosis and management.

Samandip Hothi MD1 and Viral Patel MD2

1Department of Medicine, Division of Internal Medicine and 2Department of Medical Imaging

University of Arizona College of Medicine-Tucson

Tucson, AZ USA

References

  1. Arora S, Haji A, Ng P. Adult Morgagni Hernia: The Need for Clinical Awareness, Early Diagnosis and Prompt Surgical Intervention. Ann R Coll Surg Engl. 2008 Nov;90(8):694-5. [CrossRef] [PubMed]
  2. Ly JQ. The Rigler Sign. Radiology. 2003;228(3):706-7. [CrossRef] [PubMed]
  3. Morgan TB, Nguyen DN, Tran CD, Maheshwary RK, Mickus TJ. Morgagni Hernia Causing Incarcerated Bowel and Contributing to Cardiac Arrest. Curr Probl Diagn Radiol. 2018 Jul 31. pii: S0363-0188(18)30181-6. [CrossRef]

Cite as: Hothi S, Patel V. Medical image of the month: Incarcerated Morgagni hernia. Southwest J Pulm Crit Care. 2019;18:59-60. doi: https://doi.org/10.13175/swjpcc001-19 PDF