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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: Large Complex Cerebral Arteriovenous
   Malformation 
Medical Image of the Month: Renal Cell Carcinoma with Extensive Tumor
   Thrombus
Medical Image of the Month: Mounier-Kuhn Syndrome
Medical Image of the Week: Diffuse Pulmonary Ossification
August 2019 Imaging Case of the Month: A 51-Year-Old Man with a
   Headache 
Medical Image of the Month: Reexpansion Pulmonary Edema
Medical Image of the Month: Bilateral Atrial Enlargement
Medical Image of the Month: Thymolipoma
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

 

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
Jul022019

Medical Image of the Month: Bilateral Atrial Enlargement

Figure 1. Portable chest radiograph showing elevation of the left mainstem bronchus (red arrow).

 

Figure 2. Thoracic CT scan showing right atrial enlargement (blue circle) and left atrium (red circle).

 

Figure 3. Upper Image: Static image from echocardiogram showing right atrial enlargement (white circle). Lower image: video of echocardiogram.

 

A 97-year-old woman was repeatedly admitted for dyspnea, hypoxemia and treated with antibiotics for presumed left lower lobe pneumonia. She has a past medical history of atrial fibrillation, congestive heart failure and sick sinus syndrome with placement of a cardiac pacemaker. Notably on physical examination, she had heart rate of 110 beats/minute, temperature of 98.8°F, blood pressure of 122/72 mm Hg, and a respiratory rate of 27 breaths/minute. She had a sternal heave, a grade 4/6 "blowing" holosystolic murmur, a loud S2, jugular venous distension and an enlarged liver. Chest x-ray showed obscuration of the left lower lobe - the left heart border cannot be seen, and the L mainstem bronchus is straightened and lifted superiorly (Figure 1). An image of the heart is shown from a CT abdomen obtained 6 months previously, showing cardiomegaly, particularly massive atrial enlargement (Figure 2). An ultrasound showed bilateral atrial enlargement with moderate mitral regurgitation and severe tricuspid regurgitation (Figure 3). The left ventricular ejection fraction was 55%, but with abnormal septal motion. She was treated with gentle diuresis to help relieve volume overload, and isosorbide dinitrate for preload and afterload reduction. Pulmonary hypertension was attributed to chronic mitral regurgitation. The cause was unclear - the patient remembered that her brother had rheumatic fever as a young recruit in WWII, but didn't know whether she had ever experienced it.

Atrial enlargement can be of prognostic significance. Left atrium size has been found to be a predictor of mortality due to both cardiovascular issues as well as all-cause mortality (1). Larger right atrium than left atrium has been associated with all-cause mortality in elderly patients with heart failure (2).

Robert A. Raschke, MD

University of Arizona College of Medicine-Phoenix

Phoenix, AZ USA

References

  1. Patel DA, Lavie CJ, Milani RV, Shah S, Gilliland Y. Clinical implications of left atrial enlargement: a review. Ochsner J. 2009 Winter;9(4):191-6. [PubMed]
  2. Almodares Q, Wallentin Guron C, Thurin A, Fu M, Kontogeorgos S, Thunstrom E, Johansson MC. Larger right atrium than left atrium is associated with all-cause mortality in elderly patients with heart failure. Echocardiography. 2017 May;34(5):662-7. [CrossRef] [PubMed]

Cite as: Raschke RA. Medical image of the month: bilateral atrial enlargement. Southwest J Pulm Crit Care. 2019;19(1):10-1. doi: https://doi.org/10.13175/swjpcc023-19 PDF

Sunday
Jun022019

Medical Image of the Month: Thymolipoma

Figure 1. Chest radiograph PA view revealing subtle prominence of left upper heart border (white arrow).

 

Figure 2. CT Topogram: The prominence of left heart border is discretely seen suggesting pliability of the lesion (due to supine position).

 

Figure 3. CECT axial and coronal images revealing a fat containing anterior mediastinal mass with strands of soft tissues (HU values as depicted in image).

 

Figure 4. CECT of the thorax one year after resection: post contrast image revealing no mediastinal mass lesion.

 

A 20-year-old man presented with a continuous, mild, dull aching pain affecting the left chest pain for 15 days duration. There were no aggravating or relieving factors nor any history of fever, respiratory or cardiac symptoms. The patient’s vital signs were normal and examination of the respiratory and the cardiovascular systems revealed no abnormality. Electrocardiography and biochemical investigations, including cardiac enzymes, were normal. Chest radiography (Figure 1) revealed a subtle opacity causing fullness of the aorto-pulmonary window with subtle, smooth prominence of the left upper cardiac border; the left hilum was visualised discretely through the opacity (Figure 2). The patient underwent enhanced contrast chest CT (CECT, Figure 3) for further evaluation, revealing a large mass measuring 13 x 7.9 x 5 cm in the anterior mediastinum, extending from thoracic inlet to the left cardiophrenic angle. The mass consisted predominantly of fat density, with an average attenuation of - 84 Hounsfield units (HU). Non-enhancing strands of soft tissue foci (mean, 32 HU) were also seen within the lesion. No areas of calcification or cystic degeneration were present. Planes between the subjacent mediastinal structures were preserved (Figures 2 and 3). A radiological impression of thymolipoma was offered. The patient was transferred to a tertiary care center where he underwent thoracoscopic excision and histopathology confirmed thymolipoma. Following surgery, the patient recovered uneventfully and follow up chest radiography and enhanced contrast chest CT (Figure 4) showed no evidence of lesion recurrence.

Thymolipoma is a rare benign tumor originating in the anterior mediastinum, and comprises 2-9% of all thymic neoplasms (1). Cytogenetic analyses have demonstrated that thymolipoma is a neoplasm of thymic fat (2). There is no sex or age predilection and affected patients range in age from 3-76 years. Most patients remain asymptomatic until the size of the lesion produced local mass effects, resulting in symptoms such as cough, dyspnea, hemoptysis, chest pain and hoarseness (1,3). Autoimmune diseases, including myasthenia gravis, systemic lupus erythematosus, hypogammaglobulinemia, Graves’ disease, and erythroblastopenia, may coexist in 10% patients (1).

When thymolipomas are small, the lesion may not be detectable at chest radiography. When the lesion grows larger, it classically usually “drapes” around the heart and may simulate cardiomegaly (4). Extremely large thymolipomas have been described and can mimic pericardial effusion, pericardial cysts or pericardial tumors (5). Ultrasound can be used to differentiate fluid-containing lesions, such as pericardial effusion and cysts, from the echogenic fat typical of thymolipoma (4). Excessive epicardial fat, diaphragmatic elevation, sequestration or lobar collapse may also mimic this condition at chest radiography, whereas CT and/or MRI are diagnostic, revealing circumscribed anterior mediastinal fatty mass containing islands and strands of soft tissues with no invasion of adjacent structures (3-5).

Important differential diagnostic considerations for thymolipoma at cross sectional imaging include other fat-containing mediastinal masses such as mediastinal lipoma, mediastinal lipomatosis, liposarcoma and lipoblastoma. Lipomas are encapsulated whereas liopmatosis is an unencapsulated deposition of adipose tissues, and both lesions typically show homogeneous fat attenuation with no soft tissue strands. Liposarcoma frequently occurs in the posterior mediastinum and is usually symptomatic at the time of presentation, and often manifests with inhomogeneous appearance and invasion of subjacent mediastinal structures on CT/ or MRI (6). Lipoblastoma usually occurs under the age of 3, and shows intratumoral soft tissue stranding. Thymomas do not contain fatty tissue whereas some germ cell neoplasms contain cystic areas and calcification in addition to the fatty tissue (3,6). CT is considered the modality of choice for the evaluation of mediastinal masses in general, and thymolipoma in particular. For patients in whom CT findings are equivocal, or for patients with contraindications to enhanced CT (such as contrast media allergy) MRI may be utilized for further characterization of mediastinal lesions, such as thymolipoma. Encasement or invasion of the mediastinal vasculature, esophagus, and trachea as well as involvement of the pericardium, myocardium, and pleura are accurately detected with MRI. The primary disadvantages of using MRI for mediastinal lesion characterization include limited identification of calcifications, longer imaging time, and higher cost (3,6). Since thymolipomas are benign, and typically well encapsulated, with no invasion of surrounding structures, if detected incidentally, the lesion can be followed with imaging. However, when symptoms related to local mass effect develop, surgical resection is the treatment of choice which can be performed using a minimally invasive approach, such as thoracoscopic excision, with open resection reserved for larger lesions (7). Histopathological examination of thymolipoma reveals mature adipose tissue and hyperplastic thymic structures with Hassall’s corpuscles (2).

Amit Kumar Paliwal MD1, Dr. Pradeep Jaiswal MCH (CTVS) AH

(R&R)2, and Dr. Vivek Sharma MD3

1Military Hospital Dehradun, Dehradun, Uttrakhand, India      

2Delhi Cantt, Delhi, India

3Command Hospital (CC), Lucknow, India

References

  1. Dongel I, Imamoglu H, Şahin AF, Yıldırım S, Bayram M. A rare mediastinal tumor: thymolipoma. Eur J Gen Med. 2014;11:21-3. [CrossRef]
  2. Hudacko R, Aviv H, Langenfeld J, Fyfe B. Thymolipoma: Clues to pathogenesis revealed by cytogenetics. Ann Diagn Pathol. 2009;13:185-8.[CrossRef] [PubMed]
  3. Tomiyama N, Honda O, Tsubamoto M et al. Anterior mediastinal tumors: diagnostic accuracy of CT and MRI. Eur J Radiol. 2009;69(2):280-8. [CrossRef] [PubMed]
  4. Yeh HC, Gordon A, Kirschner PA, Cohen BA. Computed tomography and sonography of thymolipoma. AJR Am J Roentgenol. 1983;140(6):1131-3. [CrossRef] [PubMed]
  5. Gamanagatti S, Sharma R, Hatimota P, Guleria R, Arvind S. Giant thymolipoma. AJR Am J Roentgenol. 2005;185(1):283-4. [CrossRef] [PubMed]
  6. Juanpere S, Canete N, Ortuno P, Martínez S, Sanchez, G, Bernado L. A diagnostic approach to the mediastinal masses. Insights Imaging. 2013;4(1):29-52. [CrossRef] [PubMed]
  7. Carapinha CP, Wainwright L, Loveland JA. A giant thymolipoma. S Afr J Child Health. 2010;4(1):20-1.

Cite as: Paliwal AK, Jaiswal P, Sharma V. Medical image of the month: thymolipoma. Southwest J Pulm Crit Care. 2019;18(6):152-4. doi: https://doi.org/10.13175/swjpcc018-19 PDF

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