Medical Image of the Week: Lymphangitic Carcinomatosis

By: Dalabih MR, Malo J

Abstract: A 64-year-old woman, never-smoker, was evaluated for shortness of breath and left leg swelling. An abnormal initial chest X-Ray lead to computed tomography (CT) scan of the chest. She was also diagnosed with deep vein thrombosis (DVT) of her left leg. CT of the chest with intravenous contrast showed a mass-like consolidation in the right upper lobe and thickening of the peripheral interlobular septa and of the bronchovascular bundles consistent with lymphangitic carcinomatosis (Figure 1). Endobronchial ultrasound (EBUS) guided transbronchial needle aspirations of the station 10 R Lymph node were positive for adenocarcinoma of lung origin. Lymphangitic carcinomatosis occurs when cancer cells spread along the pulmonary lymphatic system and result in thickening of the bronchovascular bundle, the interlobular septa, or both (1). Histopathologically, specimens show interlobular and subpleural interstitial desmoplastic thickening and obstruction of lymphatic vessels by tumor cells. It carries a poor prognosis.



Medical Image of the Week: Type A Aortic Dissection Extending Into Main Coronary Artery

By: Malik AO, Abela O, Ahsan C, Diep J

Abstract: No abstract available. Article truncated at 150 words. A 58-year-old woman with no significant past medical history, presented to the emergency department with complains of sudden onset, severe , non-radiating epigastric pain associated with nausea and vomiting. An electrocardiogram (EKG) done in emergency department showed ST segment elevation in the anterior leads (Figure 1). Blood pressure at presentation was 141/79, and she had symmetrical bilateral pulses of the upper extremities, no diastolic murmur, and no neurologic deficit. The patient was taken to catherization laboratory, for ST segment elevated myocardial infarction (STEMI). She was found have aortic dissection extending to the left main coronary artery (Figure 2). Cardiothoracic surgery was called immediately. Computed tomography angiogram (CTA) of the thoracic and abdominal aorta revealed Debakey type 1 aortic dissection. (Figure 3). The patient was taken to the operating room. Unfortunately, the patient suffered pulseless electrical activity (PEA) arrest during anesthesia induction from which she could not be revived. Aortic dissection …



Worst Places to Practice Medicine

By: Robbins RA

Abstract: No abstract available. Article truncated after 150 words. Medscape periodically publishes a “Best” and “Worst” places to practice medicine (1). We were struck by this year’s list because three of the five worst places to practice medicine are in the Southwest (Table 1). Table 1. Medscape’s “worst” places to practice medicine. 1. New Orleans, Louisiana; 2.     Phoenix, Arizona; 3. Las Vegas, Nevada; 4. Albuquerque, New Mexico; 5. Tulsa, Oklahoma. While Minneapolis rated the best place to practice, only 2 cities from the Southwest made the top 25 “Best” list-Salt Lake City at 13th and Colorado Springs at 24th. Most of the top 25 are from the Midwest or Northeast. None from California made the best places list and only the only Southern location was Virginia Beach, Virginia. Rankings resulted from the combination of twelve 50-state rankings: medical board actions per doctor; malpractice lawsuits per doctor; office-based primary care physicians per population; physician income; employer-based insurance rate per population …



The “Hidden Attraction” of Cardiac Magnetic Resonance Imaging for Diagnosing Pulmonary Embolism

By: Harhash AA, Cassuto J, Avery RJ, Kuo PH

Abstract: While various modalities exist for the diagnosis of pulmonary embolism (PE), CT pulmonary angiography (CTPA) is the most widely used and can establish the diagnosis quickly and reliably. We report a patient who presented with syncope who developed pulseless electrical activity (PEA) arrest in the emergency department. Given the presence of acute renal injury, CTA was felt to be contraindicated. A ventilation-perfusion lung (VQ) scan demonstrated low probability for PE; however, echocardiography revealed evidence for right heart strain. Subsequent cardiac magnetic resonance imaging (CMR) unexpectedly revealed a saddle PE. This case highlights the potential role for MR for the diagnosis of PE when high clinical suspicion is discordant with results of conventional imaging.



Medical Image of the Week: Pulmonary Vein Thrombosis

By: Vondrak J, Barbee B

Abstract: No abstract available. Article truncated at 150 words. A 71-year-old woman with chronic lymphocytic leukemia and remote left lower lobe pneumonectomy presented to the emergency department from an outpatient clinic with symptoms of cough, progressive shortness of breath, and fatigue for 2 weeks.  Pertinent physical examination findings included adequate oxygen saturation at room air, known II/VI systolic mitral murmur with radiation through the precordium, and a well-healed left lower lobe pneumonectomy scar.  Imaging was remarkable for acute pulmonary venous thrombosis (PVT) of the left inferior pulmonary vein with involvement of several tributary veins (Figures 1 and 2). Given the rarity of PVT, treatment guidelines have yet to be established (1); however, consensus appears to be systemic anticoagulation, thrombectomy, or resection (1-3).  Therefore, patient was initially placed on a heparin drip upon admission and was discharged on an oral anticoagulant. Pulmonary vein thrombosis (PVT) is a rare condition only described through case reports, that is potentially life threatening and …