Medical Image of the Week: Pembrolizumab-induced Pneumonitis

By: Gotway MB

Abstract: No abstract available. Article truncated after 150 words. A 76-year-old man with metastatic melanoma, undergoing treatment with pembrolizumab, an antibody against programmed cell death 1 (PD-1), beginning 8 months ago developed low-grade fever, non-productive cough, and shortness of breath. A thoracic CT scan showed multifocal, bilateral extensive lung opacities (Figure 1). The patient underwent bronchoscopy with bronchoalveolar lavage which showed non-specific inflammatory changes associated with foci of organizing pneumonia. Microbiologic studies, including Coccioides antibody enzyme immunoassay and Aspergillus antigen, were negative. The patient was begun on corticosteroid therapy for presumed medication-induced pulmonary injury, manifestation as an organizing pneumonia pattern, due to pembrolizumab. Over the ensuing months, his symptoms abated and his CT scan abnormalities regressed (Figure 2). Organizing pneumonia may occur as an idiopathic, primary pulmonary process, often referred to as “cryptogenic organizing pneumonia,” or may occur in the context of a number of systemic conditions, a situation often referred to as secondary organizing pneumonia. Among the various …

URL: http://www.swjpcc.com/imaging/2017/9/20/medical-image-of-the-week-pembrolizumab-induced-pneumonitis.html 

Medical Image of the Week: Asbestos Related Pleural Disease

By: Hunter W, Arteaga V, Palacio D

Abstract: Pleural plaques are strongly associated with inhalational exposure to asbestos (1). The lesions may take up to thirty years to develop. Plaques are typically bilateral, involve the parietal pleura, commonly along the sixth through ninth ribs and are usually absent at the lung apices and costophrenic sulci (Figures 1 and 3). On chest radiograph, the “holly leaf sign” refers to the shape of the calcifications with thickened rolled and nodular edges (Figure 2). The plaques per se are benign in nature. However, they can potentially impair lung function, resulting in restriction.  They are also markers of the individual’s greater risk of developing a lung cancer or mesothelioma.

URL: http://www.swjpcc.com/imaging/2017/9/13/medical-image-of-the-week-asbestos-related-pleural-disease.html 

Medical Image of the Week: Fast-growing Primary Malignant Mediastinal Mixed Germ Cell Tumor

By: Tian Y, Pak S, Nai Q

Abstract: No abstract available. Article truncated after 150 words. A 28-year-old man presented with progressive hemoptysis for two weeks. He had fever, cough, and night sweats for one month prior to admission that was treated as inflenza, bronchitis and/or pneumonia. He had started to experience anorexia, dysphagia, fatigue, a 30-pound weight loss, panic attacks, and the new onset of hypertension during the 3 months prior to admission. He also had intermittent middle chest pain that was aggravated by coughing for 5 months, but a cardiac catherization two months prior failed to show an abnormality. The chest x-ray and CT scan on this admission demonstrated a 15 cm large anterior mediastinal mass exerting a mass effect on the heart and medistial lymphadenopathy (Figure 1-B,C,D) which were absent on a chest x-ray performed 3 months prior to admission (Figure 1A). Core biopsy and immunohistochemical staining revealed a mixed germ cell tumor with components of seminoma and yolk-sac tumor. He was started …

URL: http://www.swjpcc.com/imaging/2017/9/6/medical-image-of-the-week-fast-growing-primary-malignant-med.html 

September 2017 Imaging Case of the Month

By: Gotway MB

Abstract: No abstract available. Article truncated after first page. Clinical History: A 48-year-old woman with no previous medical history presented with complaints of intermittent cough persisting several months following a recent upper respiratory tract infection. No hemoptysis was noted. Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. Upon close inspection, the right thorax appeared slightly asymmetrically smaller than the left. Laboratory evaluation was unremarkable. Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Frontal and lateral chest radiography (Figure 1) was performed. Which of the following statements regarding the chest radiograph is most accurate? 1. The chest radiograph shows asymmetric reticulation and interlobular septal thickening; 2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes; 3. The chest radiograph shows large lung volumes; 4. The chest radiograph shows multifocal consolidation and pleural effusion; 5. The chest radiograph shows small cavitary pulmonary nodules. …

URL: http://www.swjpcc.com/imaging/2017/9/5/september-2017-imaging-case-of-the-month.html 

September 2017 Critical Care Case of the Month

By: Dean JT III, Shackelford TR, Boivin M

Abstract: No abstract available. Article truncated at 150 words. A 73-year-old man presented with a three-day history of diffuse abdominal pain, decreased urine output, nausea and vomiting. His past medical history included diabetes, coronary artery disease, hypertension and chronic back pain. The patient reported being started on hydrochlorothiazide, furosemide, pregabalin and diclofenac within the last week in addition to his long-standing metformin prescription. Initial vitals were significant for tachypnea, tachycardia to 120 bpm, hypothermia to 35ºC and hypotension with a blood pressure of 70/40 mm Hg. Physical exam was remarkable for bilateral lung wheezing and significant respiratory distress. Laboratory examination was concerning for a pH of 6.85, pCO2 of < 5mmHg, serum lactate of 27mmol/l, WBC of 15.6 x106 cells/cc and a serum creatinine of 8.36 mg/dl. A chest X-ray showed evidence of mild pulmonary edema and a CT of the abdomen did not show any acute pathology. What is the most likely etiology of the patient’s severe acidosis? …

URL: http://www.swjpcc.com/critical-care/2017/9/2/september-2017-critical-care-case-of-the-month.html