Medical Image of the Week: Healthcare-associated Pneumonia Secondary to Aspiration

Figure 1. Panel A: Axial computed-tomography image demonstrating a foreign body within the right main-stem bronchus, with consolidation and volume loss of right lung. Panel B: Coronal view.

Figure 2. Panel A: bronchoscopy revealing an ingested foreign body in the right main-stem bronchus. Panel B: forceps retrieval yielded a large piece of broccoli.

A 57 year-old bedbound paraplegic man developed a worsening productive cough after being hospitalized for several days. He was brought to the radiology suite for a CT scan of the chest, revealing a soft tissue density within his right main-stem bronchus, with volume loss of his right lung (Figure 1). Bronchoscopy was performed, yielding a 2 cm piece of broccoli, successfully removed with forceps (Figure 2). Culture from the bronchial aspirate was positive for Pseudomonas aeruginosa. The patient’s respiratory status dramatically improved after removal of the foreign body and commencement of pathogen-directed antibiotics. This study illustrates a dramatic example of healthcare-associated pneumonia (HCAP) secondary to aspiration, as described by the American Thoracic Society / Infectious Diseases Society of America (1).

Lavi Nissim MD, Sam Alnajjar MD and Edward Vivio RT

Phoenix Baptist Hospital

2000 W. Bethany Home Road

Phoenix, AZ 85015

Reference

1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]

Reference as: Nissim L, Alnajjar S, Vivio E. Medical image of the week: healthcare-associated pneumonia secondary to aspiration. Southwest J Pulm Crit Care. 2015;11(1):1-2. doi: http://dx.doi.org/10.13175/swjpcc065-15 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1: Panel A: Axial view of the thoracic CT angiography showing aortic dissection in descending aorta where the true lumen (yellow arrow) with outer-wall calcification (red arrow) as well as false lumen with contrast (orange arrow) is seen.  Panel B: Coronal view showing the true (T) and false (F) lumen.

An 85-year-old gentleman with the past medical history significant for hypertension, smoking, and coronary artery disease presented to the emergency department (ED) with complains of sudden onset of chest pain.  His pain was described as squeezing and radiating to the back, associated with nausea and vomiting. His chest pain improved with nitroglycerin in ED.  Chest x-ray showed a tortuous aortic knob and widened mediastinum.

He underwent a CT angiogram, which showed, Stanford Type B aortic dissection, from distal aortic arch to renal arteries (Figure 1).  He was managed in the hospital conservatively with tight blood pressure control given the type of dissection and no surgical intervention was done. He was uneventfully discharged with follow up arranged with vascular surgery.

Aortic dissection is classified by Stanford Criteria as Type A which involves the ascending aorta and arch and Type B when it involves the descending aorta. Type A dissection is a surgical emergency and guidelines suggest medical / non-surgical management for Type B dissection except in cases where the pain is not controlled despite BP control, acute expansion of the false lumen, peri-aortic hematoma or distal mal-perfusion.

Hem Desai MD¹, Aung Bajaj MD¹, Kamalani Hanamaikai MD¹ & Bhupinder Natt MD²

¹Department of Internal Medicine and the ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine  

University of Arizona

Tucson, AZ USA

References

1. LePage MA, Quint LE, Sonnad SS, Deeb GM, Williams DM. Aortic dissection: CT features that distinguish true lumen from false lumen. AJR Am J Roentgenol. 2001;177(1):207-11. [CrossRef] [PubMed]
2. von Kodolitsch Y, Nienaber CA, Dieckmann C, Schwartz AG, Hofmann T, Brekenfeld C, Nicolas V, Berger J, Meinertz T. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116(2):73-7. [CrossRef] [PubMed]

Reference as: Desai H, Bajaj A, Hanamaikai K, Natt B. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2015;10(6):348-9. doi: http://dx.doi.org/10.13175/swjpcc063-15 PDF