July 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology 

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 40-year-old woman with a history of left breast malignancy diagnosed 11 years earlier, initially treated with lumpectomy, radiation, and chemotherapy (doxorubicin, cyclophosphamide, paclitaxel, followed by Herceptin), later treated with mastectomy following recurrence 2 years after diagnosis, presented with a several month history of upper respiratory infectious symptoms, including congestion, productive cough, and rhinorrhea. The patient also complained of some fatigue, although she was still active; she denied shortness of breath initially, but claimed that increasing breathlessness had developed more recently, limiting her exercise tolerance. The patient denied gastrointestinal, gynecological, musculoskeletal, or neurological complaints and no weight loss had occurred.

On admission to the hospital, her white blood cell count was mildly elevated at 14 x 10⁹ cells/L, with anemia as well (hemoglobin / hematocrit= 10 gm/dL / 28%, respectively). Her platelet count was also borderline decreased at 183 x 10⁹ cells/L. Electrolyte and liver panels showed normal values.

A frontal chest radiograph (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of six panels)

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows large lung volumes with a cystic appearance
4. The frontal chest radiograph shows mildly enlarged central pulmonary arteries
5. The frontal chest radiograph shows no abnormal findings

Reference as: Gotway MB. July 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(1):26-35. doi: http://dx.doi.org/10.13175/swjpcc090-15 PDF

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