Medical Image of the Week: Thoracic Splenosis

Figure 1. A: Axial CT of the chest without intravenous contrast demonstrates a cluster of soft tissue nodules adjacent to the left posterior hemi-diaphragm (blue arrows). B: Axial CT of the chest without intravenous contrast demonstrates absence of the spleen and a surgical clip (blue arrow) consistent with a prior splenectomy.

Figure 2. Fused technetium 99m-label sulfur colloid uptake study and axial CT of the chest without intravenous contrast demonstrates uptake of radiotracer in the previously seen soft tissue nodules adjacent to the posterior aspect of the left hemi-diaphragm (red arrows) which confirms the diagnosis of thoracic splenosis.

A 38-year-old man with a history of a motor vehicle collision about 20 years prior to presentation which resulted in multiple left-sided rib fractures, a left-sided pneumothorax requiring chest tube placement, and a high-grade splenic laceration necessitating an emergent splenectomy that presents to outpatient pulmonary clinic for evaluation of pulmonary nodules at the request of his primary care physician. He is asymptomatic. He has a 20-pack-year of smoking history and currently smokes 6 cigarettes per day. He denies any significant exposures or recent infections. He has a family history significant for heart disease and depression, but no history of malignancy. His vital signs and physical examination are normal. He had a CT of the chest performed with representative images from the study shown in Figure 1.

A nuclear medicine scan was subsequently requested which demonstrated uptake of the technetium 99m-labeled sulfur colloid in the soft tissue nodules adjacent to left hemi-diaphragm (Figure 2) confirming the diagnosis of thoracic splenosis. No further treatment or diagnostic work up was required.

Splenosis is defined as auto-transplantation of splenic tissue following traumatic or surgical disruption of the spleen. Splenosis usually occurs in the abdomen, most commonly in the left upper quadrant (1,2). However, with disruption of the diaphragm in the setting of trauma, splenic tissue can migrate into the thoracic cavity, and most often settles in the inferior, posterior left pleural space (as in our patient).  The diagnosis of thoracic splenosis should be suspected when one sees left basilar pleural nodules/masses in the setting of a previous trauma necessitating a splenectomy. A technetium 99m-labeled sulfur colloid study will demonstrate uptake of the radiotracer in the auto-transplanted splenic tissue as this radiotracer has a strong affinity for tissue arising from the reticuloendothelial system.

Gregory Gardner MD¹, Kevin Breen¹, Tammer Elaini MD², and Tiffany Ynosencio MD²

¹Department of Internal Medicine

²Division of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Khosravi MR, Margulies DR, Alsabeh R, Nissen N, Phillips EH, Morgenstern L. Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury. Am Surg. 2004 Nov;70(11):967-70. [PubMed]
2. Rosado-de-Christenson ML, Abbott GF. Diagnostic Imaging: Chest. 2^nd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 30-1.

Cite as: Gardner G, Breen K, Elaini T, Ynosencio T. Medical image of the week: thoracic splenosis. Southwest J Pulm Crit Care. 2018;16(5):285-6. doi: https://doi.org/10.13175/swjpcc066-18 PDF

Medical Image of the Week: Valley Fever Cavity with Fungus Ball

Figure 1. Chest x-ray taken in 2004 showing pulmonary nodule (arrows).

Figure 2. A: Thoracic CT scan in lung windows from 2004 showing the pulmonary nodule with cavitation. B: CT scan from 2007 showing thin-walled cavity. C: CT scan from 2008 showing fungus ball inside the cavity.  D: CT scan from 2010 showing the continued presence of the fungus ball inside the cavity.

A 72-year-old man was seen in 2010 because of hemoptysis. In 2004 a routine chest x-ray discovered a new pulmonary nodule (Figure 1, Figure 2A). Coccioidomycosis by complement fixation and IgM were negative but IgG was elevated at 0.203 (upper limit of normal 0.150).  A transthoracic needle biopsy revealed a granuloma without malignancy and no growth of any organisms. He was followed because he was asymptomatic. He remained asymptomatic but developed a thin-walled cavity (Figure 2B). However, beginning in 2008 he developed a cough with occasional hemoptysis. His thoracic CT scan was repeated and was interpreted as showing findings consistent with a fungus ball (Figure 2C). He was treated with fluconazole for about 6 months but his hemoptysis persisted and therapy was switched to itraconazole. His hemoptysis persisted although it was somewhat improved. A repeat CT scan performed in 2010 (Figure 2D) continued to show the fungus ball. He was referred to pulmonary and bronchoscopy revealed no other source of the hemoptysis; stains and cultures were negative; and he was referred to thoracic surgery for resection.

Hemoptysis from coccioidomycosis is unusual and should prompt a search for other causes (1). These could include bronchitis, malignancy, or rarely, a fungus ball as in our case. When hemoptysis is present with a fungus ball, treatment with fluconazole, itraconazole or amphotericin B is often advised although descriptions are limited to case reports. When hemoptysis persists despite drug therapy, resection of the cavity has been performed (2).

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Reference

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):238-49. [CrossRef]
2. Thadepalli H, Salem FA, Mandal AK, Rambhatla K, Einstein HE.Pulmonary mycetoma due to Coccidioides immitis. Chest. 1977 Mar;71(3):429-30. [PubMed]

Cite as: Robbins RA. Medical image of the week: valley fever cavity with fungus ball. Southwest J Pulm Crit Care. 2018;16(5):281-2. doi: https://doi.org/10.13175/swjpcc064-18 PDF