Medical Image of the Week: Chronic Bilateral Fibrocavitary Pulmonary Coccidioidomycosis

Figure 1. Chest x-ray showing bilateral upper lobe cavitation.

Figure 2. Thoracic computed tomography showed bilateral upper lobe, multiple thick-walled cavities with associated tree in bud opacities and consolidation in the right lower lobe.

Figure 3. Cytology of bronchoalveolar lavage fluid showing coccidioidomycosis spherules (arrows).

A 47-year-old Ethiopian immunocompetent male with no past medical history presented with cough and blood tinged sputum for 1 month with no fever, night sweats, or weight loss. Chest X-ray showed bilateral upper lobe cavitary lesions (Figure 1). Computed tomography of the chest showed bilateral upper lobe, multiple thick-walled cavities with associated tree-in-bud opacities and consolidation in the right lower lobe (Figure 2). TB was ruled out and a bronchoalveolar lavage (BAL) was performed. Cytology on the BAL showed the presence of Coccidioides immitis spherules (Figure 3). Serum coccidioidomycosis by complement fixation 1:64 with positive IgG by immunodiffusion; serum antigen by EIA 0.30; and urine antigen was negative. The patient was started on fluconazole and was discharged with pulmonology follow up. Bilateral cavitary lesions are rare and they can mimic the reactivation of M. tuberculosis, reinforcing the importance of including coccidioidomycosis in the differential diagnosis of bilateral cavitary lung lesions for patients in endemic areas.

Tarreq Noori MD*, Mohammed Al-Charakh MD*, and Andres Borja Alvarez MD**

Departments of Internal Medicine* and Pulmonology**

Maricopa Integrated Health System

Phoenix, AZ USA

Reference

1. Jude CM, Nayak NB, Patel MK, Deshmukh M, Batra P. Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings. Radiographics. 2014 Jul-Aug;34(4):912-25. [CrossRef] [PubMed]

Cite as: Noori T, Al-Charakh M, Alvarez AB. Medical image of the week: Chronic bilateral fibrocavitary pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2018;16(3):168-9. doi: https://doi.org/10.13175/swjpcc043-18 PDF

Medical Image of the Week: Paget-Schroetter Syndrome

Figure 1. Venous contrast study demonstrating thrombosis and flow obstruction at the thoracic outlet (arrow). 

A 22-year-old right-handed man developed acute swelling of his right upper extremity following a weekend of vigorous physical military training. There was no associated pain or numbness. Physical examination demonstrated edema of the right arm. Radial and ulnar pulses were intact, and neurological exam was normal. Venous doppler examination demonstrated thrombus in the subclavian-axillary venous system. A confirmatory venous contrast study was performed (Figure 1), followed by catheter directed lysis.  Effort related thrombosis of the subclavian vein secondary to mechanical compression at the thoracic outlet is known as Paget-Schroetter Syndrome (1). Current treatment commonly includes catheter directed clot lysis and an arbitrary three-month period of systemic anticoagulation, followed by surgical resection of the first rib (2). Post-operative balloon angioplasty of the involved venous segment improves long-term results (3). This patient underwent successful lysis, was discharged on oral rivaroxaban, and has been referred to thoracic surgery for consideration of rib resection.

Charles Van Hook MD and Ken Hirasaki MD

Longmont United Hospital

Longmont, Colorado USA

References

1. Kucher N. Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861-9.[CrossRef] [PubMed]
2. Engelberger RP, Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation. 2012;126:768-73. [CrossRef] [PubMed]
3. Illif KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 2010;51:1538-47. [CrossRef] [PubMed]

Cite as: Van Hook C, Hirasaki K. Medical image of the week: Paget-Schroetter syndrome. Southwest J Pulm Crit Care. 2018;16(3):156. doi: https://doi.org/10.13175/swjpcc031-18 PDF