Imaging

Last 50 Imaging Postings

(Most recent listed first. Click on title to be directed to the manuscript.)

July 2025 Medical Image of the Month: A Case of Severe Hiatal Hernia
   Presenting as Atypical Chest Pain 
July 2025 Imaging Case of the Month: A Growing Lung Nodule in a 
   Patient with Heart Disease
June 2025 Medical Image of the Month: Neurofibromatosis-Associated Diffuse
   Cystic Lung Disease
May 2025 Medical Image of the Month: Aspirated Dental Screw
April 2025 Medical Image of the Month: An Unfortunate Case of Mimicry
March 2025 Medical Image of the Month: An Unusual Case of Pulmonary
   Infarction
February 2025 Medical Image of the Month: Unexpected Complications of
   Transjugular Intrahepatic Portosystemic Shunt (TIPS) 
February 2025 Imaging Case of the Month: A Wolf in Sheep’s Clothing
January 2025 Medical Image of the Month: Psoriasis with Pulmonary
   Involvement
December 2024 Medical Image of the Month: An Endobronchial Tumor
November 2024 Medical Image of the Month: A Case of Short Telomeres
November 2024 Imaging Case of the Month: A Recurring Issue
October 2024 Medical Image of the Month: Lofgren syndrome with Erythema
   Nodosum
September 2024 Medical Image of the Month: A Curious Case of Nasal
   Congestion
August 2024 Image of the Month: Lymphomatoid Granulomatosis
August 2024 Imaging Case of the Month: An Unexplained Pleural Effusion
July 2024 Medical Image of the Month: Vocal Cord Paralysis on PET-CT 
June 2024 Medical Image of the Month: A 76-year-old Man Presenting with
   Acute Hoarseness
May 2024 Medical Image of the Month: Hereditary Hemorrhagic
   Telangiectasia in a Patient on Veno-Arterial Extra-Corporeal Membrane
   Oxygenation
May 2024 Imaging Case of the Month: Nothing Is Guaranteed
April 2024 Medical Image of the Month: Wind Instruments Player Exhibiting
   Exceptional Pulmonary Function
March 2024 Medical Image of the Month: Sputum Cytology in Patients with
   Suspected Lung Malignancy Presenting with Acute Hypoxic Respiratory
   Failure
February 2024 Medical Image of the Month: Pulmonary Alveolar Proteinosis
   in Myelodysplastic Syndrome
February 2024 Imaging Case of the Month: Connecting Some Unusual Dots
January 2024 Medical Image of the Month: Polyangiitis Overlap Syndrome
   (POS) Mimicking Fungal Pneumonia 
December 2023 Medical Image of the Month: Metastatic Pulmonary
   Calcifications in End-Stage Renal Disease 
November 2023 Medical Image of the Month: Obstructive Uropathy
   Extremis
November 2023 Imaging Case of the Month: A Crazy Association
October 2023 Medical Image of the Month: Swyer-James-MacLeod
   Syndrome
September 2023 Medical Image of the Month: Aspergillus Presenting as a
   Pulmonary Nodule in an Immunocompetent Patient
August 2023 Medical Image of the Month: Cannonball Metastases from
   Metastatic Melanoma
August 2023 Imaging Case of the Month: Chew Your Food Carefully
July 2023 Medical Image of the Month: Primary Tracheal Lymphoma
June 2023 Medical Image of the Month: Solitary Fibrous Tumor of the Pleura
May 2023 Medical Image of the Month: Methamphetamine Inhalation
   Leading to Cavitary Pneumonia and Pleural Complications
April 2023 Medical Image of the Month: Atrial Myxoma in the Setting of
   Raynaud’s Phenomenon: Early Echocardiography and Management of
   Thrombotic Disease
April 2023 Imaging Case of the Month: Large Impact from a Small Lesion
March 2023 Medical Image of the Month: Spontaneous Pneumomediastinum
   as a Complication of Marijuana Smoking Due to Müller's Maneuvers
February 2023 Medical Image of the Month: Reversed Halo Sign in the
   Setting of a Neutropenic Patient with Angioinvasive Pulmonary
   Zygomycosis
January 2023 Medical Image of the Month: Abnormal Sleep Study and PFT
   with Supine Challenge Related to Idiopathic Hemidiaphragmatic Paralysis
December 2022 Medical Image of the Month: Bronchoesophageal Fistula in
   the Setting of Pulmonary Actinomycosis
November 2022 Medical Image of the Month: COVID-19 Infection
   Presenting as Spontaneous Subcapsular Hematoma of the Kidney
November 2022 Imaging Case of the Month: Out of Place in the Thorax
October 2022 Medical Image of the Month: Infected Dasatinib Induced
   Chylothorax-The First Reported Case 
September 2022 Medical Image of the Month: Epiglottic Calcification
Medical Image of the Month: An Unexpected Cause of Chronic Cough
August 2022 Imaging Case of the Month: It’s All About Location
July 2022 Medical Image of the Month: Pulmonary Nodule in the
   Setting of Pyoderma Gangrenosum (PG) 
June 2022 Medical Image of the Month: A Hard Image to Swallow
May 2022 Medical Image of the Month: Pectus Excavatum
May 2022 Imaging Case of the Month: Asymmetric Apical Opacity–
   Diagnostic Considerations
April 2022 Medical Image of the Month: COVID Pericarditis
March 2022 Medical Image of the Month: Pulmonary Nodules in the
   Setting of Diffuse Idiopathic Pulmonary NeuroEndocrine Cell Hyperplasia
   (DIPNECH) 
February 2022 Medical Image of the Month: Multifocal Micronodular
   Pneumocyte Hyperplasia in the Setting of Tuberous Sclerosis
February 2022 Imaging Case of the Month: Between A Rock and a
   Hard Place
January 2022 Medical Image of the Month: Bronchial Obstruction
   Due to Pledget in Airway Following Foregut Cyst Resection

 

For complete imaging listings click here

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

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Wednesday
Jul022025

July 2025 Medical Image of the Month: A Case of Severe Hiatal Hernia Presenting as Atypical Chest Pain 

Figure 1. Portable AP chest x-ray demonstrates a heart size at the upper limits of normal with left pericardiac pulmonary opacity and opacity in the left retrocardiac region, likely related to a large hiatal hernia. To view Figure 1 in a separate, enlarged window click here

 

Figure 2. Coronal (A,B) and axial (C) reconstructions from a CT of the Abdomen and Pelvis with IV contrast performed at time of admission demonstrates a large hiatal hernia with an intrathoracic debris-filled stomach (*) and a small diaphragmatic hernia neck (arrows).  Also note areas of myocardial thinning and decreased enhancement in the LV apex (arrowheads) consistent with the patient’s history of prior myocardial infarction. To view Figure 2 in a separate, enlarged window click here

A 73-year-old woman with a past medical history including coronary artery disease (CAD), prior myocardial infarction (MI), cardiomyopathy, hypertension, obstructive sleep apnea (OSA) on CPAP, gastroesophageal reflux disease (GERD),and a history of pulmonary embolism on apixaban presented to the emergency department with six hours of chest pain. She described the pain as pressure-like, radiating from beneath the left breast to the left axilla and back. She also reported associated nausea without vomiting and poor oral intake but maintained normal bowel movements. She denied fever, chills, dyspnea, vomiting, diarrhea, constipation, or abdominal pain. The patient recalled a similar episode during her MI ten years prior, prompting her to seek medical care.

Vital signs were stable. Cardiac workup included serial troponins, both of which were negative (at 8 and 7 respectively), and an electrocardiogram (EKG) showing normal sinus rhythm without ST-T wave abnormalities. Chest x-ray (Figure 1) demonstrated a retrocardiac opacity suggestive of a hiatal hernia. Medical management included Maalox 30 mL, famotidine 20 mg, ondansetron 4 mg, metoclopramide 10 mg, IV acetaminophen 1 g, and IV morphine 4 mg. A CT scan of the abdomen and pelvis with contrast (Figure 2) revealed a large hiatal hernia containing the majority of the stomach and a small diaphragmatic hernia, raising concern for partial gastric obstruction. There was also mild gastric wall edema and several fluid-filled loops of small bowel with mild thickening, suggestive of possible enteritis. The patient was made NPO, and a nasogastric tube was inserted to low intermittent suction. General surgery was consulted, and cardiology assessed her to be at intermediate risk for surgery. On hospital day six, she underwent a successful robotic-assisted laparoscopic paraesophageal hernia repair with gastropexy.

Hiatal hernias are classified into four types. Type IV is the rarest and most complex, characterized by herniation of the stomach and additional abdominal organs such as the colon, small bowel, into the thoracic cavity through a widened diaphragmatic hiatus (1). This type is more prevalent in older adults due to progressive weakening of the phrenoesophageal membrane and chronic intra-abdominal pressure (2). Unlike type I sliding hernias, type IV hernias frequently present with obstructive symptoms, such as chest pain, nausea, and vomiting, and carry a high risk for complications like volvulus or strangulation. Minimally invasive approaches, including laparoscopic or robotic-assisted hernia reduction, crural closure, and gastropexy or fundoplication, are associated with favorable outcomes (3).

Varshita Goduguchinta DO, Raahi Patel DO, Ahmed Al-Mubaid MD, Mohammed Hammad MD

Department of Internal Medicine - Franciscan Health, Olympia Fields, IL

References

  1. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601-16. [CrossRef] [PubMed]
  2. Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg. 2005 Jan;241(1):185-93. [CrossRef] [PubMed]
  3. Mertens AC, Tolboom RC, Zavrtanik H, Draaisma WA, Broeders IAMJ. Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center. Surg Endosc. 2019 Jul;33(7):2152-2161. [CrossRef} [PubMed]

Cite as: Goduguchinta V, Patel R, Al-Mubaid A, Hammad M. July 2025 Medical Image of the Month: A Case of Severe Hiatal Hernia Presenting as Atypical Chest Pain. Southwest J Pulm Crit Care Sleep. 2025;31(1):12-13. doi: https://doi.org/10.13175/swjpccs015-25 PDF

Tuesday
Jul012025

July 2025 Imaging Case of the Month: A Growing Lung Nodule in a Patient with Heart Disease

Michael T. Stib MD

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

Phoenix, Arizona USA

Clinical History: A 36-year-old woman with a history of unspecified anemia, treated with occasional iron infusion, and Hashimoto thyroiditis presented to the Emergency Room with complaints of chest pain, sharp and non-radiating worsening in the supine position and improving with sitting upright and leaning forward, blurred vision, bilateral upper extremity weakness and numbness, and intermittent subjective low-grade fever. These symptoms had been present for about 1 month prior to presentation in the Emergency Room.

The patient’s past medical history was otherwise unremarkable. She is a 20-pack-year smoker with no allergies. Her past surgical history was remarkable only for bilateral breast augmentation, tonsillectomy, and 2 C-sections. Her only medications included a multivitamin and vitamin D3 supplementation.

The patient’s vital signs included a blood pressure of 115/71 mmHg, a pulse rate of 95 / minute, a respiratory rate of 18 / minute and a temperature of 38.4°C. Pulse oximetry on room air was 96%. The patient’s weight was 83.4 kg. The physical examination was largely unremarkable aside from possible symmetric bilateral upper extremity weakness (3/5). Deep tendon reflexes were normal and symmetric bilaterally. In particular, the breath sounds were normal bilaterally.

A complete blood count showed a mildly decreased white blood cell count at 3.3 x 109/L (normal, 3.4 – 9.6 x 109/L), with a mildly decreased absolute neutrophil count of 1.4 x 109/L (normal, 1.5 – 7 x 109/L). Her lymphocytes were decreased at 0.71 (normal, 1 – 3.4 x 109/L), but peripheral eosinophilia (30%) was present, and her absolute eosinophil count was elevated at 1.07 x 109/L (normal, 0.0 – 0.4 x 109/L). Her hemoglobin and hematocrit values were mildly decreased at 11.4 gm/dL (normal, 13.5 – 17.5 gm/dL) and 32.3 % (normal, 38.8 – 50%). The platelet count was mildly decreased at 77 x 109/L (normal, 149 – 375 x 109/L). The patient’s serum chemistries, including glucose, electrolytes (including calcium), and liver function studies were normal. The urinary drug toxicity screen and pregnancy test were negative, and coagulation parameters were normal. The thyroid stimulating hormone level was within the normal range. The D-Dimer level was elevated at 2.04 mcg/mL (normal, 0 – 0.49 mcg/mL), and her fibrinogen level was elevated at 654 ng/dL (normal, 200-393 ng/dL).  Her troponin-T level was also elevated at 0.124 ng/mL (normal, ≤0.01 ng/mL). Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal and lateral chest radiography shows a normal heart size and normal lung volumes. To view Figure 1 in a separate, enlarged window click here.

Which of the following statements regarding this chest radiograph is most accurate? (Click on the correct answer to be directed to the 2nd of 17 pages)

  1. The frontal and lateral chest radiograph shows no abnormal findings
  2. The frontal and lateral chest radiograph shows basal predominant fibrotic abnormalities
  3. The frontal and lateral chest radiograph shows large lung volumes with a cystic appearance
  4. The frontal and lateral chest radiograph shows an ill-defined opacity projected over the left base
  5. The frontal and lateral chest radiograph shows abnormal mediastinal contours
Cite as: Stib MT, Gotway MB. July 2025 Imaging Case of the Month: A Growing Lung Nodule in a Patient with Heart Disease. Southwest J Pulm Crit Care Sleep. 2025;31(1):1-11. doi: https://doi.org/10.13175/swjpccs017-25 PDF