Medical Image of the Week: Headcheese Sign

Figure 1. Representative image from thoracic CT scan showing ground glass opacities, most prominent in the lower lung fields bilaterally with air trapping.

A 95-year-old woman with a past medical history of breast cancer and mastectomy presented with fevers, cough productive of sputum and progressive dyspnea for 2 weeks. She denies any recent travel or sick contacts but has bird at home since last 10 years. She was afebrile but tachypneic with respiratory rate of 25 and sPO2 of 86% on room air. Her initial chest examination reveals coarse rhonchi in both lungs. Labs were significant for a sodium of 118 mEq/L, leukocytosis to 18,000 cells/mcL without peripheral eosinophilia. Arterial blood gas showed pO2 of 55 mm Hg, pCO2 of 48 mm Hg and pH of 7.44. An initial chest X-ray was positive for extensive bilateral pulmonary infiltrates predominantly in the mid and lower lungs with areas of airspace consolidation. Her urine Streptococcus pneumoniae antigen was negative as well as rapid influenza and a respiratory syncytial virus panel. The high resolution thoracic CT showed scattered ground glass opacities, most prominent in the lower lung fields bilaterally (Figure 1). Small more focal consolidative opacities are seen in the right upper lobe. As there was a juxtaposition of low, normal and high-attenuated area of CT scan, characteristic of the headcheese sign.

The head cheese sign is indicative of a mixed obstructive and infiltrative process (1). The low attenuated regions reflect air trapping suggestive of obstructive small airway disease and vasoconstriction due to hypoxia (2). Expiration CT may be needed to enhance low attenuation areas. This airway pathology leads to mosaic attenuation on HRCT. The most common cause of this radiological sign is hypersensitivity pneumonitis (3). As our patient had a long exposure to bird, it was probably the cause of her lung pathology. Other causes of the headcheese sign such as sarcoidosis, bronchiolitis, mycoplasma pneumonia or desquamative interstitial pneumonitis should be considered.

Learning Points:

1. Headcheese is a radiological sign suggestive of hypersensitivity pneumonitis as most common cause.
2. Occupation or any animal exposure history will be most useful in this scenario.
3. The clinician should rule out other causes such as an infectious etiology or sarcoidosis.

Ajay Adial MD, Danial Arshed MD, Lourdes Sanso MD, and Asma Iftikhar MD

Pulmonary/Critical Care Medicine

New York-Presbyterian/Queens

New York, NY USA

References

1. Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the image--the 2004 Fleischner lecture. Radiology. 2006 May;239(2):322-38. [CrossRef] [PubMed]
2. Hirschmann JV, Pipavath SN, Godwin JD. Hypersensitivity pneumonitis: a historical, clinical, and radiologic review. Radiographics. 2009 Nov;29(7):1921-38. [CrossRef] [PubMed]
3. Patel RA, Sellami D, Gotway MB, Golden JA, Webb WR. Hypersensitivity pneumonitis: patterns on high-resolution CT. J Comput Assist Tomogr. 2000 Nov-Dec;24(6):965-70. [CrossRef] [PubMed]

Cite as: Adial A, Arshed D, Sanso L, Iftikhar A. Medical image of the week: headcheese sign. Southwest J Pulm Crit Care. 2018;16(4):192-3. doi: https://doi.org/10.13175/swjpcc040-18 PDF 

Medical Image of the Week: Sarcoidosis

Figure 1. The AP supine chest radiograph depicts bilateral hilar calcified lymphadenopathy with characteristic popcorn appearance of the lymph nodes (white arrows).  Incidentally noted are a tunneled dialysis catheter terminating in the right atrium and median sternotomy wires from a previous coronary artery bypass graft surgery.

We present a 58-year-old African American man with a complicated medical history including long-standing sarcoidosis that has caused him chronic, unrelenting pain for two decades.  He initially underwent placement of an intrathecal morphine pump, but recently began complaining of increasing pain.  Consequently, he was seen at our hospital for interrogation of his pain pump by the interventional radiologist, and was incidentally noted to have bilateral calcified hilar lymphadenopathy on fluoroscopic imaging.  A dedicated chest x-ray confirmed the abnormality, which was consistent with his known diagnosis of sarcoidosis.

Sarcoidosis is a complex disease process characterized by noncaseous granulomas that can affect various organ systems, with pulmonary involvement in up to 90% of cases (1).  Though sarcoidosis is a diagnosis of exclusion, clinicians should recognize that bilateral hilar lymphadenopathy is highly concerning for the underlying noncaseating granulomatous disease (2).  The most common pattern of lymphadenopathy is well-defined, bilateral, symmetric hilar and right paratracheal lymph node enlargement. Bilateral hilar lymph node enlargement, alone or in combination with mediastinal lymph node enlargement, occurs in an estimated 95% of patients affected with sarcoidosis (1). Although bilateral hilar adenopathy may be a feature of other disease processes including infections (especially fungal or mycobacterium) and malignancy (metastases or lymphoma), sarcoidosis is the most common cause of bilateral hilar lymphadenopathy in the absence of specific clinical features of these processes. The enlarged lymph nodes eventually calcify, and the chronicity of the disease process directly correlates to hilar lymphadenopathy calcification, occurring in up to 20% of patients after 10 years (3).  Of note are the popcorn like calcifications within perihilar lymph nodes silhouetting the normal vascular anatomy (Figure 1).

Amrit Hansra, MD and Unni Udayasankar, MD

Department of Medical Imaging

University of Arizona

Tucson, AZ

References

1. Criado E, Sánchez M, Ramírez J, Arguis P, de Caralt TM, Perea RJ, Xaubet A. Pulmonary sarcoidosis: typical and atypical manifestations at high-resolution CT with pathologic correlation. Radiographics. 2010;30(6):1567-86. [CrossRef] [PubMed]
2. Baughman RP, Culver DA, Judson MA. A concise review of pulmonary sarcoidosis. Am J Respir Crit Care Med. 2011;183(5):573-81. [CrossRef] [PubMed]
3. Miller BH, Rosado-de-Christenson ML, McAdams HP, Fishback NF. Thoracic sarcoidosis: radiologic-pathologic correlation. Radiographics. 1995;15(2):421-37. [CrossRef] [PubMed]

Cite as: Hansra A, Udayasankar U. Medical image of the week: sarcoidosis. Southwest J Pulm Crit Care. 2016;12(2):62-3. doi: http://dx.doi.org/10.13175/swjpcc003-16 PDF