January 2016 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 44 year-old man presented with refractory heart failure following the relatively asymptomatic detection of severe aortic regurgitation at auscultation 11 years earlier. When the valvular disease was discovered, the patient’s left ventricular ejection fraction was 25%. He underwent open aortic valvular replacement and his systolic function stabilized on medication in the years that followed, but eventually his cardiac function deteriorated further and he was listed for cardiac transplant.

As part of the pre – transplant evaluation frontal and lateral chest radiography (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 a relatively circumscribed opacity at the left base
2. The frontal chest radiograph shows abnormal mediastinal contours
3. The frontal chest radiograph shows basal predominant fibrotic abnormalities
4. The frontal chest radiograph shows large lung volumes with a cystic appearance
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. January 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;12(1):13-9. doi: http://dx.doi.org/10.13175/swjpcc001-16 PDF

Medical Image of the Week: Prozac Eyes

Figure 1. 60-second epoch shows the slow rolling eye movements (red arrow) and rapid eye movements (green arrows) seen during NREM stage 2 sleep.

A 59-year-old man with a past medical history significant for hypertension, obesity and depression underwent an overnight polysomnogram for high clinical suspicion for obstructive sleep apnea. His current medications include doxepin, fluoxetine, bupropion, ambien and amlodipine. A snapshot during NREM sleep is shown (Figure 1).

Fluoxetine (Prozac®) is a potent selective serotonin reuptake inhibitor (SSRI).“Omnipause” neurons in the brainstem inhibit saccadic eye movements. NREM eye movements result from the potentiation of serotonergic neurons that inhibit these neurons (1). These eye movements occur during all stages of NREM sleep. These atypical eye movements have been reported to be present with a lower incidence with use of other antidepressants, benzodiazepines and neuroleptics and they tend to persist even after discontinuation of the medication (2). The clinical significance of these eye movements is unknown.

Safal Shetty MD, Sarah Patel MD, Kenneth S. Knox MD

Section of Pulmonary, Allergy, Critical Care & Sleep Medicine

Banner University Medical Center

Tucson, AZ USA

References

1. Schenck CH, Mahowald MW, Kim SW, O'Connor KA, Hurwitz TD.Prominent eye movements during NREM sleep and REM sleep behavior disorder associated with fluoxetine treatment of depression and obsessive-compulsive disorder. Sleep. 1992;15(3):226-35. [PubMed]
2. Geyer JD, Carney PR, Dillard SC, Davis L, Ward LC. Antidepressant medications, neuroleptics, and prominent eye movements during NREM sleep. J Clin Neurophysiol. 2009;26(1):39-44. [CrossRef] [PubMed] 

Cite as: Shetty S, Patel S, Knox KS. Medical image of the week: prozac eyes. Southwest J Pulm Crit Care. 2015;11(6):284. doi: http://dx.doi.org/10.13175/swjpcc128-15 PDF