Medical Image of the Week: Atherosclerotic Aneurysm of Great Vessels

Figure 1.Unsual appearance of the aortic root with irregular contours and a 41 x 37mm dilatation at the level of the sinuses of Valsalva.

Figure 2. Saccular outpouchings of the intrathoracic great vessels.

Figure 3. Video of the MRI images of the intrathoracic vascular abnormalities.

A 60 year-old man with a 33 pack-year history of tobacco abuse, presented with difficulty speaking and voice change for several weeks. His review of systems was positive for fatigue, night sweats and weight loss. Physical exam of the oropharynx with flexible laryngoscopy demonstrated immobile bilateral true and false vocal cords fixed in the para-median position without laryngeal lesions. Concern for intra-thoracic process with recurrent laryngeal nerve involvement, a computed tomography (CT) of the chest and thoracic vessels demonstrated unusual appearing arteries with multiple penetrating atherosclerotic ulcers versus saccular aneurysms scattered throughout the aorta and its major branches (Figures 1 and 2). A magnetic resonance imaging (MRI) with contrast, demonstrated multiple foci of saccular outpouchings involving the arch vessels distal to their origins with the largest dilatation measuring 26 x 25 mm in the case of proximal innominate (Figure 3). Although imaging lacked resolution, it was specialist opinion that patient likely had compression of recurrent laryngeal nerve leading to vocal cord dysfunction without significant airway compromise.

Atherosclerotic aneurysms of the great vessels are rare with evidence limited to case series (1,2). Patient presentation varies dependent on the structures involved including embolic phenomenon from atherosclerosis. Surgical intervention with endovascular approach remains treatment of choice with good success rate.

Given our patient’s poor nutritional status, multiple co-morbidities and diagnosis of large colonic mass, risks of surgery outweighed benefits of intervention and thus outpatient follow up was recommended.

Faraz Jaffer, MD and Don Leo Pepito, MD

Department of Internal Medicine

Banner-University Medical Center – South

Tucson, AZ

References

1. Cury M, Greenberg RK, Morales JP, Mohabbat W, Hernandez AV. Supra-aortic vessels aneurysms: diagnosis and prompt intervention. J Vasc Surg. 2009;49(1):4-10. [CrossRef] [PubMed]
2. Kasashima F, Urayama H, Ohtake H, Watanabe Y.Intrathoracic aneurysm of the innominate and right subclavian arteries: report of a case. Surg Today. 2001;31(1):51-4. [CrossRef] [PubMed] 

Cite as: Jaffer F, Pepito DL. Medical image of the week: athersclerotic aneurysm of great vessels. Southwest J Pulm Crit Care. 2015;11(5):231-2. doi: http://dx.doi.org/10.13175/swjpcc104-15 PDF 

Medical Image of the Week: Cutaneous Coccidioidomycosis

Figure 1. Right distal anterior thigh. Fungal culture grew Coccidioides immitis from biopsy.

A 46-year-old Hispanic man with no known past medical history presents to his primary care physician for a progressively worsening “rash” located over his right thigh. Patient described the lesion as raised, scaly, and itchy. It has been “growing” for the past one year and started out as a small “pimple”. Patient denied any trauma to the effected region over this time period. Surgical history was significant for a splenectomy 15 years prior that was needed after a traumatic accident. He works in construction and lives in southern Arizona. He denied alcohol, tobacco and or illicit drug use. Patient has attempted to treat this skin lesion with over the counter hydrocortisone ointment with no relief. He denied any other associated symptoms including fever/chills, headache, vision changes, night sweats, weight loss, cough, shortness of breath, and or joint pains. Vital signs were stable upon presentation. Physical exam was entirely benign other than the isolated skin lesion shown above (Figure 1). It measured roughly 5cm at its greatest dimension and was located just superior the right knee on the anterior portion of the distal thigh. Nodularity was appreciated upon palpation but no tenderness was noted. Areas of erythema were non-blanching. Small satellite lesions were seen on the perimeter.

He was sent to a dermatologist and biopsies were performed. Light microscopy and culture confirmed the diagnosis of cutaneous coccidioidomycosis. Initial laboratory work revealed a normal complete blood count and complete metabolic panel. Serum coccidioides IgM antibody was negative but IgG was confirmed to be positive with a reflex complement fixation titer of 1:16. Chest X-ray was normal. Patient was started on oral fluconazole 400mg daily. Repeat coccidioides IgG titers decreased to 1:8 at a four- week follow-up. Patient has been tolerating the medication well and skin lesion has begun to regress.

Norman Beatty MD¹ and Mayar Al Mohajer MD²

¹Departments of Internal Medicine and ²Infectious Diseases

University of Arizona College of Medicine

Tucson, AZ

Cite as: Beatty N, Al Mohajer M. Medical image of the week: cutaenous coccidioidomycosis. Southwest J Pulm Crit Care. 2015;11(5):226-7. doi: http://dx.doi.org/10.13175/swjpcc110-15 PDF