Medical Image of the Week: Coccidioidomycosis Pneumothorax

Figure 1. Right-sided pneumothorax (A) with subsequent placement of pigtail catheter and re-expansion of right lung (B).  CT shows bilateral multifocal airspace consolidation with nodules and cavitary interstitial disease (C).

Figure 2. PAP stain (A) and GMS stain (B) demonstrating Coccidioidomycosis from BAL (magnification, 400x).

A 36-year-old man with AIDS and disseminated coccidioidomycosis presented with severe right chest pain, shortness of breath, and a right-sided pneumothorax on CXR. A pigtail catheter was placed with near resolution of the pneumothorax. A bronchoscopy with bronchoalveolar lavage revealed spherules on cytology as well as coccidioidomycosis on culture. No other pathogens were identified. The pigtail catheter was removed three days later with resolution of the pneumothorax.

Rupture of subpleural coccidioidomycosis cavity into the pleural space resulting in pyopneumothorax and/or bronchopleural fistula is rare with reported rates of 1.4 – 2.6% for cavitary lesions (1).  Despite antiretroviral therapy and an undetectable viral load, disease was unresponsive to fluconazole.  Therapy was subsequently initiated with amphotericin B lipid complex, which resulted in significant improvement of his disease.

Ishna Poojary MD,  Christopher Geffre MD PhD,  Tirdad Zangeneh DO MA and Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference

1. Tiu CT, Cook J, Pineros DF, Rankin LF, Lin YS, Ghitan M, Brichkov I, Shaw JP, Chapnick EK. Pneumothorax in a young man in Brooklyn, New York. Clin Inf Dis. 2011;53(12);1296-7. [CrossRef] [PubMed] 

Reference as: Poojary I, Geffre C, Zangeneh T, Campion J. Medical image of the week: coccidioidomycosis pneumothorax. Southwest J Pulm Crit Care. 2013;7(4):251-2. doi: http://dx.doi.org/10.13175/swjpcc140-13 PDF

Medical Image of the Week: Pneumatosis Intestinalis Secondary to Massive Acute Blood Loss

Figure 1. Coronal view of a non-contrast CT scan demonstrating pneumatosis intestinalis of the distal small bowel, ascending colon, and superior mesenteric vein (arrows).

Figure 2. Transverse cross-section of severe pneumatosis secondary to acute blood loss intestinal ischemia (arrows).

The patient was a 32 year-old male with a past medical history significant for end stage liver disease secondary to severe alcoholism who was found with an altered mental status.  In the emergency department, the patient divulged he had been throwing up blood clots in the preceding days.  Shortly into his presentation he began throwing up voluminous bright red blood.  Initial hemoglobin concentration was 2.8 mg/dL.  CT scan of the abdomen revealed pneumatosis within the ascending colon, small bowel, and mesenteric veins.  Despite massive transfusion efforts and two episodes of successful cardiac resuscitation the patient expired.

Seth Assar, MD; Herman Solorzano; Ishna Poojari, MD; Maria del Carmen Luraschi Monjagatta, MD

The University of Arizona College of Medicine at South Campus, Tucson, Arizona

References

1. Pieterse AS, Leong AS, Rowland R. The mucosal changes and pathogenesis of pneumatosis cystoides intestinalis. Hum Pathol. 1983;16(7):683-8. [CrossRef]
2. Heng Y, Schuffler MD, Haggitt RC, Rohrmann CA. Pneumatosis intestinalis: a review. Am J Gastroenterol. 1995;90(10):1747.[PubMed] 

Reference as: Assar S, Solorzano H, Poojari I, Monjagatta MCL. Medical image of the week: pneumatosis intestinalis secondary to massive acute blood loss. Southwest J Pulm Crit Care. 2013;7(4): . doi: http://dx.doi.org/10.13175/swjpcc135-13 PDF