Medical Image of the Week: Right Neck Mass with Thoracic Extension

Figure 1. Coronal MRI image showing cavitary lesion (1.9 cm, yellow arrow) in the right lower lobe and multiple enlarged mediastinal and hilar lymph nodes with the largest lymph node measuri 2 x 2.5 cm.

Figure 2. Coronal MRI image of neck showing ill-defined infiltrative mass (2.8 x 4.1 x 6.4 cm, yellow star) in the right lateral neck posterior to the sternocleidomastoid muscle and jugular vein.

Figure 3. Right upper lobe endobronchial lesion (yellow arrow).  Biopsy showed Coccidioides spherules.

Figure 4. Hematoxylin and eosin (upper panel) and Gomori's methenamine silver stain stains of 4R lymph node showing Coccidioides spherule.

A 28-year-old female with a history of chronic pancreatitis s/p total pancreatectomy and auto-islet cell transplantation developed a progressively enlarging right neck mass of 4 weeks duration. Coccidioides IgM antibodies were negative and IgG antibodies were positive by immunoassay (EIA), with titers 1:4 by complement fixation (CF).  Fine needle aspiration with subsequent excisional biopsy of the right neck mass was performed and showed reactive lymphoid hyperplasia without fungal elements.  Bronchoscopy with right upper lobe endobronchial biopsy and 4R lymph node endobronchial ultrasound-fine needle aspiration revealed granulomatous inflammation and Coccidioides spherules on Gomori's methenamine silver stain.  Fungal cultures from the right neck mass fine needle aspiration, endobronchial biopsy, and 4R lymph node grew Coccidioides after three weeks of culture.

Tauseef Afaq Siddiqi, MD¹

Candy Wong, MD¹

Robert Ricciotti, MD²

Afshin Sam, MD¹

¹ Department of Medicine, Section of Pulmonary, Allergy, Critical Care and Sleep Medicine 

² Department of Pathology

University of Arizona

Tucson, AZ 85724

Reference as: Siddiqi TA, Wong C, Ricciotti R, Sam A. Medical image of the week: right neck mass with thoracic extension. Southwest J Pulm Crit Care. 2013;6(5):196-8. PDF

Medical Image of the Week: Ascending Cholangitis from Biliary Obstruction

Figure 1 – Sagittal view of the gallbladder on ultrasound showing gallstone (red arrow).

Figure 2 – Cholangiogram showing multiple filling defects in the gallbladder (red arrowheads) and diffuse dilatation of the common bile duct to 16mm with no contrast flow into the duodenum (arrow), suggestive of distal obstruction.

A 79 year old man with a history of quadriplegia presented to an outside hospital in septic shock.  He was found to have an elevated total bilirubin of 10 mg/dL, direct bilirubin of 7 mg/dL, alkaline phosphatase of 405 U/L, and lipase of 370 U/L.  Imaging showed cholelithiasis with likely intra- and extrahepatic biliary duct dilatation.  The patient underwent placement of a biliary drain with clinical improvement.  Additional imaging was requested prior to endoscopic retrograde cholangiopancreatography (ERCP), but magnetic resonance cholangiopancreatography (MRCP) was unavailable due to metallic implants.  Interventional radiology performed a cholangiogram using the biliary drain which confirmed biliary obstruction.  ERCP was then performed, with significant biliary sludge found and two stents placed.

Candy Wong, MD¹, Preethi William, MD² and Gordon Carr, MD¹

¹Division of Pulmonary and Critical Care Medicine

²Department of Medicine

University of Arizona

Tucson, Arizona

Reference as: Wong C, William P, Carr G. Medical image of the week: ascending cholangitis from biliary obstruction. Southwest J Pulm Crit Care. 2013;6(4):187-8. PDF