July 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

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: 0.75 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 completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options 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, 2017-December 31, 2018

Clinical History: An 81–year old non-smoking woman presented with complaints of shortness of breath for one month, more so when laying down. The patient had a history of Sjögren syndrome established 13 years earlier. She notes a history of dryness of the eyes and upper airways. Her medications included 5 mg prednisone daily as well as various vitamins and supplements. While she complained of several medication “allergies,” none were serious and most appeared to represent side effects or untoward reactions to medications as opposed to true allergic reactions. Her past medical history included arthritis, possible obstructive sleep apnea, kidney stones, and orthostatic hypotension, the latter thought to be related to her Sjögren syndrome. Her surgical history included a sternotomy for thymoma resection years earlier.

Her physical examination was unremarkable except for diminished breath sounds at the left base; her vital signs were within normal limits.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) & lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the chest radiographic findings? (click on the correct answer to be directed to the second of eleven pages)

1. Chest radiography shows an elevated left hemidiaphragm
2. Chest radiography shows bibasilar fibrotic-appearing opacities
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows multifocal bronchiectasis
5. Chest radiography shows small pulmonary nodules

Cite as: Gotway MB. July 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;17(1):15-27. doi: https://doi.org/10.13175/swjpcc086-18 PDF 

Medical Image of the Week: Intracavitary View of Mycetoma

Figure 1. Thoracic CT scan shows Monod’s sign, a mycetoma within an existing cavity, in the left upper lobe.

Figure 2. A: Current thoracic CT scan. B: thoracic CT scan 8 months earlier.

Figure 3. Bronchoscopic views of the cavity with intracavitary mycetoma in the left upper lobe.

A 46-year-old Hispanic man with no medical history presents to the pulmonary service for a second opinion regarding his unresolved pneumonia that initially presented as fever and cough; he did not have hemoptysis. He was found to have left upper lobe cavitary lesion and had been diagnosed with Aspergillus multiple times, with the initial diagnosis one year prior to presentation. He was seen by an outside pulmonologist and was placed on voriconazole 200 mg/day. Since being on the voriconazole he has not been feeling better. He continued to note symptoms of productive cough, fatigue, and weakness. Monod’s sign (Figure 1) is appreciated on CT imaging during initial encounter at an outside facility. Comparison of parenchymal damage is seen in Figure 2 comparing CT scans 8 months apart. Patient’s fungal cavity was appreciated on bronchoscopic exam (Figure 3). Ultimately, he was evaluated by cardiothoracic surgery and underwent a left upper lobectomy which he tolerated well.

Aspergillomas present as a mycetoma within an existing cavity. Monod’s sign is the radiographic finding of a mycetoma within the existing cavity as evidenced in the CT scan. This is not to be confused with the air-crescent sign which is seen more often with invasive aspergillosis, a separate clinical entity. This case is unique given its unique radiographic sign along with the visualization of fungal cavity from within through the bronchoscope.

Steve Tseng, DO and Raed Alalawi, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

References

1. Pesle GD, Monod O. Bronchiectasis due to aspergilloma. Dis Chest. 1954;25(2):172-183. [PubMed]
2. Thompson BH, Stanford W, Galvin JR, Kurihara Y. Varied radiologic appearances of pulmonary aspergillosis. Radiographics. 1995 Nov;15(6):1273-84. [CrossRef] [PubMed]

Cite as: Tseng S, Alalawi R. Medical image of the week: Intracavitary view of mycetoma. Southwest J Pulm Crit Care. 2018;16(6):360-1. doi: https://doi.org/10.13175/swjpcc082-18 PDF