March 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: 0.25 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 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: A 56-year-old woman with no significant past medical history underwent routine breast imaging (MRI) which showed an abnormality outside the breast (images not shown). She has a sister with recently-diagnosed breast malignancy. The patient smoked for 30 years, quitting 10 years ago. Her surgical history is remarkable only for a tubal ligation and hysterectomy, and she is asymptomatic. Her medications consist only of vitamins and supplements.

Laboratory evaluation showed a normal complete blood count, electrolyte panel, and liver function tests. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest imaging.

Which of the following represents the most accurate assessment of the frontal chest imaging findings? (Click on the correct answer to proceed to the second of ten pages)

1. Chest frontal imaging shows a focal right lung nodule
2. Chest frontal imaging shows basilar fibrosis
3. Chest frontal imaging shows mediastinal and peribronchial lymphadenopathy
4. Chest frontal imaging shows multiple, bilateral small nodules
5. Chest frontal imaging shows normal findings

Cite as: Gotway MB. March 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(3):126-37. doi: https://doi.org/10.13175/swjpcc041-18 PDF 

Medical Image of the Week: Acute Pneumonitis Secondary to Boric Acid Exposure

Figure 1. Panel A: A normal baseline chest radiograph obtained a few months prior to the current presentation. Panel B: A chest radiograph obtained at the day of admission with respiratory distress post exposure to boric acid powder that shows diffuse hazy opacities of the lungs. Panel C: Representative image form thoracic computed tomography obtained on day of admission shows extensive diffuse central predominant ground glass opacification. Panel D: A chest radiograph obtained 3 days after large dose of systemic steroid given for a presumptive diagnosis of acute pneumonitis. Rapid improvement of the bilateral airspace disease is suggestive of resolving inflammation.

Figure 2. Video of thoracic computed tomorgraphy in lung windows obtained on the day of admission.

A 33-year-old man presented with acute severe dyspnea and pleuretic chest pain one day after accidental inhalational exposure to boric acid powder. The patient was spraying boric acid in his apartment to kill bugs and he got trapped in a poorly ventilated area with a cloud of the dusted boric acid for more than a minute. He did not feel any significant symptoms initially. Overnight he started to develop shortness of breath and chest tightness. The patient visited an urgent care where he was reassured due to normal chest radiograph and was given a course of oseltamivir empirically due to a widespread influenza epidemic. After a few hours the patient’s symptoms got much worse and he presented to the emergency department with severe pleuretic chest pain and respiratory distress. The patient required 5 liters of oxygen to keep his saturation above 90%. His chest images showed extensive bilateral airspace disease suggestive of either pulmonary edema, multifocal pneumonia or inflammatory pneumonitis. His microbiologic work up was negative including influenza PCR. Echocardiogram was normal. With his recent exposure to boric acid inhalation an acute chemical pneumonitis was suspected. The patient received systemic high dose prednisone for 3 days and he improved significantly clinically and on imaging. His oxygen saturation was 97% on room air 4 days post admission.

Boric acid is an odorless partially water-soluble antiseptic, insecticide, flame retardant, neutron absorber, and a precursor to other chemical compounds (1,2). The material safety data sheet for boric acid suggests that it may be also toxic to kidneys, cardiovascular system, central nervous system (CNS) (2). Repeated or prolonged exposure to the substance can produce target organ damage (1,2)

Huthayfa Ateeli, MBBS¹, Laila Abu Zaid, MD², Sachin Chaudhary, MD¹

¹Pulmonary and Critical Care Division, Department of Medicine, University of Arizona, Tucson, AZ USA

²Department of Medicine, University of Arizona, Tucson, AZ USA

References

1. Agency for Toxic Substances & Disease Registry. Toxicological profile of boron. November 2010. Available at: https://www.atsdr.cdc.gov/toxprofiles/tp26.pdf (accessed 2/27/18).
2. ScienceLab.com. Material Safety Data Sheet: Boric acid MSDS. October 10, 2005. May 21, 2013. Available at: http://www.sciencelab.com/msds.php?msdsId=9927105 (accessed 2/27/18).

Cite as: Ateeli H, Zaid LA, Chaudhary A. Medical image of the week: acute pneumonitis secondary to boric acid exposure. Southwest J Pulm Crit Care. 2018;16(2):108-9. doi: https://doi.org/10.13175/swjpcc025-18 PDF