December 2017 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 57-year-old woman with a past medical history remarkable only for hyperlipidemia undergoing statin therapy presented with a history of slowly progressive dyspnea on exertion for at least months, possibly longer. The patient denied cough, hemoptysis, and chest pain.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 96% on room air while resting. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable. Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing.

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

Figure 1. Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of nine pages)

1. The chest radiograph appears normal
2. The chest radiograph shows bilateral, symmetric lower lobe reticulation suggesting fibrotic disease
3. The chest radiograph shows left upper lobe collapse
4. The chest radiograph shows linear right lower lobe opacity suggesting scarring
5. The chest radiograph shows numerous small miliary nodules

Cite as: Gotway MB. December 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(6):2563-66. doi: https://doi.org/10.13175/swjpcc149-17 PDF

Medical Image of the Week: Yellow Nail Syndrome

Figure 1. Photographs showing the patient’s discolored, yellowish nails.

Figure 2. Representative images from the thoracic CT scan in lung windows showing bronchiectasis most marked in the left upper lobe.

A 67-year-old woman with a previous history of yellow nail syndrome presented with a long history of cough, increased sputum production, recurrent swelling in her lower extremities and recurrent respiratory infections. Physical examination revealed non-pitting edema in the lower extremities and discolored nails (Figure 1). A thoracic CT scan showed bronchiectasis in the left upper lobe (Figure 2). She did not have a history of pleural effusions or chronic sinusitis.

Yellow nail syndrome is very rare disorder associating yellow nail discoloration, bronchiectasis and lymphedema (1). Other frequent manifestations include sinusitis and recurrent pleural effusions. The disease is most frequently isolated but may be associated with other diseases implicating the lymphatic system, autoimmune diseases or cancers. The symptoms result from lymphatic impairment but the cause of the impairment is unknown. Treatment is symptomatic for each component. Vitamin E, combined with fluconazole, is usually prescribed to treat yellow nails and achieves a partial or complete response. Spontaneous resolution is also possible. Although prognosis is usually considered to be good, a Kaplan–Meier survival curve estimated median survival at 132 months, shorter than that of a paired-control population (2).

Lewis J. Wesselius MD

Departments of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

References

1. Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis. 2017 Feb 27;12(1):42. [CrossRef] [PubMed]
2. Maldonado F, Tazelaar HD, Wang CW, Ryu JH. Yellow nail syndrome: analysis of 41 consecutive patients. Chest. 2008;134:375–81. [CrossRef] [PubMed]

Cite as: Wesselius LJ. Medical image of the week: yellow nail syndrome. Southwest J Pulm Crit Care. 2017;15(4):230-1. doi: https://doi.org/10.13175/swjpcc142-17 PDF