Medical Image of the Week: Asbestos Related Pleural Disease

Figure 1. Chest radiograph demonstrates bilateral coarse calcification, most elongated and vertically oriented in nature (white arrows). Also note coarse calcification outlining the hemidiaphragms (dark arrows). Editor's note: the patient's only chest x-ray was two different AP views which are merged above.

Figure 2.  Holly leaf. Its shape is similar to the irregular thickened nodular edges of pleural plaques on chest radiograph, referred to as “the holly leaf sign”.

Figure 3. Thoracic CT shown in soft tissue (A: top) and lung (B: bottom) windows clearly localizes the calcifications to the parietal pleura.

Pleural plaques are strongly associated with inhalational exposure to asbestos (1). The lesions may take up to thirty years to develop. Plaques are typically bilateral, involve the parietal pleura, commonly along the sixth through ninth ribs and are usually absent at the lung apices and costophrenic sulci (Figures 1 and 3). On chest radiograph, the “holly leaf sign” refers to the shape of the calcifications with thickened rolled and nodular edges (Figure 2). The plaques per se are benign in nature. However, they can potentially impair lung function, resulting in restriction.  They are also markers of the individual’s greater risk of developing a lung cancer or mesothelioma.

Wesley Hunter MS IV¹, Veronica Arteaga MD², and Diana Palacio MD²

¹College of Medicine and ²Department of Medical Imaging

University of Arizona

Tucson, AZ USA

Reference

1. Norbet C, Joseph A, Rossi SS, Bhalla S, Gutierrez FR. Asbestos-related lung disease: a pictorial review. Curr Probl Diagn Radiol. 2015 Jul-Aug;44(4):371-82. [CrossRef] [PubMed] 

Cite as: Hunter W, Arteaga V, Palacio D. Medical image of the week: asbestos related pleural disease. Southwest J Pulm Crit Care. 2017;15(3):116-7. doi: https://doi.org/10.13175/swjpcc104-17 PDF

Medical Image of the Week: Fast-growing Primary Malignant Mediastinal Mixed Germ Cell Tumor

Figure 1. A: Chest radiograph taken 3 months prior to presentation. B: Chest radiograph showing large mediastinal mass (arrows). C: Coronal view of thoracic CT in soft tissue windows showing the large mediastinal mass (arrows). D: Lateral view of thoracic CT showing large mediastinal mass.

A 28-year-old man presented with progressive hemoptysis for two weeks. He had fever, cough, and night sweats for one month prior to admission that was treated as inflenza, bronchitis and/or pneumonia. He had started to experience anorexia, dysphagia, fatigue, a 30-pound weight loss, panic attacks, and the new onset of hypertension during the 3 months prior to admission. He also had intermittent middle chest pain that was aggravated by coughing for 5 months, but a cardiac catherization two months prior failed to show an abnormality. The chest x-ray and CT scan on this admission demonstrated a 15 cm large anterior mediastinal mass exerting a mass effect on the heart and medistial lymphadenopathy (Figure 1-B,C,D) which were absent on a chest x-ray performed 3 months prior to admission (Figure 1A). Core biopsy and immunohistochemical staining revealed a mixed germ cell tumor with components of seminoma and yolk-sac tumor. He was started on chemotherapy, to which he responded well. The malignant mediastinal germ cell tumor in this case is fast-growing and most likely of extragonadal origin. The majority of tumors occ in men between 20 and 35 years (1). The symptoms of these tumor and nonspecific as described in our case, which may lead to a low index of suspicion of malignant tumor with resultant delayed diagnosis.

Yufei Tian, Stella Pak, and Qiang Nai

Department of Medicine

University of Toledo Medical Center

Toledo, Ohio USA

Reference

1. Carter BW, Marom EM, Detterbeck FC. Approaching the patient with an anterior mediastinal mass: a guide for clinicians. J Thorac Oncol. 2014 Sep;9(9 Suppl 2):S102-9. [CrossRef] [PubMed]

Cite as: Tian Y, Pak S, Nai Q. Medical image of the week: fast-growing primary malignant mediastinal mixed germ cell tumor. Southwest J Pulm Crit Care. 2017;15(3):114-5. doi: https://doi.org/10.13175/swjpcc103-17 PDF