Search Journal-type in search term and press enter
Southwest Pulmonary and Critical Care Fellowships

Imaging

Last 50 Imaging Postings

(Most recent listed first. Click on title to be directed to the manuscript.)

December 2024 Medical Image of the Month: An Endobronchial Tumor
November 2024 Medical Image of the Month: A Case of Short Telomeres
November 2024 Imaging Case of the Month: A Recurring Issue
October 2024 Medical Image of the Month: Lofgren syndrome with Erythema
   Nodosum
September 2024 Medical Image of the Month: A Curious Case of Nasal
   Congestion
August 2024 Image of the Month: Lymphomatoid Granulomatosis
August 2024 Imaging Case of the Month: An Unexplained Pleural Effusion
July 2024 Medical Image of the Month: Vocal Cord Paralysis on PET-CT 
June 2024 Medical Image of the Month: A 76-year-old Man Presenting with
   Acute Hoarseness
May 2024 Medical Image of the Month: Hereditary Hemorrhagic
   Telangiectasia in a Patient on Veno-Arterial Extra-Corporeal Membrane
   Oxygenation
May 2024 Imaging Case of the Month: Nothing Is Guaranteed
April 2024 Medical Image of the Month: Wind Instruments Player Exhibiting
   Exceptional Pulmonary Function
March 2024 Medical Image of the Month: Sputum Cytology in Patients with
   Suspected Lung Malignancy Presenting with Acute Hypoxic Respiratory
   Failure
February 2024 Medical Image of the Month: Pulmonary Alveolar Proteinosis
   in Myelodysplastic Syndrome
February 2024 Imaging Case of the Month: Connecting Some Unusual Dots
January 2024 Medical Image of the Month: Polyangiitis Overlap Syndrome
   (POS) Mimicking Fungal Pneumonia 
December 2023 Medical Image of the Month: Metastatic Pulmonary
   Calcifications in End-Stage Renal Disease 
November 2023 Medical Image of the Month: Obstructive Uropathy
   Extremis
November 2023 Imaging Case of the Month: A Crazy Association
October 2023 Medical Image of the Month: Swyer-James-MacLeod
   Syndrome
September 2023 Medical Image of the Month: Aspergillus Presenting as a
   Pulmonary Nodule in an Immunocompetent Patient
August 2023 Medical Image of the Month: Cannonball Metastases from
   Metastatic Melanoma
August 2023 Imaging Case of the Month: Chew Your Food Carefully
July 2023 Medical Image of the Month: Primary Tracheal Lymphoma
June 2023 Medical Image of the Month: Solitary Fibrous Tumor of the Pleura
May 2023 Medical Image of the Month: Methamphetamine Inhalation
   Leading to Cavitary Pneumonia and Pleural Complications
April 2023 Medical Image of the Month: Atrial Myxoma in the setting of
Raynaud’s Phenomenon: Early Echocardiography and Management of
   Thrombotic Disease
April 2023 Imaging Case of the Month: Large Impact from a Small Lesion
March 2023 Medical Image of the Month: Spontaneous Pneumomediastinum
   as a Complication of Marijuana Smoking Due to Müller's Maneuvers
February 2023 Medical Image of the Month: Reversed Halo Sign in the
   Setting of a Neutropenic Patient with Angioinvasive Pulmonary
   Zygomycosis
January 2023 Medical Image of the Month: Abnormal Sleep Study and PFT
   with Supine Challenge Related to Idiopathic Hemidiaphragmatic Paralysis
December 2022 Medical Image of the Month: Bronchoesophageal Fistula in
   the Setting of Pulmonary Actinomycosis
November 2022 Medical Image of the Month: COVID-19 Infection
   Presenting as Spontaneous Subcapsular Hematoma of the Kidney
November 2022 Imaging Case of the Month: Out of Place in the Thorax
October 2022 Medical Image of the Month: Infected Dasatinib Induced
   Chylothorax-The First Reported Case 
September 2022 Medical Image of the Month: Epiglottic Calcification
Medical Image of the Month: An Unexpected Cause of Chronic Cough
August 2022 Imaging Case of the Month: It’s All About Location
July 2022 Medical Image of the Month: Pulmonary Nodule in the
   Setting of Pyoderma Gangrenosum (PG) 
June 2022 Medical Image of the Month: A Hard Image to Swallow
May 2022 Medical Image of the Month: Pectus Excavatum
May 2022 Imaging Case of the Month: Asymmetric Apical Opacity–
   Diagnostic Considerations
April 2022 Medical Image of the Month: COVID Pericarditis
March 2022 Medical Image of the Month: Pulmonary Nodules in the
   Setting of Diffuse Idiopathic Pulmonary NeuroEndocrine Cell Hyperplasia
   (DIPNECH) 
February 2022 Medical Image of the Month: Multifocal Micronodular
   Pneumocyte Hyperplasia in the Setting of Tuberous Sclerosis
February 2022 Imaging Case of the Month: Between A Rock and a
   Hard Place
January 2022 Medical Image of the Month: Bronchial Obstruction
   Due to Pledget in Airway Following Foregut Cyst Resection
December 2021 Medical Image of the Month: Aspirated Dental Implant
Medical Image of the Month: Cavitating Pseudomonas
aeruginosa Pneumonia
November 2021 Imaging Case of the Month: Let’s Not Dance
the Twist
Medical Image of the Month: COVID-19-Associated Pulmonary
Aspergillosis in a Post-Liver Transplant Patient
Medical Image of the Month: Stercoral Colitis
Medical Image of the Month: Bleomycin-Induced Pulmonary Fibrosis
in a Patient with Lymphoma
August 2021 Imaging Case of the Month: Unilateral Peripheral Lung
   Opacity
Medical Image of the Month: Hepatic Abscess Secondary to Diverticulitis
   Resulting in Sepsis
Medical Image of the Month: Metastatic Spindle Cell Carcinoma of the
   Breast
Medical Image of the Month: Perforated Gangrenous Cholecystitis

 

 

For complete imaging listings click here

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

-------------------------------------------------------------------------------------------  

Monday
Dec022024

December 2024 Medical Image of the Month: An Endobronchial Tumor

Figure 1. PA (A) and lateral (B) CXR from a woman with wheezing demonstrating a right perihilar nodule projecting within the lingula (circled) with associated atelectasis. To view Figure 1 in a separate, enlarged window click here.

 

Figure 2. Inspiratory (A) and expiratory (B) axial CT images demonstrating a mass obstructing the lingular bronchus (*) with post-obstructive mucus plugging (arrow) and air-trapping (circled). Axial image from an FDG PET-CT (C) demonstrates moderate FDG uptake within the nodule (arrowhead). No other areas of tracer uptake were seen to suggest nodal metastatic disease. To view Figure 2 in a separate, enlarged window click here.

 

Figure 3. Images from virtual bronchoscopic reconstructions from the patient’s CT (A) demonstrating a nodule obstructing the lingular bronchus. Image from bronchoscopy (B) obtained just prior to biopsy correlates nicely with virtual bronchoscopic findings. To view Figure 3 in a separate, enlarged window click here.

 

Figure 4. Low-power (A) and high-power (B,C) hematoxylin & eosin-stained pathology slides from the nodule demonstrating submucosal tumor adjacent to airway cartilage (*). The tumor contains some squamoid-appearing cells (B) as well as some mucinous cells (C, arrows) and intermediate-appearing cells (C, arrowhead). To view Figure 4 in a separate, enlarged window click here.

 

A 61-year-old woman was for wheezing. She reported that the symptoms were sudden in onset and persisted for 2 months without improvement. There was no infectious prodrome, no history of an aspiration event, and the symptoms had no exacerbating or relieving factors. The patient reported a past medical history of reflux (controlled on omeprazole), dyslipidemia, hypertension, and migraine headaches. Her past surgical history includes remote histories of breast augmentation, hysterectomy and salpingo-oophorectomy, cholecystectomy, and urethral sling. The patient was a never-smoker with no history of illicit drug use, travel, or exposures. Family history was non-contributory. The patient medications included Crestor, Thiazide, Imitrex, Losartan, and Omeprazole. No known drug allergies.

Her vital signs were normal. Physical exam demonstrated an inspiratory wheeze which was diffuse and best appreciated anteriorly. A PA and Lateral chest x-ray was done at the time of initial referral (Figure 1). A CT scan was subsequently obtained (Figure 2), the results of which led to a PET-CT (Figure 2) and, eventually, bronchoscopy with biopsy (Figure 3). Pathological results were consistent with a low-grade mucoepidermoid carcinoma (MEC) (Figure 4). The patient subsequently underwent left upper lobectomy with lymph node dissection. Surgical pathology demonstrated a 2.5 cm well-differentiated MEC with negative margins; all sampled lymph nodes were negative for malignancy.

MEC in the lungs is rare, accounting for 0.1%-0.2% of pulmonary malignancies (1). These tumors are thought to arise from minor salivary glands in the tracheobronchial tree (2). They are classified as low grade or high grade based on histological criteria (3). On imaging, these tumors are more common in lobar or segmental airways and tend to be round or lobular with well-circumscribed margins. They tend to be vascular and demonstrate heterogeneous enhancement on contrast-enhanced CT. Because they arise from the lining of the airways, they are often associated with post-obstructive findings like mucus plugging, air-trapping, atelectasis, and pneumonia. Patients usually present with symptoms related to endoluminal growth, including persistent cough/sputum, wheezing, dyspnea, hemoptysis, and/or recurrent pneumonias. Patients are often initially mis-diagnosed with asthma, bronchitis, or COPD. The patients frequently do not have a smoking history, which can be helpful when ordering a differential diagnosis. The lesions often demonstrate submucosal growth so bronchial washings/brushings are often negative, as was the case for this patient. This case is a good reminder of the “other” endobronchial tumors, which also include carcinoid tumors (well-circumscribed, vascular, more common in bronchi as opposed to trachea), adenoid cystic carcinoma (usually involve the trachea as a “cylindroma”, have submucosal and perineural growth), sarcomas (chondrosarcoma, sarcoma metastases), hamartomas (often contain fat and/or popcorn calcifications), and tracheobronchial papillomatosis (younger patients, multiple cavitary lesions) (4).

Clinton E. Jokerst MD, Matthew T. Stib MD, Carlos Rojas MD, Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Phoenix, AZ USA

References

  1. Miller DL, Allen MS. Rare pulmonary neoplasms. Mayo Clin Proc. 1993 May;68(5):492-8. doi: [CrossRef] [PubMed]
  2. Ishizumi T, Tateishi U, Watanabe S, Maeda T, Arai Y. F-18 FDG PET/CT imaging of low-grade mucoepidermoid carcinoma of the bronchus. Ann Nucl Med. 2007 Jul;21(5):299-302. [CrossRef][PubMed]
  3. Yousem SA, Hochholzer L. Mucoepidermoid tumors of the lung. Cancer. 1987 Sep 15;60(6):1346-52. [CrossRef] [PubMed]
  4. Park CM, Goo JM, Lee HJ, Kim MA, Lee CH, Kang MJ. Tumors in the tracheobronchial tree: CT and FDG PET features. Radiographics. 2009 Jan-Feb;29(1):55-71. [CrossRef] [PubMed]
Cite as: Jokerst CE, Stib MT, Rojas C, Gotway MB. December 2024 Image of the Month: An Endobronchial Tumor. Southwest J Pulm Crit Care Sleep. 2024;29(6):57-59. doi: https://doi.org/10.13175/swjpccs051-24 PDF
Saturday
Nov022024

November 2024 Medical Image of the Month: A Case of Short Telomeres

Figure 1. PA (A) and lateral (B) CXR demonstrating small lung volumes with peripheral reticulonodular opacities. The findings are highly suggestive of pulmonary fibrosis. To view Figure 1 in a separate, enlarged window click here.

 

Figure 2. Axial CT images from the upper (A), mid (B), and lower lungs (C). Images demonstrate a rather nonspecific pattern of fibrosis consisting of patchy areas of reticulation, ground glass, and septal line thickening. The findings are peripheral-predominant, but there was no predilection for the lung bases vs. apices. No subpleural honeycombing was seen. To view Figure 2 in a separate, enlarged window click here.

 

Figure 3. Results from telomere length testing of lymphocytes (A) and granulocytes (B). The results of both tests put the patient below the 10th percentile with the granulocyte telomere length being below the 1st percentile. To view Figure 3 in a separate, enlarged window click here.

 

A 50-year-old woman was referred to our institution for further evaluation of her ILD. Her history of present illness began during the COVID-19 pandemic, when she noticed that she had trouble climbing stairs while wearing a mask. She also had a slowly progressive cough which, at first, she attributed to seasonal allergies. Eventually her symptoms prompted pulmonary function testing at an outside institution, which showed moderately severe restriction with a DLco 40% of predicted. Chest x-ray (Figure 1) and chest CT (Figure 2) demonstrated findings of pulmonary fibrosis. The patient worked as an accountant and was a life-long nonsmoker. No concerning exposure history and no history of any medications associated with pulmonary fibrosis. Her family history is remarkable for a brother diagnosed with IPF at age 49, currently status post lung transplant. Her sister and father were both diagnosed with alpha-1-antitrypsin (both died in their 50’s). The patient also reports premature graying of her hair, at age 17. The combination of family history, gray hair, and pulmonary fibrosis prompted further testing for short telomeres, which was positive (Figure 3). The patient was diagnosed with interstitial lung disease secondary to short telomere syndrome.

Telomeres are short repeating nucleotides that the end of chromosomes that protect them from gradual degradation during aging (1). Short telomere syndromes (STSs) are accelerated-aging syndromes often caused by heritable gene mutations that result in decreased telomere length. Organ systems with increased cell turnover, such as skin, lungs, bone marrow, and GI tract, are most commonly affected (2). The relationship between telomere length and interstitial lung disease is complicated. The first association between genetically determined telomere abnormalities and lung fibrosis was observed for the telomeropathy dyskeratosis congenital (DC), an entity characterized by skin abnormalities, bone marrow failure, and pulmonary fibrosis, which was observed in 19% of patients (3). Mutations in other telomere related genes have subsequently been identified in familial and sporadic idiopathic interestitial pneumonias (4-6). Short telomeres have been identified in about 25 percent of sporadic cases of IPF (7) and should be suspected in patients with familial pulmonary fibrosis and/or early onset IPF in patients with signs of premature aging, such as developing gray hair at a young age.

Clinton E. Jokerst MD, Matthew T. Stib MD, Carlos A. Rojas MD, Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Phoenix, AZ USA

References

  1. Martínez P, Blasco MA. Telomere-driven diseases and telomere-targeting therapies. J Cell Biol. 2017 Apr 3;216(4):875-887. [CrossRef] [PubMed]
  2. Mangaonkar AA, Patnaik MM. Short Telomere Syndromes in Clinical Practice: Bridging Bench and Bedside. Mayo Clin Proc. 2018 Jul;93(7):904-916. [CrossRef] [PubMed]
  3. Knight S, Vulliamy T, Copplestone A, Gluckman E, Mason P, Dokal I. Dyskeratosis Congenita (DC) Registry: identification of new features of DC. Br J Haematol. 1998 Dec;103(4):990-6. [CrossRef] [PubMed]
  4. Cronkhite JT, Xing C, Raghu G, Chin KM, Torres F, Rosenblatt RL, Garcia CK. Telomere shortening in familial and sporadic pulmonary fibrosis. Am J Respir Crit Care Med. 2008 Oct 1;178(7):729-37. [CrossRef] [PubMed]
  5. Diaz de Leon A, Cronkhite JT, Katzenstein AL, et al. Telomere lengths, pulmonary fibrosis and telomerase (TERT) mutations. PLoS One. 2010 May 19;5(5):e10680. [CrossRef] [PubMed]
  6. Newton CA, Batra K, Torrealba J, et al. Telomere-related lung fibrosis is diagnostically heterogeneous but uniformly progressive. Eur Respir J. 2016 Dec;48(6):1710-1720. [CrossRef] [PubMed]
  7. Armanios MY, Chen JJ, Cogan JD, et al. Telomerase mutations in families with idiopathic pulmonary fibrosis. N Engl J Med. 2007 Mar 29;356(13):1317-26. [CrossRef] [PubMed]
Cite as: Jokerst CE, Stib MT, Rojas CA, Gotway MB. November 2024 Medical Image of the Month: A Case of Short Telomeres. Southwest J Pulm Crit Care Sleep. 2024;29(5):45-47. doi: https://doi.org/10.13175/swjpccs049-24 PDF