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.)

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
May 2021 Imaging Case of the Month: A Growing Indeterminate Solitary
   Nodule

 

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.

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

Wednesday
Aug022023

August 2023 Medical Image of the Month: Cannonball Metastases from Metastatic Melanoma

Figure 1. Upright PA chest radiograph (A) demonstrates innumerable rounded nodules with a slight lower lung predilection. Coronal reconstruction from a subsequent chest CT with contrast (B) confirms innumerable round, solid and non-calcified pulmonary nodules most consistent with a “cannonball” pattern of pulmonary metastatic disease.

 

Figure 2. Axial susceptibility-weighted (A) and pre-contrast T1-weighted (B) images from a brain MRI centered on one (of many) intracranial lesions. This lesion in the posterior right cerebral hemisphere demonstrates a large amount of surrounding susceptibility artifact (A) consistent with blood product, indicating a hemorrhagic metastasis, common in metastatic melanoma which can be very vascular in nature.  There is elevated T1 signal surrounding the lesion (B), also consistent with hemorrhage. There is T1 signal in the center of the lesion as well (arrow), which could represent hemorrhage but could also represent melanin, which is T1 bright and can suggest the primary tumor histology (melanoma).

 

A 48-year-old man with a significant smoking history presented with progressive dyspnea, a mildly productive cough with brown-tinged sputum, headache, weight loss, and progressive back pain over a period of 8 weeks. The patient had no known history of lung conditions. As part of their initial evaluation, the patient received a frontal CXR and was found to have innumerable rounded pulmonary nodules throughout the lungs, which were consistent with a “cannonball” pattern of pulmonary metastatic disease (Figure 1A). A subsequent CT confirmed innumerable pulmonary metastases (Figure 1B). An MRI of the brain and spine revealed hemorrhagic brain metastases (Figure 2), spinal metastases, and bone metastases. A biopsy of a lesion in the left iliac bone confirmed the diagnosis of metastatic melanoma.

This case highlights the so-called “cannonball” pattern of pulmonary metastatic disease with innumerable round nodules throughout the lungs with a slight lower lung predilection, consistent with a hematogenous spread of disease to the lungs. Classically, this pattern consists of numerous well-circumscribed relatively large lesions in the lungs with a pattern resembling multiple small "cannonballs". The distribution of nodules is random, and the factors that distinguish a cannonball pattern from a miliary pattern of pulmonary metastatic disease are that cannonball metastases are larger and less numerous compared to a miliary pattern of pulmonary metastatic disease (1,2). Although cannonball pattern of pulmonary metastatic disease is classically described in the setting of metastatic renal cell carcinoma, prostate cancer, choriocarcinoma, and sarcoma, it has been reported for a variety of other primary cancers, including melanoma. Similar cases of late-stage metastatic melanoma presenting as widely metastatic disease of unknown origin has also been reported (3).

Melanoma spreads to the lungs through hematogenous dissemination, resulting in the cannonball (or miliary) lesions observed on imaging. Specifically, when these lesions are small and distributed throughout the lung, they commonly indicate metastatic melanoma. While this classical presentation can be pathognomonic, it is important to consider other potential diagnoses, including malignancy, infectious diseases, and rheumatologic conditions. Malignant causes encompass metastatic colorectal cancer, breast cancer, renal cell carcinoma, choriocarcinoma, prostate carcinoma, and adrenal carcinoma. Additionally, non-cancerous causes include infectious etiologies such as septic emboli, coccidiomycosis, histoplasmosis, miliary tuberculosis, and nocardiosis. It is also important to note that rheumatologic conditions like granulomatosis with polyangiitis (Wegener's granulomatosis) can present with the cannonball sign; however, they typically involve both the upper and lower lungs. In this case, the lesions were determined to be due to metastatic melanoma, which had spread to the lungs via hematogenous dissemination.

For this patient, an oncologist was consulted, who recommended that the patient undergo treatment with ipilimumab and nivolumab. The response rate for this treatment regimen generally exceeds 50%, and more than 50% of individuals continue to survive after 5 years. Frequently, when extensive metastases are observed on imaging, healthcare providers often assume a limited life expectancy and tend to lean towards discussions of hospice care. However, it is important to keep in mind that even in cases of extensive metastatic disease, many cancers can be effectively treated with novel and highly effective immunologic anticancer medications.

Andrew Barsoum MD, Mueez Hussain MD, Ranjit Sivanandham MD, and Sina Bagheri MD.

Southwest Healthcare System

Murrieta, California 

References

  1. Ammannagari N, Polu V. 'Cannon ball' pulmonary metastases. BMJ Case Rep. 2013 Jan 8;2013:bcr2012008158. [CrossRef][PubMed]
  2. Andreu J, Mauleón S, Pallisa E, Majó J, Martinez-Rodriguez M, Cáceres J. Miliary lung disease revisited. Curr Probl Diagn Radiol. 2002 Sep-Oct;31(5):189-97. [PubMed]
  3. Lowe A, Bray JJH. Late-stage melanoma presenting with cannonball metastases. BMJ Case Rep. 2020 Dec 12;13(12):e237969. [CrossRef][PubMed]
Cite as: Barsoum A, Hussain M, Sivanandham R, Bagheri S. August 2023 Medical Image of the Month: Cannonball Metastases from Metastatic Melanoma. Southwest J Pulm Crit Care Sleep. 2023;27(2):23-25. doi: https://doi.org/10.13175/swjpccs025-23 PDF
Tuesday
Aug012023

August 2023 Imaging Case of the Month: Chew Your Food Carefully

Michael B Gotway MD1 and Yasmeen M Butt MD2

1Departments of Radiology and 2Laboratory Medicine, Division of Anatomic Pathology

Mayo Clinic-Arizona

Scottsdale, Arizona USA

History of Present Illness

A 50-year-old woman presents with a history of chronic dyspnea and cough, becoming particularly problematic following COVID-19 infection 4 months prior to presentation. While she did experience significant periodic oxygen desaturations during her COVID-19 infection, she was not hospitalized for this illness. The patient also reported wheezing in the previous few weeks. 

Past Medical History, Family History and Social History

The patient’s past medical history was also notable for gastroesophageal reflux disease as well as both Coombs positive and iron deficiency anemia. She reports a history of asthma, well controlled with inhaler use.

The patient’s past surgical history included adenoidectomy, cholecystectomy, and gastric laparoscopic band placement.

Her medications included prednisone (20 mg daily), dextroamphetamine-amphetamine, furosemide, omeprazole, fluoxetine, zolpidem (Ambien), daily Bactrim, occasional Loratadine (Claritin). She also utilized an albuterol inhaler and Fluticasone-based (both Flonase and Breo Ellipta) inhalers.

The patient is a former smoker, ½ pack-per day for 26 years, having quit 11 years prior to presentation. She also reported a history of vaping (agent inhaled unclear) for 8 years, quitting 3 years earlier. She has no known allergies. She drinks alcohol socially and denied illicit drug use.

Physical Examination

The patient’s physical examination showed her temperature to be 99°F with normal pulse and respiratory rate but her blood pressure elevated at 160/90 mmHg. She was obese (263 lbs., BMI= 41). Bilateral basal rales were noted at her examination, but no other abnormal physical examination findings were detected.

Laboratory Evaluation

The patient’s room air pulse oximetry was 85%. A complete blood count showed an upper normal white blood cell count at 1.9 x109/L (normal, 4.5 – 11 x109/L). Her hemoglobin and hematocrit values were 10.7 gm/dL (normal, 12 – 16 gm/dL) and 37.1% (normal, 36 – 46%). The patient’s serum chemistries and liver function studies were entirely normal. The patient had an elevated anti-nuclear antibody titer at 1:320. An echocardiogram noted diastolic dysfunction but normal left ventricular contractility.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography.

Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the second of 11 pages)

  1. Frontal chest radiography shows normal findings
  2. Frontal chest radiography shows marked cardiomegaly
  3. Frontal chest radiography shows mediastinal lymphadenopathy
  4. Frontal chest radiography shows pleural effusion
  5. Frontal chest radiography shows multifocal peribronchial consolidation
Cite as: Gotway MB, Butt YM. August 2023 Imaging Case of the Month: Chew Your Food Carefully. Southwest J Pulm Crit Care Sleep. 2023;27(2):15-22. doi: https://doi.org/10.13175/swjpccs034-23 PDF