Category Archives: Radiology Rounds

Every other week Radiology Rounds cases

Radiology Rounds – 3/28/2023

Posted on by

It is Tuesday #RadiologyRounds time! We are in a pleural state of mind here at Pulm PEEPs. This is another great case authored by rockstar-associate editor @TessLitchman

A 65-year-old man with cirrhosis presents to the ED with progressive shortness of breath:

The CXR has a right lower opacity decreasing in density that is silhouetting the right hemi-diaphragm without signs of volume loss on the right concerning for pleural effusion. There is also associated atelectasis adjacent to the effusion

What is your next step for this patient?

This patient had a bedside POCUS revealing a simple pleural effusion and abdominal ascites. He also had a CT scan performed:

Based on his imaging and history, the most likely diagnosis on the differential was a hepatic hydrothorax. Here is some more information on hepatic hydrothoraces:

A transudative effusion was confirmed on thoracentesis, and no other clear etiologies were identified The treatment of hepatic hydrothorax should always start with medical management of volume overload in cirrhosis. Pleural procedures can be used for disease that is refractory

Radiology Rounds – 3/14/2023

Posted on by

We are back with another #RadiologyRounds! This week’s case comes from our Associate Editor @luke_hedrick

A portable film is obtained on a 65 yo woman with COPD presenting with progressive dyspnea and cough.

The image shows near complete opacification of the left lung. There is no ipsilateral or contralateral tracheal deviation which you would expect with atelectasis or a large pleural effusion, respectively. A CT chest is obtained to better visualize the parenchyma.

The CT chest shows all three findings as noted below.

Yes! There is still aeration in some of the upper lobe, which would not be the case if this were caused by profound atelectasis. Also, atelectasis of such a large territory of the lung would usually cause traction on surrounding structures.

Having seen the CT, can you explain why the x-ray showed aeration in the inferior, left hemithorax? This is from the overlap of the left upper and lower lobes when viewed anteriorly. The sagittal view of the CT demonstrates this nicely.

Radiology Rounds – 2/14/23

Posted on by

What better way to celebrate Valentine’s Day than with a new #RadiologyRounds?! We think it is time for a Lung-centered holiday, but until then enjoy this case.

The patient’s pneumothorax was managed conservatively with observation and temporary 100% oxygen via a non-rebreather for nitrogen washout. The consolidations and effusion were concerning, so the patient had a CT chest performed.

Radiology Rounds – 1/31/23

Posted on by

For today’s #RadiologyRounds we have a combined Radiology and Ventilator imaging rounds! You’re in the ICU caring for a young patient on a ventilator when you are called to the bedside for a desaturation.

You perform an inspiratory hold and see that the PIP, plateau, and difference between peak and plateau have all increased. On exam you hear bilateral mechanical breath sounds anteriorly. You order a CXR and the student asks a question about the waveforms

There are pressure deviations corresponding to the flow deviations.

There is no clear patient effort The fact that the PIP and plat have changed makes water in the tubing or cardiac oscillations less likely.

You think this is mucus, with a plug ball-valving in a bronchus

The CXR arrives and shows right lower lobe collapse.

A bedside bronchoscopy is performed with large mucus plugs suctioned out of the RLL and RML. Afterward, the patient’s oxygenation is improved, the flow deviations resolve, and the plateau pressure drops to 19

Radiology Rounds – 1/18/23

Posted on by

We are back with our first #RadiologyRounds of 2023!

While chronic lung infections and infertility are overlapping symptoms for CF and Primary Ciliary Dyskinesia, the history of neonatal respiratory syndrome, ear infections and lower lobe bronchiectasis are most consistent with PCD

In up to 50% of people with PCD, you can get complete reversal of thoracic and abdominal organs. In this film you can see the heart in the right hemithorax, the gastric bubble on the right with the liver on the left resulting in elevation of the left hemidiaphragm

In patients with clinical symptoms and two decreased levels of nasal nitric oxide these findings suggest a PCD diagnosis but evaluation of the cilia structure and function as well as genetic testing are other diagnostic evaluations to confirm a diagnosis of PCD

Primary ciliary dyskinesia is a autosomal recessive disorder that results in motile ciliary dysfunction and clinical manifestations can vary depending on which organs are involved

Radiology Rounds – 12/6/22

Posted on by

Time for Tuesday #RadiologyRounds!

A 40-year-old patient s/p allogeneic stem cell transplant for AML 6 months prior presents with progressive dyspnea. The exam is unrevealing and imaging is obtained.

The patient’s CT reveals mosaic attenuation. Mosiac attenuation is a pattern of scattered regions of the lung with differing densities. The abnormal portions can be those that appear white or black.

Tip: Inspiratory and expiratory films can help identify the cause!

The patient had PFTs that showed severe obstruction, and significant change from PFTs prior to the stem cell transplant. Inspiratory and expiratory CT confirmed significant areas of gas trapping. She was diagnosed with bronchiolitis obliterans secondary to chronic GVHD

Radiology Rounds – 11/22/22

Posted on by

We are back with another #RadiologyRounds for you!

A middle-aged male presents with sub-acute fatigue, fevers and dyspnea on exertion. His admission labs are notable for severe neutropenia (ANC < 500)

This patient has evidence of a halo sign which represents local vessel invasion or hemorrhage

The patient undergoes evaluation. RVP, sputum culture and serum galactomannan and 1-3-B-d-glucan are negative. A BAL with transbronchial biopsies are obtained.

The patient was found to have pulmonary mucormycosis and was started on IV liposomal amphotericin-B.

Want to learn more about this case? Take a listen to our Fellow’s Case Files from Baylor College of Medicine

Radiology Rounds – 11/8/22

Posted on by

This week’s #RadiologyRounds is brought to you by our newest contributor, Nick Ghionni! We’ll dive into a classic Radiology Sign and talk about what it represents, and how it helps inform your differential.

In this case, the patient underwent a biopsy that showed no malignancy but grew NTM! Given that NTM can be superimposed on malignancy, repeated biopsies were done that corroborated. She is being treated with close monitoring.