Radiology Rounds – 3/12/24

A #RadiologyRounds case with 3 different imaging modalities! A 65+ year old man never smoker, former marathoner has had 2-3 years of progressive non-productive, incessant cough with decreasing exercise tolerance. Some select CT scan slices are below

You are considering multiple etiologies including airway bleeding, pneumothorax, and hemothorax. You grab an ultrasound and perform a lung / pleural POCUS. Here is what you see

The long POCUS shows an area of lung sliding and an area without any lung sliding. This is called lung point and is diagnostic of a pneumothorax. To get a better look at this, you can use M-mode.

A CXR confirmed the finding of a pneumo. He was trialed on 100% oxygen but repeat CXR showed the pneumothorax was expanding. He had a chest tube placed with re-expansion of his lung and no air leak. It was able to be removed the next morning without incident

Here is our algorithm for pneumothorax!

Both BAL and tbbx returned positive for MAI complex. He was HIV neagative. Given his persistent and bothersome symptoms, he was started on treatment for pulmonary MAC with a macrolide, ethambutol and a rifamycin with plan for 6 months of therapy. He improved with this

Radiology Rounds – 1/16/24

We are back with another #RadiologyRounds for 2024 featuring high-yield imaging findings and teaching points for you to review

In this immunosuppressed patient, you find a reverse halo sign, right pleural effusion and left lower lobe consolidation.

Serum fungal markers are negative but given the reverse halo sign, you empirically start Amphotericin B given concern for pulmonary mucormycosis.

Given the profound neutropenia, the patient was predisposed and mucor was identified on lung tissue biopsy and IV Amphotericin-B was continued.

Radiology Rounds – 12/19/23

As we approach the end of the year, we know that the hospital and clinic keep on rolling, so here is a CXR and pulmonary differential based #RadiologyRounds if you’re on for the holiday blocks A woman in her 50s has hypoxemia after being admitted with a femur fracture

The CXR shows signs of a left upper lobe collapse. The upper lungs should be the most lucent, with increased opacity as you go down. LUL collapse can be subtle, but you can see increased haziness at the lung apex. There is also rib crowding and left hemidiaphragm elevation. You can also see a small luftsichel sign. Luftsichel sign is a thin strip of air that can be seen between the collapsed LUL and the superior mediastinum created by the still-aerated superior segment of the lower lobe. The collapse is better appreciated on CT.

Bronchoscopy was performed to investigate the etiology of the lobar collapse. On the bronchoscopy there was an endobronchial lesion completely occluding the left upper lobe bronchus. The mass was biopsied and sent for histopathology

Endobronchial lesions can be malignant or benign, and within malignancy then can be primary or secondary. This patient had no clinical signs of pneumonia and no clear reason to mucus plug so malignancy was top of the differential. Here are differential considerations:

The pathology returned positive for a carcinoid tumor, which can typically arise as endbronchial lesions. PET/CT showed only local disease (femur fracture unrelated), and she is planned for rigid bronchoscopy with laser therapy and corecath ablation for definitive resection.

Radiology Rounds – 11/21/23

We’re back with another #RadiologyRounds by Pulm PEEPs Associate Editor Tess Litchman. An immunosuppressed 65-year-old man presents with neutropenic fever. He is started on empiric broad-spectrum antibiotics with vancomycin and zosyn. Serum beta-D-glucan is positive.

Further, workup reveals a positive serum galactomannan and a BAL PCR that is positive for Aspergillus. The patient is diagnosed with invasive aspergillosis and started on voriconazole. A repeat CT is obtained in 3 weeks. What do you think of the evolving findings?

Radiology Rounds – 11/07/23

We are excited to bring you another #RadiologyRounds

We have a middle-aged immunocompromised male presenting with neutropenic fevers, progressive cough and dyspnea. He has no sick contacts or recent travel.

He was found to have primarily right upper alveolar opacities and blunting of the right costophrenic angle. He rapidly decompensated with acute hypoxemic respiratory failure requiring mechanical ventilation. A CT chest showed dense consolidations with air bronchograms.

The urinary antigen and sputum culture were positive for Legionella and the patient was continued on Macrolide therapy. See our infographic for high-yield teaching points for Legionnaires’ Disease

Radiology Rounds – 9/5/23

Tuesday is time for another #RadiologyRounds! Time for some CXR reading and a differential diagnosis mnemonic Two women presented to the hospital with similar presentations. They are both in their 80s with multiple weeks of cough, fever, and fatigue. Here are the CXRs

The CXRs both showed cavities. They are thick-walled (>4mm) and gas-filled. Cavitary lung lesions are seen within infiltrates, nodules, or masses. There can be an air-fluid level within the cavity. Cysts have thinner walls. The findings were confirmed on CT scan

Cavitary lung lesions can have a broad differential so it is helpful to have a systematic approach. To make it easy, when you see this just remember: CAVITY

Bonus points to anyone who can fill in the Y

Both patients were ultimately diagnosed with pulmonary abscesses which improved with prolonged courses of antibiotics with anaerobic and gram-negative coverage.

Radiology Rounds – 8/22/23

Time for #RadiologyRounds! This week we have a man in his 70s with CLL s/p treatment now in remission. He had fevers, a dry cough, and malaise that initially improved outpatient with antibiotics but have now recurred.

Check out the video of his CT scan here

The CT had multiple findings including small nodules, consolidations, and bands of fibrosis around the secondary pulmonary nodules. This is known as Arcade-Like Sign and has classically been described with COP. While it can make you think COP, it has a low sensitivity

The patient underwent bronchoscopy with Tbbx given the suspicion for OP. The BAL was negative for bacterial, viral, fungal, or mycobacterial infection. The histopathology revealed organizing pneumonia. The patient was started on glucocorticoids and all symptoms improved

Radiology Rounds – 8/8/23

Time for another Radiology Round by our Associate Editor Tess Litchman!

We have an older-aged woman found to have gastric and duodenal ulcers requiring multiple abdominal surgeries and transhepatic biliary drainage presenting with respiratory distress

She underwent pleural fluid drainage with the following pleural fluid studies

She ultimately had a right chest tube placed with 1.6 liters of green pleural fluid was drained

Given concern for a bilothorax, a pleural and serum bilirubin test were added. Her pleural bilirubin level was 17.2 and her serum bilirubin level was 0.5. Her chest tube was maintained, IV antibiotics were started and multi-disciplinary meetings occurred to determine next steps.