Medical image of the week: pulmonary amyloidosis

A 61-year-old man with chronic obstructive pulmonary disease (COPD) on oxygen and chronic steroids presented with a mechanical fall. Initial vital signs and laboratory studies were unremarkable. A chest radiograph performed in the emergency department to evaluate for fractures demonstrated innumerable, high-density pulmonary nodules most pronounced and confluent in the periphery and lung bases (Figure 1). Computed tomography of the chest demonstrated multiple pulmonary nodules and masses with course, eccentric calcifications (Figure 2). Further workup, including biopsies of the masses and full body imaging, revealed primary pulmonary amyloidosis limited to the lung parenchyma. Primary amyloidosis, a disorder of extracellular proteinaceous fibril deposition, is rarely seen affecting the lung parenchyma as the only site of disease as demonstrated here (1). The gentleman underwent autologous bone marrow transplant and did well for approximately 5 years before he developed a progressive cough, hemoptysis, and increased oxygen requirements. He is now being evaluated for lung transplant

Medical image of the week: bilateral symmetrical nephromegaly

No abstract available. Article truncated at 150 words. A 70-year-old man was evaluated for symptoms of fatigue, abdominal pain and a 20 pound weight loss. Abdominal imaging was obtained as a part of work up and showed hepatomegaly, splenomegaly, nephromegaly, mesenteric infiltration and diffuse lymphadenopathy (Figures 1 and 2). A liver biopsy was obtained and a diagnosis of diffuse large B-cell lymphoma was made. The patient opted for a palliative approach and was discharged to an inpatient hospice after a short hospital stay. Bilateral symmetrical nephromegaly is an uncommon radiological finding in adults, and in the absence of infection, the differential includes HIV-associated nephropathy, amyloidosis, lymphoma, acute tubular necrosis and lupus nephritis. Also seen in Figure 1 is the "misty mesenteric sign" (white arrow) which is a term used to describe the CT appearance of mesenteric fat with increased attenuation and stranding (1). A number of processes can lead to the appearance including infiltration by inflammatory cells, edema ..

Medical image of the week: Westermark sign

A 71 year old man was evaluated in the Emergency Department for acute onset of dyspnea. On exam he was tachypneic, tachycardic and hypoxemic requiring 6 L/min of oxygen. He had recently underwent prostatectomy for prostate cancer. Past medical history was also significant for coronary artery disease treated with coronary bypass. The chest x-ray (Figure 1) shows unilateral oligemia concerning for a pulmonary embolus and the CT angiogram of the chest (Figure 2) confirms the diagnosis. While the chest radiograph is normal in the majority of pulmonary emboli, the ‘Westermark sign’ may be seen in up to 2% of the cases (1). It represents a focus of oligemia seen distal to a pulmonary embolism. The finding is a result of a combination of dilation of the pulmonary artery proximal to the thrombus and the collapse of the distal vasculature

Medical image of the week: Leriche syndrome

No abstract available. Article truncated at 150 words. A 68-year-old man with GOLD stage 4 COPD was admitted to the Intensive Care Unit for worsening hypoxic and hypercarbic respiratory failure. The patient was treated with steroids for COPD exacerbation, and required continuous BIPAP. On hospital day 2 concern arose for possible pulmonary embolism given worsening oxygenation despite BIPAP, and a thoracic CT angiogram was performed. On imaging, an incidental finding was discovered that the patient had complete occlusion of his aortic artery at the level of the renal arteries with extensive collaterals throughout the abdomen (Figure 1). The patient had palpable pulses in both feet and extremities were warm to touch bilaterally with recovered circulation, as verified on CT runoff (Figure 2). Vascular surgery was consulted, and a decision was made for no surgical intervention given the extensive collateral system and likely chronic time course. On further questioning the patient had limited ability to ambulate due to claudication. ..

Medical image of the week: thoracic splenosis

No abstract available. Article truncated after 150 words. A 38-year-old man with a history of a motor vehicle collision about 20 years prior to presentation which resulted in multiple left-sided rib fractures, a left-sided pneumothorax requiring chest tube placement, and a high-grade splenic laceration necessitating an emergent splenectomy that presents to outpatient pulmonary clinic for evaluation of pulmonary nodules at the request of his primary care physician. He is asymptomatic. He has a 20-pack-year of smoking history and currently smokes 6 cigarettes per day. He denies any significant exposures or recent infections. He has a family history significant for heart disease and depression, but no history of malignancy. His vital signs and physical examination are normal. He had a CT of the chest performed with representative images from the study shown in Figure 1. A nuclear medicine scan was subsequently requested which demonstrated uptake of the technetium 99m-labeled sulfur colloid in the soft tissue nodules adjacent to left

Medical image of the week: superior vena cava syndrome

No abstract available. Article truncated after 150 words. A 65 year old Native American man with past medical history significant for hypertension presented with a two week history of generalized edema, most prominent in the face and upper extremities. The patient had gained 30 lbs in the previous 6 months. He denied any fever, night sweats, dyspnea, hemoptysis, change in voice, chest pain, abdominal pain, nausea, vomiting, or hematemesis but did acknowledge a 40+ pack-year smoking history. Family history was significant for two brothers deceased from lung cancer. On presentation, he was hemodynamically stable, had visibly distended neck veins and collateral veins on the chest and abdomen. Routine laboratory tests included a comprehensive metabolic panel remarkable for mild transaminitis, complete blood count with thrombocytopenia (69,000) and mild anemia (hemoglobin 13.5). Urinalysis and infectious workup were unremarkable. A CT chest/abdomen/pelvis confirmed superior vena cava (SVC) syndrome from a thrombus in the right atrium extending cephalad into the SVC and ..

Medical image of the week: diffuse axonal injury

No abstract available. Article truncated at 150 words. An 18-year-old man without any significant past medical history presented to the emergency room trauma bay as an unrestrained passenger involved in a head-on collision at 85 mph. In the emergency room, he was found to have a GCS of 6 and was intubated for airway protection. A non-contrast CT of the head demonstrated hyperdense foci in the frontal lobes at the gray-white junction (Figure 1A) and a hyperdense focus in the pons (Figure 1B) consistent with punctate hemorrhages. An MRI of the brain with a gradient recall echo (GRE) sequence (Figure 2) demonstrated more pronounced hypointense foci consisent with hemorrhage. In the setting of the patient’s deceleration injury, the summation of his clinical and imaging findings was consistent with diffuse axonal injury. Diffuse axonal injury (DAI) is pattern of closed head injury that results in a traumatic shear injury to the neuronal axons secondary to sudden deceleration and change ..