Summaries and links to STR Webinar cases

I am a co-presenter of cases at the weekly Society of Thoracic Radiology Cardiothoracic Case Webinar. In this page I present a list of the cases (with brief descriptions) I presented until February 23rd, 2023 and links to them.

Here are the cases listed by date until February 23rd.

February 23rd, 2023.
Case Description
Carcinoid heart in metastatic small bowel neuroendocrine tumor. The pulmonic and tricuspid valves (leaflets) were substantially diseased and replaced.
Mycobacterial spindle cell pseudotumor in a patient with AIDS. This distinctive lesion (in this context) presents as an endobronchial mass near the carina.
Deviation of a right PICC into the right superior intercostal vein. A CT confirms its location. I’ve not seen this before!
February 16th, 2023.
Case Description
Knife stab through peripheral hemidiaphragm. It’s easy to miss this small defect if the path of the knife is unknown.
Quantum mottle (noise) from underexposure on digital radiography. This fine salt-and-pepper appearance of image noise is distinctive.
A pneumothorax permits visualization of the inferior pulmonary ligament. Air is present anterior and posterior to the ligament.
A large esophageal pulsion diverticulum. An esophagram nicely shows the anatomy.
Dislodgment of a right ventricular pacemaker lead during cardiac surgery. It moved proximally with a loop into the IVC.
Spontaneous pneumothorax from a large bulla-like cystic lesion which was resected. Histopathologic findings of Placental Transmogrification of lung are present in the adjacent lung. I’ve included excerpts of the operative findings and pathology images.
February 9th, 2023.
Case Description
The performance of a CTA in a patient on peripheral AV ECMO for cardiogenic shock. These may be challenging to interpret.
Interlobular septal emphysema (and mild pneumomediastinum) in the Macklin phenomenon. This is the result of blunt chest trauma.
Dislodgment of a right atrial appendage pacemaker lead during cardiac surgery. This may easily be overlooked in the presence of many other medical devices.
February 2nd, 2023.
Case Description
Bulging fissure sign in necrotizing bacterial pneumonia. The findings are present on radiography and chest CT.
Severe constrictive bronchiolitis in rheumatoid arthritis. The Case Summary has excerpts of spirometry values and curves.
Embolization of large fragments of tricuspid valve vegetations. Perhaps the largest vegetations I’ve seen! Ultrasound images are included.
Recurrent episodes of bowel obstruction from colon herniation through an iatrogenic hemidiaphragm defect. The defect is well depicted on the Coronal and Sagittal CT Series.
An aspirated two-tooth denture was present in the right main bronchus for years before retrieval. Don’t ask. I don’t know!
Unilateral hemidiaphragm paralysis from phrenic nerve injury during complicated surgery. I’ve included fluoroscopy Series.
Intra-diaphragmatic bronchogenic cyst. It was surgically removed and examined.
Ring calcification in the peripheral portion of a nodule with central necrosis. This may represent a consequence of cocci infection.
January 26th, 2023.
Case Description
Intralobular gradient in lung edema with Karst Mountain sign. This was a consequence of myocardial infarction which is also shown on the chest CT.
Metastatic cardiac angiosarcoma. The metastases have the classic morphology: a solid center with a ground-glass halo.
Findings of remote mantle radiation therapy for lymphoma. The findings are: calcified mediastinal tissue; para-mediastinal radiation fibrosis; and very substantial calcified atherosclerosis.
Metastatic calcifications in a growing and calcifying focal RML opacity. This occurred after liver transplantation. Examination of the resected lesion revealed the diagnosis. Very weird!
January 12th, 2023.
Case Description
Incomplete repair of a large defect of traumatic hemidiaphragm rupture. This was an unavoidable surgical conclusion. Herniation of a small portion of stomach through a small remnant defect is present.
Boerhaave syndrome with very subtle radiographic findings. The presence of lower mediastinal air requires proper use of display window settings – WW and WL.
Asymmetric right lung edema from partial thrombosis of a mechanical mitral valve. The thrombus entrapped one leaflet resulting in substantial regurgitation. Cardiac ultrasound and fluoroscopic evaluation of the valve demonstrated this. The valve was replaced.
A typical RML carcinoid tumor traversed the fissure into the lower lobe. A portion of the anterior RLL needed to be resected. I wonder if the fissure was incomplete.
A resected (very small) lesion showed adenocarcinoma in situ, with purely lepidic growth, within foci of fibrosis. I’ve included annotated histopathology slides.
January 5th, 2023.
Case Description
Cystic lung disease associated with light chain MGUS. I’ve seen cystic lung disease in many various forms of lymphoplasmacytic proliferative disorders; this is the first time with a form of MGUS.
Aspiration of a common nail. It caused a modest degree of proximal bronchiectasis with impaction of secretions. It was easily removed via bronchoscopy.
Accumulation of pleural effusions in the context of fluid overload. A key observation of the latter in this case is the development of substantial chest wall soft tissue edema.
Erosion of an esophageal stent into left main bronchus. This was discovered on CT after findings of a bronchopulmonary aspiration syndrome developed.
The effect on a chest image when an inapplicable study was stipulated. In this instance a “lateral” projection was specified for the “PA” projection.
December 15th, 2022.
Case Description
Unexpected discovery of a pulmonary synovial cell sarcoma on coronary artery CT. The lesion was uneventfully removed.
A large pulmonary desmoid fibromatosis-like tumor. On FDG-PET it is minimally metabolically active.
VV ECMO using a Crescent cannula. I’ve included pictures to illustrate its construction and proper placement.
Another case of the Crescent VV ECMO cannula. Our physicians now use this in place of the Avalon device.
November 17th, 2022.
Case Description
A solitary ACTH-producing pulmonary nodule. The patient presented with signs and symptoms of Cushing Disease. The lesion was removed.
Carcinoid heart with pulmonary and tricuspid valve disease. An appendiceal neuroendocrine tumor was excised several years before! Recurrence with nodal— but not liver — metastases is present. The valves were replaced.
Pulmonary capillary hemangiomatosis in explanted lungs after transplantation. No pulmonary opacities are present on CT!
A fractured pacemaker lead in the costoclavicular space. One has to zoom-in on the region to perceive the finding. It’s easy to forget to do so.
November 3rd, 2022.
Case Description
Pulmonary veno-occlusive disease. Substantial, persistent interstitial lung edema is the dominant CT finding. This was confirmed by histopathological examination of the explanted lungs.
October 27th, 2022.
Case Description
Recurrence of a paraspinal hydatid cyst. An unknown procedure was performed in the remote past. This is an extrapleural lesion with some extension into the spinal canal via a neuroforamen. It was excised. I’ve included intra-operative pictures.
A dramatic example of bronchiectasis in ABPA. The best finger-in-glove sign I’ve seen.
A flipped – about 90 degrees – pectoral subcutaneous port. No surprise – attempted needle access failed.
October 20th, 2022.
Case Description
Limited aortic dissection – Svensson class 3 lesion (Circulation.1999;99:1331-1336.) . This was located in the usual place: the medial aspect of the proximal ascending aorta. A substantial amount of mediastinal blood, blood in the shared adventitias of the aorta and pulmonary artery walls, and hemopericardium are present.
Imaging of a supercharged substernal colonic interposition. In this case the supercharged vascular support is a connection between the left internal mammary artery and a colonic artery. This is discernible on the CT.
Discovery of an aspirated pill in the bronchus intermedius on a CTPA procedure. It was removed via bronchoscopy – images are included.
September 15th, 2022.
Case Description
Tracheal stenosis as a complication of prolonged intubation. The degree of associated mural thickening in the involved segment is unusual. The segment was excised.
Pulmonary veno-occlusive disease and capillary hemangiomatosis in MCD/scleroderma. Corresponding pathology findings are present in the explanted lungs. I’ve included annotated pathology images.
Substantial asymmetric disease in chronic pulmonary thromboembolism. Surgical endarterectomy was performed.
Collateral pathways in SVC stenosis attributed to prolonged catheterization in a patient with chronic renal failure. Dilated azygos, left superior intercostal, and hemiazygos veins are conspicuous on radiography and CT.
September 8th, 2022.
Case Description
Anterior mediastinal parathyroid adenoma. This is unusually large and in an unusual location. It was removed.
A case of hemidiaphragm eventration. Classic morphologic and fluoroscopy findings are present. I’ve included series from the fluoroscopy procedure. A nice comparison is between the sagittal CT and the fluoroscopic images.
A false-postive declaration of solitary embolism in a subsegmental artery. This is a great teaching example of the effect of cardiac pulsation on left lower lobe vessels.
September 1st, 2022.
Case Description
Subtle abnormal mediastinal-lung interface from paraspinal hematoma in a blunt trauma victim. This is from vertebral fracture.
Another case of abnormal mediastinal-lung interfaces from paraspinal hematoma in a blunt trauma victim . This is not subtle. Extensive lung contusions are also present.
A pectoral pacemaker is changed in orientation and the leads uncoiled. This was an intentional enlarging of the pacemaker pocket! The patient had localized discomfort attributed to a “tight” pocket.
Deposition of radio-opaque Histoacryl glue in pulmonary lobular arteries. This inadvertently occurred during closure of a pelvic AVM. The patient was asymptomatic. It’s a nice depiction of lobular arterial anatomy!
Neck subcutaneous emphysema after the patient suppressed a cough while smoking marijuana. This has been attributed to retrograde passage of air into the parotid glands and gland alveolar rupture. It has been described in multiple contexts associated with an abrupt rise in intra-oral pressure. It resolved without complication.
A central lobar mass occludes pulmonary arteries with peripheral lobar hemorrhage reflective of arterial ischemia. It is a small cell cancer.
August 18th, 2022.
Case Description
Stylish nipple-related adornments. We can call these bilateral hangman adornments!.
A flipped pectoral deep brain stimulator can. The leads uncoiled quite a lot.
Black smoke phenomenon likely due to a congenital bronchial artery to pulmonary artery communication. This simulates a pulmonary embolus. In this patient with cardiomyopathy an additional associated finding is asymmetric lung edema in the involved lobe. The inflow of systemic arterial blood accounts for this. Two interesting findings!
Hemidiaphragm paralysis from iatrogenic phrenic nerve injury during valvular cardiac surgery. I’ve included several image series from hemidiaphragm fluoroscopy.
A flipped-over pectoral infusion port. This was suspected when an attempt at needle insertion/ infusion failed.
August 4th, 2022.
Case Description
Pulmonary hemorrhage in the primary antiphospholipid antibody syndrome. This is an uncommon, but well recognized, association.
Diffuse micronodules in disseminated Mycobacterium Hemophilum disease. The diagnosis of the condition was made by means of a skin biopsy in the context of a chronic skin condition. The nodules (review the MIPS Series) resolved with anti-microbial therapy.
Reactivation tuberculosis in the context of COVID-19 infection. The new consolidation was initially assumed to be community-acquired bacterial pneumonia. It was diagnosed on the basis of a sputum-positive PCR result for the organism.
A large (primary) pericardial abscess. This was caused by Staph. aureus and was surgically drained.
July 21st, 2022.
Case Description
Pulmonary and myocardial (left atrial and left ventricular myocardium) calcifications. These are a consequence of decades of chronic renal failure.
The value of knowing operative details when analyzing unusual vascular findings on post-operative CT angiography. The findings relate to the direct insertion of a left Impella device into the ascending aorta, and its subsequent removal.
Inadvertent passage of a stent from the true to the false lumen during surgical management of acute aortic dissection. The resultant expansion of the false lumen severely compressed the true lumen with consequent severe malperfusion of abdominal visceral vessels.
CT-pathologic correlation in smoking-related interstitial fibrosis. I’ve included annotated images of the pathology findings. Typical “ropy” fibrosis is present. The lobe was removed for a cancer.
July 7th, 2022.
Case Description
Tracheal fracture from blunt chest trauma. Of course, substantial pneumomediastinum is present. Surgical repair was performed.
Displaced intimal calcifications in distal aortic arch on chest radiography in Type B aortic dissection. This is a subtle finding of relevance when acute aortic syndrome is a clinical consideration.
Small nodules—-some cavitated–in Langerhan’s cell histiocytosis (presumed) These resolved after smoking cessation.
Classic findings of hemidiaphragm eventration. I’ve included videofluoroscopy and my report of the examination. Hemidiaphragm plication was performed.
Another case of complex tracheal lacerations from blunt chest trauma. Surgical repair was performed. I’ve included excerpts of the operative report.
High origin of the right renal artery. It’s not a rare anatomic variant.
June 23rd, 2022.
Case Description
Leadless right atrial and ventricular pacemakers. This combination of devices is under investigation for bradyarrhythmias.
Fatal acute exacerbation (presumed) of a fibrosing lung disorder. No other plausible etiology of this acute episode of deterioration was evident.
Familial pulmonary fibrosis. I’ve included a pathology report of a surgical lung biopsy.
June 16th, 2022.
Case Description
Explosive pleuritis in acute pulmonary infection. The rapid increase in the size of the left pleural effusion is impressive. Findings of necrotizing pneumonia/abscess are present in the left lower lobe.
Development of emphysema in AL amyloidosis. This phenomenon is well described, a consequence of the parenchymal deposition of protein.
Classic case of exogenous lipoid pneumonia, presenting as multifocal (including nodular) opacities. After the clinical diagnosis, the patient described nightly ingestion of mineral oli when questioned.
April 28th, 2022.
Case Description
Acute aortic mural injury in blunt chest trauma, including intra-mural hematoma. The amount of mural hematoma is unusual, extending into the proximal brachiocephalic arteries.
Small B-cell lymphoma discovered as a mass on lung cancer screening CT. This pathologic diagnosis was a surprise.
An indolent marginal zone B-cell lymphoma presenting as an extrapleural mass on radiography. Inexplicably, this was diagnosed several years later even though it had been perceived and reported. It grew modestly over time.
Multiple myeloma diagnosed after the discovery of “cysts on the jaws” on a dental Panorex and clavicle lesions on chest radiography. Pathologic fractures are present in some of the lytic clavicular lesions.
April 14th, 2022.
Case Description
A malpositioned LV vent in the left superior pulmonary vein. This was placed via the right superior pulmonary vein and is intended to be in the left ventricular cavity. A LV vent is often placed to mitigate left ventricular overdistention in central AV ECMO.
Initial malpositioned veno-venous ECMO cannula. When two IVC cannulas are present, the tips should be around 10 cm apart to avoid “recirculation” of returned oxygenated blood.
Bilateral hemidiaphragm muscle atrophy in familial neuralgic amyotrophy that involved (in part) both phrenic nerves. The CTs show diffuse muscle atrophy. I’ve included fluoroscopy images. Thoraco-abdominal paradox was present on visual inspection of thoracic versus abdominal wall motion.
April 7th, 2022.
Case Description
Right supra-clavicular venous malformation (presumed) Calcified phleboliths are present!.
Rounded atelectasis mimicking a pulmonary infection in an oncology patient. Unusually, the periphery of the opacity is partially aerated.
Findings of fibrotic hypersensitivity pneumonitis on surgical lung biopsy. I’ve included annotated pathology images.
March 24th, 2022.
Case Description
HAART annuloplasty device for aortic annulus reconstruction. This device may be used in selected patients in lieu of valve replacement in cases of aortic valve regurgitation or bicuspid stenosis.
CT-pathologic correlation in a surgical lung biopsy for ILD I’ve included annotated pathology images.
Pulmonary cysts in diffuse large B-cell lymphoma. Cysts may occur in a diverse variety of benign and malignant lymphoproliferative disorders.
March 10th, 2022.
Case Description
Focal fat in right ventricular myocardium in tuberous sclerosis. No cystic lung disease is present.
Pneumothorax ex vacuo adjacent to new right upper lobe collapse. A classic!.
Spontaneous diminution of fluid in a post-pneumonectomy space over a few months. The patient was always asymptomatic.
Evolution of lung disease in the anti-synthetase syndrome. On a later examination, I suggested the presence of evolving fibrosis, but the opacities substantially resolved. Don’t diagnose traction bronchiectasis when the bronchi are not really dilated!.
A cardiac bronchus supplying air to its own mini-lobe. A congenital classic, too.
February 24th, 2022.
Case Description
Delayed appearance of traumatic rupture of the left hemidiaphragm. The patient sustained lower rib fractures. He returned with symptoms and pleural fluid several days later. Even in retrospect, the diaphragm defect is not visible!
End-stage Langerhan’s Cell Histiocytosis. I’ve included annotated images of histopathologic findings in the explanted lungs.
Chronic fibrotic hypersensitivity pneumonitis on surgical lung biopsy. I’ve included annotated images of the histopathologic findings.
Diagnosing pleural space and subphrenic pathology on a rib series. This turned out to be a liver abscess and adjacent pleural fluid.
February 17th, 2022.
Case Description
Pulmonary dendriform ossifications in fibrotic NSIP in a patient with chronic scleroderma. This “adds” to the range of lung parenchymal disorders that may be associated with these ossifications.
February 10th, 2022.
Case Description
Pulmonary arterial hypertension in context of PAPVR and superior sinus venosus-type ASD. On CT in this context, always look at the pulmonary veins as well. It’s easy to overlook the PAPVR and then not look for the ASD.
Findings of fibrotic hypersensitivity pneumonitis on a surgical lung biopsy. I’ve included annotated images of the histopathological findings.
A bronchiolar pattern in vaping-associated pulmonary injury. The nature of these centrilobular opacities is nicely demonstrated on thin MIP images.
Lung cysts from parenchymal deposition of immunoglobulin-associated light chains in a patient with CLL. The patient presented with COVID-19 pneumonia. Cysts are present in the apical lungs on a neck CT performed years earlier.
January 27th , 2022.
Case Description
Necrotizing pneumonia and para-pneumonic effusion due to Strep. anginosis. I’m a strong advocate of performing contrast-enhanced CT in this clinical situation. It’s much easier to perceive the regions of parenchymal necrosis and separate pleural fluid from these.
The development of hypervolemic lung edema (fluid overload) in a patient with emphysema being treated for pneumonia Emphysema may substantially change the appearance of lung edema – the old adage of “regions without capillaries can’t get wet.”
Dysmorphic lung in a patient with prune belly syndrome. I’m not sure how best to describe the pulmonary and vascular findings that are present. This is generally attributed to the effects of oligohydramnios on the developing lungs. I don’t know of a better potential explanation.
January 20th , 2022.
Case Description
Shrinking lung syndrome in SLE. The findings are new from several years earlier. Expectedly, a diminished FVC was confirmed on PFTs.
A patient with a PICC experienced PVCs when she lay down on her left side! I had not encountered this before. A left lateral decubitus image showed that the PICC moved further into the low right atrium by about 5cm. The PICC was withdrawn. After encountering this, I found Case Reports of this phenomenon in the literature.
Lung and brain dissemination of Nocardia nova in an immunosuppressed patient being treated for lymphoma. A CT-guided biopsy of an apical lesion yielded the diagnosis.
The intra-lobular gradient sign in lung edema. This was likely hydrostatic edema; the patient improved with diuretic therapy. The authors state that the morphology suggests the Karst Mountain Tops in traditional Chinese paintings.
January 6th , 2022.
Case Description
A Type A dissection not observed on a CTPA performed for possible pulmonary embolism. Very similar to the case I showed on December 9th, 2021, the aorta was not opacified. The diagnosis was made on a CTA the next day. It’s important to ensure opacification of the aorta on a CTPA to avoid this circumstance. The proximal location of the circumferential tear is in the aortic root, and difficult to see because of vascular pulsation artifact. Use a fast scanner or cardiac gating for these examinations.
Appearance of a TandemHeart device on chest radiography. The location of the left atrial cannula is unexpected when it comes up the IVC. It is passed through the inter-atrial septum.
Evolution of left ventricular myocardial calcifications in a patient with severe pancreatitis and acute renal failure. The LV ejection fraction remained normal. When severe, this may produce a heart of stone.
Hydrostatic lung edema with so-called lamellar pleural effusions. This is actually sub-pleural interstitial edema, not pleural fluid. It’s unusual to see this on frontal radiography. A CTA confirms the presence of infective aortic valve endocarditis with substantial regurgitation shown on ultrasound.
December 16th, 2021.
Case Description
Slow growth of a thymoma. This was assumed to likely represent a right phrenic nerve schwannoma because of its location mostly in the right hemithorax. It grew slowly over several years. It was removed. Pathology: a thymoma!
Asymmetric enlargement of the right hemidiaphragm crus in inclusion body myositis. This is odd. It was an unanticipated imaging finding. The patient presented with lower extremity muscle weakness. The diagnosis was confirmed on a biceps muscle biopsy.
December 9th, 2021.
Case Description
A large opacity with bizzare calcifications on chest radiography. It turned out to be a large, solitary osteosarcoma metastasis (in an older person) with a distant history of the same.
A classic case of inversion of pulmonary blood flow from mitral valve stensois. The inversion reflects chronic, not acute, pulmonary vascular hypertension.
Inadvertent arterial PICC placement. One sees this very uncommonly.
Subtle displacement of intimal calcium reflecting an acute aortic dissection on a CTPA examination. This case exemplifies very important points: with short scan duration, the aorta may not be opacified on a CTPA examination; the intimomedial flap not depicted; and the diagnosis missed. Be sure your CTPA protocol images the chest after passage of contrast-opacified blood through the entire heart and aorta. It may be prudent to use a ROI on the descending aorta for the bolus-tracking protocol. Our scanners are fast!
December 2nd, 2021.
Case Description
The combination of peripheral AV ECMO and a left ventricular Impella device to manage severe cardiogenic shock. Here the Impella device decompresses the left ventricle which may be overdistended consequent on the left ventricular afterload increase associated with the institution of ECMO flow.
Embolized methylmethacrylate cement after vertebral body augmentation. It’s coincidental that someone just posted an example of this on Twitter !
Unilateral pulmonary opacities from an aspiration event. This happened during colonoscopy, explaining the involvement of the left lung!
November 18th, 2021.
Case Description
Right aortic arch with isolated left subclavian artery In this situation, the left subclavian artery may arise from the left pulmonary artery. In this instance, it is perfused via retrograde flow in the left vertebral artery. A ligamentum arteriosum completes the ring. It was surgically ligated.
Multiple small, Type 1 minimal aortic mural injuries in the descending aorta. The seatbelted patient was injured in a car crash. The filling defects are consistent with, at least in part, associated surface thrombi.
Externalization of the conducting cable in a Riata right ventricular pacemaker lead. This is a consequence of a design and manufacturing - associated defect.
Severe cystic disease and constrictive bronchiolitis attributed to severe RSV infection (with a prolonged intensive care hospital course) in early childhood . I’ve included some pathology images from examination of the removed right lower lobe in which the largest cysts were present.
November 11th, 2021.
Case Description
Right upper lobe PAPVR with a superior sinus venosus-type ASD The chest radiograph demonstrates a so-called balanced distribution of blood flow, with distended pulmonary arteries and veins. The shunt parameter (Qp • Qs) from MRI is 2.3 !
Severe (idiopathic) constrictive bronchiolitis. The profound – and diffuse – air-trapping was not perceived on the CT. It’s important to know about the extent of expiratory airflow limitation demonstrated on spirometry (included) to avoid a misperception. I’ve also included annotated pathology images from the surgical lung biopsy specimens.
Classic findings of CTEPH, with images acquired after surgical endarterectomy. The chest radiographs are also great for teaching the proper analysis of blood vessels on radiography.
November 4th, 2021.
Case Description
Recurrent H-type tracheoesophageal fistula in an adult. This young patient reported many years of an intermittent, troublesome cough. She had a fistula repaired in early childhood.
STAT6-positive solitary fibrous tumor. This large tumor was a surprise finding on chest radiography performed for a non-respiratory problem.
Sporadic constrictive bronchiolitis. Chest radiography in this patient is unrevealing. The diagnosis was confirmed on histopathologic examination of the explanted lungs after transplantation.
Smoking-related pulmonary disease. As in the patient above, chest radiography is unrevealing. The findings are consistent with emphysema (particularly paraseptal) and the pulmonary accumulation of smoker’s macrophages. Large bullae are not present.
October 21st, 2021.
Case Description
A long, unusual anterior junction line produced by bilateral anterior pneumothoraces in a trauma victim. I thought initially that this was an unusual distribution of left pleural air. The CT clarified the findings.
Small bilateral transcostal lung herniations after lung transplantation. These herniations are at the lateral aspects of the clamshell chest incision.
The appearance of small doppler electrodes on chest radiography and CT. The components of a Cook doppler device used for monitoring blood flow in a soft tissue flap used for closure of a disrupted sternal incision.
Evolution of white lungs in a patient on veno-venous ECMO for COVID-19 pneumonia. Around the time the image was acquired, the applied ventilator tidal volume was around 25cm.
The passage of mediastinal air into the anterior pneumoretroperitoneum in a ventilated patient with COVID-19 pneumonia. The air passes into the upper abdomen between the sternal and costal attachements of the hemidiaphragms at the Foramina of Morgagni. This is the classic article describing the phenomenon.
October 7th, 2021.
Case Description
Left hemidiaphragm paralysis attributed to pembrolizumab-associated phrenic nerve palsy. This patient with metastatic melanoma was treated with pembrolizumab beginning in June 2020. The imaging findings were noted in “routine” surveillance imaging in January 2021. Neuropathies are reported adverse events in the context of immune checkpoint - inhibitor therapies.
The bird’s nest sign in pulmonary septic embolism caused by Klebsiella. Tricuspid valve vegetations were seen on cardiac ultrasound. The patient also had a severe unilateral endophthalmitis. An aspirate of vitreous fluid yielded the bacterium on culture.
The unexpected recurrence of thymoma perceived on chest radiography obtained for cough. The thymoma was resected sometime in the 1990s. The unifocal recurrence was resected. Thymomas may grow very slowly.
September 30th, 2021.
Case Description
Rapidly shifting lobar atelectasis in an I.C.U. patient. When right upper lobe atelectasis occurred, adjacent pleural gas was present. The gas disappeared when the lobe subsequently expanded (no intervention). I believe this is an example of pneumothorax ex vacuo.
Multiple concurrent pathologies in an AIDS patient. They are: skin, pulmonary, and nodal Kaposi sarcoma; primary effusion lymphoma (characteristic pleural cellular findings); and Castleman’s disease in a biopsied lymph node. The examined nodal tissue and pleural lymphoid cells were HHV-8 and EBV-positive.
Multifocal foci of Diffuse Large B-cell Lymphoma. The sites included: pleural and, particularly, extrapleural tumor sheets; peri-portal tumor; multi-level spinal and para-spinal tumor. The diagnosis was made via a biopsy of paraspinal tumor. We also considered IgG4-related sclerosing disease as a plausible explanation for the findings.
September 23rd, 2021.
Case Description
Infectious endocarditis affecting a prosthetic aortic valve with involvement of the aortic root, annulus, and subvalvular left ventricular outflow tract - aorto-mitral curtain. On radiography, the orientation of the valve is abnormal with dehiscence confirmed during cardiac catheterization and CTA.
Behcet’s disease with substantial thrombotic occlusion of pulmonary arteries and focal aneurysms. Multiple pulmonary infarcts are present. The aneurysms were managed with intra-vascular coils. Later, one of the coils unfolded into an adjacent airway (artery-airway fistula), and then uncoiled up the trachea.
Transmyocardial perforation of an atrial pacemaker lead with a resultant right pneumothorax. The right pneumothorax was perplexing as the leads were inserted via the left subclavian vein. On frontal radiography the atrial lead does not appear abnormal! On cardiac ultrasound the lead was discerned as abnormal in position, and pericardial fluid was present. Lead revision was performed.
September 16th, 2021.
Case Description
Unusual anatomic variants present on chest CTA: a right bronchial artery arising from the left subclavian artery; and a strange left atrial diverticulum (outpouching) . Sometimes, unusual things occur together.
An EZ Bronchial Blocker and aortic thrombus about a left ventricular Impella device. The bronchial device (unilateral lung ventilation – the balloon is inflated) is a subtle finding on radiography. The occurrence of thrombus about the aortic portion of the device shouldn’t be surprising, I suppose.
Stent graft-induced new entry tear – SINE This tear occurred hours after placement of the stent for treatment of a complicated Type B aortic dissection. That’s unusual. They usually occur weeks or months later and in relation to the distal end of the stent.
Chronic, unrepaired traumatic rupture of left hemidiaphragm. Many healed rib fractures are present. I thought this was going to be thoracic splenosis upon review of chest radiography. A previous spine MRI shows that it has been present for many years.
September 9th, 2021.
Case Description
Caseous calcifications in mitral valve annulus and within left ventricular myocardium. The latter are very unusual and enigmatic.
A flank stab with the knife traversing the left hemidiaphragm. The resultant hemidiaphragm defect is quite large with bowel herniating into the basal hemithorax.
A retained guidewire within a jugular vein catheter. It was recognized after a few days. An unusual event! The catheter-guidewire combination was removed uneventfully.
The tip of the iceberg sign and other findings in a bronchial carcinoid. Regional hyperinflation is present about the lesion.
Adenocarcinoma with diffuse aerogenous tumor spread. Multifocal, multilobar ground glass opacities are present as well as many Cheerios.
September 2nd, 2021.
Case Description
Traumatic rupture of the anterior right hemidiaphragm. The focal rupture involved the lung visceral pleura and transversalis fascia, with pleural and anterior peritoneal air. The surgeon could see lung from the abdomen during reparative surgery.
Explosive pleuritis after CT-guided aspiration of a peripheral lung lesion (that had internal necrosis). Rapid accumulation of pleural fluid occurred. Strep. anginosis was cultured from the fluid.
A case of anti-synthetase syndrome-associated ILD. Anti-Jo-1 antibody is involved.
Another case of anti-synthetase syndrome-associated ILD. In this instance, anti-EJ glycyl-tRNA was present.
August 12th, 2021.
Case Description
Unilateral pulmonary embolism simulating intimal sarcoma. These emboli produced filling defects with apparent scalloped margins.
Incidental discovery of a thymic lesion on CT done for possible embolism. The morphology and attenuation characteristics are quite consistent with a cyst. A MRI could have been done for confirmation or in follow-up, averting surgical removal.
Langerhan’s histiocytosis involving lung, mastoids-temporal bones, and the iliac bone. The lung findings (reticulations and cystic disease) are consistent with so-called burned out disease.
Evolution of dystrophic nodal calcifications in treated small cell cancer. An unusual event!
A superior accessory fissure delimiting consolidation. The consolidation is caused by COVID-19 pneumonia.
Classic signs of fibrotic NSIP. These are: the exuberant honeycombing, the straight edge, and the anterior upper lobe signs.
August 5th, 2021.
Case Description
Thymic carcinoma with pleural tumors at presentation. The largest pleural lesion is intrafissural at the junction of the right major and minor fissures. On histopathologic examination, foci of neuroendocrine differentiation are present.
Surgical lung biopsy of ILD. It’s difficult to categorize this on histopathologic grounds. Airway-centric disease distribution, and the presence of ill-defined granulomas, suggest an inhalational disorder like hypersensitivity pneumonitis. Annotated pathology slides are included.
Primary coccidioidomycosis. Septal lines are present in the affected lobe. The imaging findings are easily mistaken for cancer – the initial presumptive diagnosis.
Cholangiocarcinoma metastases simulating lung consolidation from pneumonia. I think it’s likely that a lepidic growth pattern is present. Solid nodules are also present.
A left atrial outpouching. The morphology and location are consistent with a so-called atrial diverticulum.
The effect of a pulmonary artery cannula on the distribution of contrast-opacified blood in the pulmonary arteries. The cannula is present for extra-corporeal right ventricular assistance. The cannula tip is in the intra-pericardial right pulmonary artery. The returned blood is not opacified diluting contrast medium delivered via the SVC. If this were a CTPA for embolism, evaluation of the right lung would be problematic.
July 29th, 2021.
Case Description
A strange case of acute aortic syndrome with substantial hemothorax. The patient presented with a large left pleural effusion. It turned out to be a hemothorax. Left para-aortic mediastinal blood is present at the level of the distal aortic arch. No extra-luminal extravasation of contrast-opacified blood was present. And none occurred on several follow-up examinations on succeeding days, although ulcer-like projections developed and the aortic lumen increased in caliber. An endovascular stent was ultimately placed. This might be a strange manifestation of penetrating atherosclerotic ulcer.
July 22nd, 2021.
Case Description
Acute, fatal fistula between a pulmonary artery and contiguous bronchus. This patient presented with acute, severe hemoptysis. The disruption of the pulmonary artery segment and its communication with the contiguous bronchus was demonstrated on CT, as well as an intra-luminal abnormality in the airway lumen. An autopsy showed findings consistent with an abscess with bacteria on staining. I wondered about an aspirated foreign body.
Type A aortic dissection with a circumferential tear close to the aortic root. Retrograde prolapse of the proximal flap through the aortic valve in diastole was seen on TEE. A short segment of aorta above the tear location shows the empty aorta sign. The case also shows a fenestration between the true and false lumens at the base of the brachiocephalic artery, that results in persistent perfusion of the false lumen after (hemiarch) surgery.
Typical findings of non-fibrotic hypersensitivity pneumonitis on CT. A mosaic attenuation pattern due to air-trapping is conspicuous. I don’t think a surgical lung biopsy was necessary, but annotated pathology slide images are included.
July 8th, 2021.
Case Description
A new case of asymmetric, right upper lobe-dominant lung edema caused by severe mitral valve regurgitation. This complements the case I showed last week! I’ve included excerpts of the ultrasound report and the surgical procedure to perform a valve repair.
The use of two cannulae to perform veno-venous ECMO. Nowadays, we usually see a single dual-channel cannula inserted via a jugular vein. In this circumstance, one cannula tip is in the supra-hepatic IVC; the other in the lower SVC.
Pulmonary hypertension produced by a superior sinus venosus-type ASD. As expected, partial anomalous pulmonary venous return to the upper SVC is present. This was managed by means of the Warden procedure.
Correction of a pectus carinatum sternal deformity by a modified Ravitch procedure. I’ve included excerpts of the Op. report that detail the fundamental components of the procedure.
A coral reef aorta involving the upper abdominal aorta. This is the second case I’ve seen.
July 1st, 2021.
Case Description
Asymmetric, right upper lobe-dominant lung edema caused by severe mitral valve regurgitation. The mitral valve disease was identified on cardiac ultrasound and confirmed during surgical replacement of the same.
A tracheostomy tube misplaced outside the tracheal lumen. A “subtle” radiographic diagnosis confirmed on clinical evaluation. It’s not clear why or how this happened after initial, uneventful placement.
Right supra-hilar granulomatous fibrosing disease causing asymmetric lung edema. CT shows the extent and location of the tissue surrounding the right superior pulmonary vein in that location.
June 24th, 2021.
Case Description
Cystic lung disease in Waldenstrom macroglobulinemia. Cystic disease, consequent on pulmonary deposition of immunoglobulin-associated protein, may occur in a variety of lymphoplasmacytic proliferative disorders. In addition to cysts, several nodules, with calcium or bone within, are present, consistent with amyloid deposition. Waldenstrom’s may cause systemic amyloidosis.
Imaging findings consistent with acute lung injury edema attributed to tumor lysis syndrome in a patient treated for AML with high blast cell count. This diagnosis is speculative but quite plausible in this context.
Durvalumab-associated acute pulmonary toxicity. This immune checkpoint inhibitor was employed to treat lung cancer. The opacities resolved upon cessation of drug ingestion and low-dose oral steroid. (Opacities in the right upper lobe represent evolving radiation fibrosis.)
An unusual opacity in the post-pneumonectomy space immediately after surgery represents an intercostal muscle flap transposed to the bronchial stump. Once the space fills with fluid, it will only be visible on computed tomography as a subtle low-attenuation opacity because some extrapleural fat is typically included during flap creation.
A flow/mixing phenomenon (black smoke) simulates a pulmonary embolus. This is likely inflow of bronchial artery blood as extensive, chronic airway disease is present, with bronchiectasis.
Fluid and air trapped by Surgicel-Fibrillar simulates a mediastinal abscess after aortic surgery. A mediastinal exploration was conducted because abscess was suspected on imaging. No pus was found. This material is an absorbable hemostatic agent.
An IMH with an intramural blood pool was unexpectedly discovered in a patient who fell down stairs at home. It was unchanged a day later. We speculate the fall was not the proximate cause of this.
April 29th, 2021.
Case Description
Dilated azygos vein due to infra-hepatic interruption of the IVC. In this situation, the azygos is acting as an alternative pathway for blood flow to the right atrium. On CT, the hemiazygos vein is also dilated.
An EZ Blocker device for single lung ventilation. This device is very difficult to perceive on radiography. The opaque portions are very thin.
A diffuse fibrosing ILD likely due to fibrotic hypersensitivity pneumonitis. Annotated images of findings on surgical lung biopsy are provided.
Non-fibrotic hypersensitivity pneumonitis on surgical lung biopsy. I wish I had been asked to review the images prior to the biopsy. Typical imaging findings are present.
Primary mediastinal germ cell tumor – yolk sac tumor on pathologic examination. As is typical, the serum AFP level was markedly elevated.
Typical extrapleural hematoma from blunt chest trauma. The extrapleural (displaced) fat sign is present. It was drained via limited thoracotomy. Excerpts of the Operative Report are included.
April 15th, 2021.
Case Description
Many chest injuries from manual chest compressions during CPR. These include rib fractures, a sternal fracture, a retrosternal hematoma, a large anterior chest wall hematoma, subcostal extrapleural hematomas and, possibly, anterior lung contusions.
Marijuana dabbing-associated acute lung injury. This patient has been dabbing once or twice a day for several months.
Pulmonary metastases (some with cavitation) from a malignant uterine PEComa. PEComas, which are mesenchymal tumors, include LAM and angiomyolipomas.
A penetrating atherosclerotic ulcer with intramural hematoma — that isn’t. One pitfall in this case was not acquiring a non-enhanced CT series; the other was the existence of a false lumen from a prior dissection.
April 1st, 2021.
Case Description
A small esophageal traction diverticulum. A contiguous, calcified lymph node is present. On the recent CT, the diverticulum is filled with ingested food.
Iatrogenic pulmonary infarction from surgical stapling of pulmonary vessels. This occurred during resection of a colonic cancer metastasis in the central right lower lobe.
An iatrogenic diaphragmatic hernia resulting in gastrothorax. This complicated resection of a very large left adrenal tumor — a ganglioneuroma. It was diagnosed on the first post-operative day with radiography and CT.
Infectious thoracic diskitis presenting as a paraspinal opacity and disk space narrowing. This was an unexpected finding on radiography for assessment of the position of a PICC used to treat a lumbar diskitis.
March 18th, 2021.
Case Description
Mediastinal hemangioma demonstrated on multiple imaging modalities. Characteristic findings are present on CT, MRI, and FDG-PET. The only missing finding is the presence of calcified phlebolith-like structures. A CT-guided core biopsy yielded concordant findings of a vascular lesion.
An ALK-positive Inflammatory Myofibroblastic Tumor presenting as an incidental solitary pulmonary nodule. Its lobulated and slightly spiculated margins certainly suggest a primary lung adenocarcinoma.
Unicentric Castleman’s disease — hyaline vascular type— presents as a small extra-pleural lesion. This was a surprise!.
March 11th, 2021.
Case Description
Use of an extra subcutaneous lead to achieve a defibrillation threshold. Usually only one right ventricular lead with shocking coil(s) is need with an AICD device. Sometimes an extra is needed. It may be placed in a vessel, such as the azygos vein or, as in this instance, in the subcutaneous chest wall
Another case of the use of extra defibrillation leads. In addition to a subcutaneous electrode, another one was placed in the coronary sinus. The latter is quite unusual.
Segmental tracheal stenosis after intubation in the context of severe Stevens-Johnson syndrome. Inflammatory tracheal (and elsewhere, such as the mouth) mucosal injury was already present before intubation.
Hemidiaphragm plication for substantial eventration. Typical CT findings of eventration are present on CT. Findings at surgery confirmed this (operative report excerpts are included) although not anticipated beforehand.
A midline subcutaneous dermal piercing produces an opaque object on radiography. Zooming-in reveals the nature of the adornment.
March 4th, 2021.
Case Description
A left paraspinal interface produced by pathology in the right hemithorax. In this instance, some right pleural fluid accumulated in the lower azygo-esophageal recess of the mediastinum, displaced the esophagus leftward, and presented to the left of the spine.
Calcified mediastinal nodes from remote histoplasmosis. One of the nodes is very enlarged with a milk-of-calcium appearance on CT.
February 25th, 2021.
Case Description
Classic “textbook” rheumatoid nodules. They healed with resultant small parenchymal scars.
An interesting additional sign of pneumomediastinum. This is the appearance of a new right-convex mediastinal-lung interface on frontal radiography when mediastinal air contacts the right-lateral wall of the ascending aorta, rendering it visible.
February 18th, 2021.
Case Description
Pulmonary cysts (speculatively) representing pleuropulmonary blastoma (PPB) Type 1 -regressed. The history is supportive of this speculation: the patient had lung cysts removed in the ? neonatal period and had kidney lesions. Calcified kidney lesions (presumably cystic nephromas) are present on a current abdominal CT. This is an informative article on the notion of regressed Type 1 PPB and the association of PPB with the DICER1 tumor predisposition syndrome.
Progression of cystic disease and thin-walled bronchiectasis in Sjogren syndrome. This phenomenon, mistakenly attributed to LIP, is a consequence of the deposition of light chains in the lung, upregulation of macrophage-associated matrix metalloproteinase activity, and the resultant degradation of extra-cellular matrix, including airway-associated elastin.
February 11th, 2021.
Case Description
Dynamic evolution of Type A acute aortic syndrome with (limited) incomplete dissection. The initial examination shows an intramural hematoma in the ascending aorta. A follow-up the next day shows a new intimo-medial flap in the descending aorta. Careful evaluation of the proximal ascending aorta shows (on some series) a focal intimal disruption — mushroom configuration-like— confirmed at surgery. This entity is usually elusive on imaging, as described in this article.
Distinguishing between pleural fluid and lung atelectasis on bedside radiography. This is often very difficult, sometimes impossible, as shown in this case: bilateral lower lobe atelectasis simulates pleural fluid. The visible vessels in the lower lungs are located in the aerated right middle and left upper lobes.
February 4th, 2021.
Case Description
Asymmetric hydrostatic lung edema in the transplanted lung after unilateral transplantation. This exemplifies the adage that portions of lung that do not contain capillaries cannot become wet. This applies to the native emphysematous lung in this instance. In addition, this case demonstrates pseudo-emboli in the native right lung due to slow flow and incomplete mixing of opacified and non-opacified blood — the black smoke phenomenon.
A calcified fibrin sheath in the right brachiocephalic vein. This is attributable to long-term catheterization of this vein.
The effect of emphysema on the appearance and distribution of lung edema on radiography and CT. This is a great companion case to the one above. Findings on chest radiography may be very difficult to discern as possible lung edema.
Findings of left subpulmonic pleural effusion on radiography. This case also demonstrates the separation of air in the gastric fundus from the apparent hemidiaphragm — a new finding from the prior examination.
January 28th, 2021.
Case Description
Evolution of radiation fibrosis after stereotactic ablative radiation therapy of two lesions. The opacities slowly increased over about a year but remained within the 50 Gy iso-dose field perimeter. I’ve included images of the iso-dose curves that are useful in a case like this.
A central small cell cancer with a peripheral opacity of pulmonary hemorrhage-infarction. On CT one can see slow flow in peripheral vessels distal to a tumor-encased peri-hilar pulmonary artery. This is a great 1954 Thorax article on this phenomenon.
Enlarged hila from substantial vessel-distending pulmonary emboli. This 29-year-old person presented with syncopal episodes.
Transient hemidiaphragm elevation from an interscalene nerve block. The anesthesia was given in the context of extremity surgery.
January 21st, 2021.
Case Description
A calcified perihilar node becomes a LUL broncholith with resultant obstructive atelectasis. A left upper lobectomy was performed. I’ve included bronchoscopy images.
Multifocal, multilobar pulmonary IgG4-sclerosing disease on surgical biopsy. Multiple imaging patterns are present, including subpleural (simulating sarcoidosis a bit) and airway-centric disease. This is a very unusual case with classic histopathologic findings. I wish I had the pathology slides.
Bilateral thoracoliths with internal calcifications. Soft tissue surrounds the calcifications, supporting the notion that these originate as foci of extra-pleural fat necrosis that somehow end up in the pleural space.
January 14th, 2021.
Case Description
Pathway for passage of mediastinal air into anterior abdominal extra-peritoneal space. Air may pass from the chest into the upper abdomen via the sternocostal triangles — the Foramina of Morgagni. This classic article from 1978 nicely describes this.
Chronic pulmonary thromboembolism managed with surgical pulmonary endarterectomies. Chest radiography shows irregular and asymmetric distention of some pulmonary arteries, contrasted with small vessels distal to obstructed vascular segments, in different regions.
Fibrotic hypersensitivity pneumonitis on surgical lung biopsy. I’ve included annotated images of the histopathologic findings.
Another case of fibrotic hypersensitivity pneumonitis on surgical lung biopsy. I’ve included annotated images of the histopathologic findings for this case also.
An example of the unusual, subtle finding mislabelled lamellar effusion in lung edema. This actually represents subpleural interstitial edema and is located just above the lateral costophrenic sulci on the frontal projection.
Large, fatal right atrial/mediastinal tumor in a smoker, nominally undifferentiated on histopathologic examination. Because cells of rhabdoid morphology are present, this is speculatively an instance of a SMARCA4-deficient lung cancer. Immunohistochemical evaluation for the absence of the associated BRG1 gene product was not performed.
December 10th, 2020.
Case Description
Amyopathic MDA-5 antibody-associated fibrosing interstitial lung disease. The patient presented with Gottron papules and Mechanic’s Hands. I was expecting an anti-synthetase antibody. This dermatopulmonary syndrome may be associated with severe, progressive lung disease.
A large chest wall (extrapleural) hematoma caused by a fractured rib fragment lacerating an intercostal artery. The person fell off a ladder. The hematoma is associated with a classic (displaced) extrapleural fat sign. Active extravasation of contrast-opacified blood is visible adjacent to the fracture. The associated vessel was subsequently embolized.
Non-perceivable (on radiography) posterior dislocation of the right sternoclavicular joint in a blunt trauma victim. It’s very easy to go by this on CT, too.
Pneumomediastinum from the Macklin Phenomenon in a person with severe vomiting. Air in the connective tissue sheaths about pulmonary veins is conspicuous.
Severe and extensive tracheal and bronchial wall thickening in the victim of a house fire. Acute lung injury did not (surprisingly) develop. The presence of a vascular occlusive device for an AVM is an unrelated finding.
TEVAR management of a leaking aortic aneurysm associated with subsequent identification of an endoleak. It was identified as a Type 1a (distal) endoleak, but an additional stent did not occlude it. It is presumably a Type 2 leak from an lumbar vessel.
November 26th, 2020.
Case Description
Primary coccidioidomycosis in a renal transplant recipient. The procedure was performed many months ago. She has recently been traveling extensively in a van, visiting many southwestern states.
Osseous matrix in pulmonary osteosarcoma metastases. Early CT examinations show subtle tumor-associated vascular distention of lobular pulmonary arteries. These are best evaluated with thin-ish MIP slabs.
November 19th, 2020.
Case Description
Tubular opacity of biosealant used in CT-guided lung biopsy mistaken for possible AVM. The associated mild FDG activity is likely from accumulating macrophages trying to gobble up the material.
Origin of right vertebral artery from the distal aortic arch. It courses behind the esophagus to reach its usual vertebral location.
Pneumomediastinum from the Macklin phenomenon in a lung transplant patient. An interesting finding is septal emphysema in the lungs.
November 12th, 2020.
Case Description
Classic evolution of a pulmonary infarct (on radiography) after acute pulmonary embolism. One could not have predicted this when viewing the CTPA which showed consolidative opacities consistent with pulmonary hemorrhage. On the lateral projection, it has a hump-shaped interface with adjacent lung.
Giant cell arteritis (presumed) with substantial involvement of femoral, subclavian, carotid, and vertebral arteries. It slowly improved with oral steroid. Residual mural thickenings are still present.
Large tophi of gout about the sternoclavicular and shoulder joints. I’ve included hand radiographs that show classic findings of severe gout.
Pneumothorax ex vacuo after placement of LUL bronchial valves for emphysema. This developed as a consequence of the obstructive LUL atelectasis.
October 29th, 2020.
Case Description
Multiple adenocarcinomas in situ with annotated pathology images. One was resected via a lobectomy. I’m not sure why this was done. It had increased minimally from 6mm to 10mm over about four years, without the development of any opacity within the pure GGO. Several smaller lesions were present adjacent to it, not visible on CT. A smaller, identical lesion is present in the LUL, minimally increased in size as well.
Sarcoidosis presenting as a dominant RML mass with many smaller nodules elsewhere in the lungs. An initial CT-guided core biopsy generated confusion because many lymphoid follicles were present in the specimen. We don’t know why. I’ve included annotated pathology images showing many compact, hyalinizing granulomas.
Extramedullary pulmonary hematopoiesis (presumed) in chronic polycythemia vera. The patient also has pulmonary hypertension, a common accompaniment.
October 15th, 2020.
Case Description
Endobronchial carcinoid-associated LLL atelectasis very difficult to perceive on chest radiography. This was not perceived on serial radiography performed over several months. It’s a nice example of what I call a hidden lesion.
Intra-vascular metastases from urothelial cancer producing lobular infarction (presumed). We not uncommonly see intra-vascular metastases as tree-in-bud-type opacities. This occurrence is rare.
Perceiving pulmonary emboli when contrast-enhanced pulmonary artery blood is 127 H.U. This was not a CTPA examination, but the emboli are (subtly) visible.
Constrictive bronchiolitis as a late complication of stem cell transplantation for myeloma. The findings may be overlooked when a mosaic attenuation pattern is extremely subtle. When previous CTs are available for comparison, review them side-by-side. And review any spirometry testing results (from PFTs) available.
September 24th, 2020.
Case Description
Pneumomediastinum in a weight-lifter going for his personal best. A nice example of the Macklin phenomenon in action.
Assessment of the proper positioning of an Intra-aortic Balloon Pump. Even when the tip is properly positioned just below the origin of left subclavian artery, the balloon may still extend across abdominal visceral arteries, as shown in this case. A limited number of balloon sizes are available. In most cases, of course, no untoward consequences ensue.
Human metapneumovirus pneumonia. This occurred in an immunocompetent patient in the community. It has no special imaging features.
Epicardial fat pad sign of pericardial fluid on the frontal projection. This is a very unusual occurrence. Just the right amount and orientation of epicardial fat is necessary for this sign to appear.
Transpleural collaterals from internal mammary artery branches in CTEPH. This is shown on CT and conventional angiography performed to identify a possible arterial bleeder after surgical pulmonary endarterectomy.
September 10th, 2020.
Case Description
Bronchial atresia with calcified structure within. This is the first time I’ve seen this phenomenon. I wonder if the intraluminal bronchial contents has calcified.
Spontaneous proximal migration of a CRT-D coronary vein lead. This will diminish the efficacy of resynchronization on left ventricular ejection. It may need to be repositioned, but not in this case because a LVAD had already been placed.
Transformation of treated solid lung adenocarcinoma metastases into thin-walled cysts. This is certainly not in the usual differential diagnosis for such cysts.
August 27th, 2020.
Case Description
Interstitial pneumonia with immune features. A surgical lung biopsy (annotated slides are included) showed three findings consistent with connective tissue disease-associated ILD: pleuritis; peri-bronchiolar lymphoid follicles; and cellular non-specific interstitial pneumonitis.
August 20th, 2020.
Case Description
Straight back syndrome. This patient has no cardiorespiratory symptoms or murmurs. I’m not sure it’s appropriate to assign this label based solely on imaging findings.
Small cell cancer with extensive tumor in the left para-aortic mediastinum. In a case like this, it’s important expressly to determine the presence or absence of the following: vocal cord paralysis; phrenic nerve dysfunction; and occlusion of the left superior pulmonary vein. All are present here. Asymmetric FDG uptake is present in the functional right vocal cord; the left diaphragmatic crus is atrophic and the hemidiaphragm elevated; left upper lobe edema is present, not to be mistaken for lymphangitic tumor spread.
A tracheal bronchus supplying the apical segment of the RUL and a wandering right superior pulmonary vein. Anomalous airway and vascular findings often occur concurrently— we call this Kanne’s Rule
August 13th, 2020.
Case Description
Hydrostatic lung edema due to severe aortic valve regurgitation in marked dilatation of the aortic root. This case nicely shows that marked dilatation of the aortic root may not be perceivable on chest radiography.
Fleischner and Westermark signs in acute, extensive pulmonary embolism. The associated vascular findings on chest radiography are easy to miss. Attempted catheter thrombolysis failed; the patient suddenly arrested (PEA) necessitating emergency institution of peripheral AV ECMO and surgical embolectomy.
August 6th, 2020.
Case Description
Pulmonary Dendriform Ossifications. I don’t know why a surgical lung biopsy was performed. It wasn’t indicated. The profusion increased slightly over many years. But I’ve included annotated images of the pathology findings on H&E slides. We don’t get to see that often!
The evolution of extensive subpleural cysts in COVID-19 pneumonia-associated acute lung injury necessitating ventilatory support . This occurrence has been reported.
Acute lung injury edema as a consequence of the Differentiation Syndrome. This typically occurs in the context of treatment of acute promyelocytic leukemia with all-trans-retinoic acid (particularly).
July 30th, 2020.
Case Description
Intercostal artery disruption by an acute rib fracture fragment. Active extravascular extravasation of contrast-opacified blood is demonstrated on CT. VRT images are provided. A Gelfoam intercostal artery embolization procedure was performed.
Protek Duo cannula for right ventricular assistance. This device permits assistance by insertion of the dual-channel cannula via a jugular vein.
Progression of scleroderma-associated ILD over years to the presence of so-called exuberant honeycombing in the lower lungs. At this stage of fibrosis, a lung biopsy would likely show findings of Usual Interstitial Pneumonia.
Breast cancer radiation therapy-associated Organizing Pneumonia. This enigmatic condition should not be confused with actual radiation injury/fibrosis. It responds to steroid therapy, as in this patient.
July 23rd, 2020.
Case Description
RV perforation by retained vascular sheath in the context of pacemaker placement. This adverse occurrence is simply…strange.
Large right atrial thrombus with pulmonary emboli. This is also an odd case. On cardiac ultrasound (included) it prolapsed slightly through the tricuspid valve in atrial systole. It was surgically removed.
Very delayed diagnosis of lung adenocarcinoma with eventual aerogenous spread to other lobes. On initial imaging—an abdominal CT—it has morphologic features of focal pneumonia with (pseudo)cavitation.
Lung disease in a young patient with a current diagnosis of systemic juvenile idiopathic arthritis. The lung disease has some findings consistent with follicular bronchiolitis and foci of subpleural cystic change. One of our discussants (T.H.) suggested the possibility of the COPA syndrome. I’ll update this if more information about this possibility becomes available.
July 16th, 2020.
Case Description
Very vascular pleural metastatic renal cell cancer. Parasitism from systemic arteries, particularly the lateral thoracic artery, is extensive.
Obstructive left lower lobe collapse caused by a carcinoid tumor. This is an excellent teaching case of the direct and indirect signs of lobar collapse. These can be relatively subtle and easily overlooked.
A new subcentimeter nodule caused by Mycobacterium kansasii. This was noted on a CT obtained for planning a cardiac procedure. It was cultured from the aspirate of a CT-guided sampling procedure.
Desmoplastic malignant mesothelioma. Diagnosis was a bit delayed as the pleural effusion was attributed to a parapneumonic effusion.
July 2nd, 2020.
Case Description
Tourniquets fixing cannulae used for extracorporeal right ventricular assistance. The opaque portions produce unusual opacities adjacent to the cannulae on chest radiography. They fix the cannulae at their entrance in the chest wall.
Extensive invasion of metastatic chondrosarcoma metastases into contiguous pulmonary veins. These may potentially be misperceived as venous thrombosis.
Multiple foci of endobronchial metastases from clear cell carcinoma of kidney. Two of these were diagnosed as such via bronchoscopy.
Imaging of a so-called probe-patent foramen ovale. This is a nice example of this as an incidental finding on non-cardiac computed tomography.
Acute lung injury edema as a manifestation of acute fat embolism (presumed). This was observed several hours after intra-medullary nailing of a femur fracture. The right upper lobe is relatively spared because of pulmonary emboli— confined to that region — demonstrated on CTPA two days before!
Mild enlargement of intra-thoracic nodes (mostly hilar and peri-hilar) in COVID-19 pneumonia. This is present on a CTPA that confirmed a concern for acute pulmonary embolism.
An acute extra-pleural hematoma mistaken for hemothorax in a trauma victim. This has a nice example of the extrapleural fat sign produced by inward displacement of extra-pleural fat. It was surgically drained.
June 25th, 2020.
Case Description
Slow-growing solitary fibrous tumor This asymptomatic lesion was observed in the basal left hemithorax on an abdominal CT. It had grown a bit over 10 years. It was STAT-6 positive, a very prevalent finding.
Isolated intra-tracheal metastasis from clear cell renal cancer. It was removed via bronchcoscopy. The patient later developed subcentimeter parenchymal metastases, growing very slowly over years.
Inflammatory myofibroblastic tumor as incidental lung nodule. As in this case, ALK rearrangements may occur, additional evidence of a clonal neoplasm.
Difficult-to-classify interstitial fibrosing lung disorder. I’ve included details of the clinical presentation and annotated pathology images from a surgical lung biopsy. This is not an unusual circumstance. With respect to the possibility of UIP of IPF, this would be: Indeterminate for UIP on CT.
June 18th, 2020.
Case Description
Chronic hypersensitivity pneumonitis on surgical lung biopsy No CT features are present that predict the pathological findings. Only minimal upper lung zone abnormality is present. Annotated pathology slides are included.
Recurrent pulmonary infections over years associated with Congenital Pulmonary Airway Malformation I’ve included excerpts of the Operative Findings and Pathology Report.
BioZorb 3D Bioabsorbable Marker on chest radiography. This was placed in a breast lumpectomy site.
May 28th, 2020.
Case Description
Hydatid cysts (Echinococcus granulosis), one with a classic Water Lilly sign. As is typically the case, the patient is a shepherd. In the Western states, farmers often employ Peruvian or Spanish (Basque region) shepherds to tend their sheep. Opacity in the lobe is consistent with cyst rupture into the adjacent lung. This cyst was resected. Excerpts of the Operative Report are included.
Florid smoking-related Desquamative Interstitial Pneumonia (DIP). I’ve included slides from the surgical lung biopsy that show the classic Smoker’s Macrophages containing fine, brown pigment.
Embolization of a shotgun pellet into the apical right ventricle. Many pellets are present in the abdomen and pelvis.
May 21st, 2020.
Case Description
Discovery of a (presumed) thymoma in a trauma patient. The associated mediastinal-lung interface is a subtle finding on initial bedside radiography. We know that the discovery of thymomas is not a rare event in other contexts, for example, CT screening for lung cancer.
Post-transplantation lymphoproliferative disorder after lung transplantation. FDG-avid nodular lung lesions is the dominant imaging manifestation, a common occurrence.
A leiomyosarcoma presenting as a lower hemithorax mass, contiguous with aorta and esophagus, associated with tumor mass in the left retrocrural space and pleural effusion. The precise point of origin cannot be discerned, as such. The diagnosis was made by transesophageal needle core biopsy.
Multiple mycotic aneurysms of pulmonary arteries as a consequence of tricuspid valve endocarditis in a drug abuser. The findings suggest pulmonary emboli in some locations (no DVT was present in lower extremity veins). The tricuspid valve vegetations are visible on CT. Nodular and cavitary-nodular pulmonary lesions are also present.
May 14th, 2020.
Case Description
Tracheal wall laceration from a neck gunshot. On the axial CT the finding is quite subtle, manifesting as a bulge involving the left posterior-lateral wall.
Incarcerated and ischemic stomach which is herniated through an iatrogenic defect following liver transplantation surgery. Periodic imaging over a period of years show (in retrospect) progressive enlargement of the defect with ultimate herniation of the stomach through it. It’s curious that the defect is on the left side.
Transpleural collaterals from chest wall to pulmonary veins in Budd Chiari syndrome. A positive late ultrasound bubble study was attributed to intra-pulmonary communications between pulmonary arteries and veins (as one may see in the Hepatopulmonary Syndrome), not the case in this instance.
May 7th, 2020.
Case Description
Spontaneous connection of varices with left inferior pulmonary vein in cirrhosis. The cirrhosis is this patient is a consequence of chronic right atrial hypertension after Glenn and Fontan procedures for pulmonary atresia.
April 30th, 2020.
Case Description
ILD in the anti-Jo-1 synthetase syndrome. The imaging findings are consistent with a (presumed) combination of Organizing Pneumonia and cellular NSIP. The patient was started on mycophenolate therapy.
Diffuse interstitial edema with large septal lakes, some simulating nodular pulmonary disease. The edema resolved with diuretic therapy and time. The precise cause in this patient with diabetes remains elusive.
Interstitial fibrosis with basal honeycombing in a patient with severe rheumatoid arthritis and scleroderma, with calcinosis. Radiographs of the patient’s hands are included.
April 23rd, 2020.
Case Description
Granulomatous-lymphocytic interstitial lung disease (presumed) with Evan’s syndrome and likely immunodeficiency. This patient initially presented with a nose bleed and thrombocytopenia, and was subsequently discovered to have a Coombs-positive hemolytic anemia. He has experienced an unusual number of infections and his IgG level is low. The association between GL-ILD and various immunodeficiency states is well recognized.
Pleural and peritoneal tuberculosis. The patient had a travel history to Kenya. Stains for acid-fast organisms on pleural and peritoneal fluid were negative but cultures eventually grew MTb.
April 16th, 2020.
Case Description
Chronic pleural effusions after lung transplantation resulting in formation of multiple foci of round atelectasis This is the first time I’ve seen this degree of chronic persistence of pleural effusions. A right pleural biopsy revealed chronic fibrous pleuritis.
Vascular leak syndrome and refractory chronic serositis (pleuritis and pericarditis) as a manifestation of chronic GVHD after stem cell transplantation for leukemia. I’ve not previously encountered this rare entity. Here is a Case Report about it.
March 26th, 2020.
Case Description
Management of a severely leaking descending aortic aneurysm with TEVAR. First, a carotid-left subclavian bypass was performed. Then multiple, overlapping endovascular stent grafts were deployed. The landing zone of the most-proximal stent is just beyond the origin of the left carotid artery.
Surgical management of an ascending aortic aneurysm with an aortic graft and a frozen-elephant trunk procedure. The ascending aorta and arch were replaced with a multi-sidearmed Hemashield graft with anastamoses of the brachiocephalic ateries to the sidearms. The endovascular stent of the frozen elephant trunk may be used if a procedure involving the descending aorta becomes necessary in the future.
Identifying a pneumothorax in the context of severe bullous emphyema with the so-called double wall sign. This may be useful when it’s difficult to separate bullae from possible pleural space air. One certainly doesn’t want to drain a mis-diagnosed bulla.
March 12th, 2020.
Case Description
Traumatic aortic IMH adjacent to a vertebral body fracture. The proximity of the aortic mural injury and fracture strongly suggest a causal association. An intervention for it was not performed.
Oversewn sidearm of a Hemashield ascending aortic graft produces a pseudo-pseudoaneurysm. The sidearm was used for antegrade cerebral perfusion during the operation. It was removed thereafter. Knowledge of the procedure is very useful when reporting a CT performed after surgical management of acute aortic syndrome.
Opportunistic Legionella micdadei pneumonia in a patient with CLL. The consolidative opacities initially suggested more-common bacterial etiologies, with cavitation occurring later.
Opportunistic Geotrichum capitatum pneumonia in leukemic patient with neutropenia. Infection due to this ubiquitous organism typically occurs only in the context of neutropenia.
March 5th, 2020.
Case Description
Classic rheumatoid nodules. Many are subpleural in location; some are cavitated.
Acquired transcostal herniation of lung and the adjacent liver. This occurred during an intense episode of coughing. The patient reported immediate, severe chest wall pain. The disrupted intercostal muscles, and the separation between the ribs, is impressive! One rib is fractured. The defect was surgically repaired.
February 27th, 2020.
Case Description
Apical nodule in left hemithorax produced by T1 nerve root schwannoma (presumed). The lesion protrudes into the apical hemithorax with a sharp and well-defined interface with the left lung.
Inadvertent injection of a fair amount of air into a peripheral vein during a pressure bag infusion of fluid on the way to the CT scanner. The patient was hypotensive due to pericardial tamponade from spontaneous hemopericardium attributed to anticoagulation. Small amounts of air are present in anterior segments of pulmonary arteries. Nothing untoward happened subsequently.
Limited acute lung injury edema attributed to isocyanate inhalation. On the two occasions in which this occurred, the patient was working (welding and drilling) with plastic items that were heated with resultant vaporization of fumes. Prompt spontaneous improvement occurred.
February 20th, 2020.
Case Description
Left anterior chest wall chondrosarcoma. The findings on chest radiography are, as expected, elusive. The very small nodules present on chest radiography turn out to be foci of cartilagenous matrix in a large tumor.
Iatrogenic right hemidiphragmatic defect, consequent on liver resectional surgery, associated with later bowel herniation and obstruction I think this is the first time I’ve seen this particular complication.
February 13th, 2020.
Case Description
Pulmonary neovascularity in severe familial pulmonary artery hypertension. These unusual tortuous and corkscrew vessels are not AVMs. This is an article that describes radiologic-pathologic correlation in surgical lung biopsies:PMID:16267251
Type-3 traumatic acute aortic mural injury with intra-mural hematoma. The intra-mural hematoma extends into the proximal left subclavian artery.
February 6th, 2020.
Case Description
Pseudothrombus in left ventricle due to flow stasis adjacent to apical scarring from myocardial infarct. The filling defect disappears on the portal venous phase of this abdominal CT examination.
January 30th, 2020.
Case Description
Necrotizing Staph. pneumonia complicating Influenza A infection This infection progressed very rapidly (~ 24 hours) to the occurrence of multiple areas of parenchymal cavitation.
Phrenic nerve injury in the context of supraclavicular vascular surgery A subclavian-to-carotid transposition was performed for subclavian artery stenosis. New diaphragmatic elevation was noticed on immediate post-operative radiography.
Lobar ischemia as a consequence of difficult surgery with unintended interruption of vascular supply. Lung tissue was removed with a stapling device when a thymic carcinoma was noted to invade contiguous lung. The entire lobe was then removed at a second operation.
Acute Legionella pneumophila pneumonia. Multilobar consolidation was present on clinical presentation. A Legionella-related antigen was present on urine testing.
Pleuroparenchymal fibroelastosis on surgical lung biopsy. This is a sporadic (very mild) instance of this condition. This usually manifests as a complication of lung or stem cell transplantation or in the context of familial fibrosis.
January 23rd, 2020.
Case Description
Three synchronous adenocarcinomas in one lobe A range of imaging patterns is present: a part-solid opacity; an opacity with pseudocavitation; a pure groundglass opacity.
A penetrating atherosclerotic ulcer. It’s difficult to separate this from a saccular aneurysm with eccentric thrombus. Because the patient presented with acute, severe chest pain, management was initiated with placement of an endovascular stent graft.
A chronic Type B dissection with findings of leakage of blood into the mediastinum. Strange peripheral calcifications are present in the wall of the large false lumen as well as within luminal thrombus. The patient was not considered a surgical candidate.
Groundglass opacities of so-called hypervascularity and many tortuous pulmonary arteries in chronic idiopathic pulmonary hypertension. I’ve included an article that purports to demonstrate the histopathologic counterparts of the groundglass opacities.
January 16th, 2020.
Case Description
Sarcoidosis with multiple opacities demonstrating the sarcoid galaxy sign. Some of the opacities are associated with air bronchograms.
Myriad systemic arteries supplying regions of chronic bronchiectasis. In addition to arteries arising close to the celiac artery, one vessel arises close to the origin of the right brachiocephalic artery.
Inversion of pulmonary blood flow in chronic mitral regurgitation I’ve included a CT coronal slab MPR which nicely shows the distended superior pulmonary veins. The patient had surgery for pericardial restriction in the remote past.
Findings consistent with chronic hypersensitivity pneumonitis on surgical lung biopsy. I would not have been able to suggest this from the CT findings.
January 9th, 2020.
Case Description
Lemierre’s syndrome with supraclavicular abscess, left brachiocephalic vein clot, and pulmonary septic emboli Fusobacterium necrophorum was cultured from blood.
Metastatic multisystemic epithelioid hemangioendothelioma. Pulmonary, osseous, and hepatic disease was present at diagnosis. It progressed in an aggressive way.
Secondary spontaneous pneumothorax in Marfan syndrome The tall and slender patient reported a history of Marfan syndrome in an uncle. Small cysts are present in the lung, one subpleural on the side of pneumothorax. At Marfan.org, we calculated a z-score of greater than 2 because of the patient’s dilated aortic root. This, with the family history, is sufficient for the diagnosis.
December 26th, 2019.
Case Description
Necrotizing pseudomonas apical lung pneumonia in vaping person This is odd. It has a bird’s nest sign and central cavitation. Regional interstitial lung edema is curiously present. It healed to leave a thin-walled cavity. I don’t know whether it’s related in any way to the vaping.
Contrast administration through a PICC in the SVC for a CTPA flipped it into the jugular vein. A CXR obtained afterwards shows the PICC back in its initial position. This occurrence has been reported. I guess we shouldn’t be surprised at the “hose pipe action-reaction phenomenon.”
Displacement of a PICC from the SVC when the arms were lifted for a lateral projection of the chest Now this one is weird. Have you ever seen or heard of this before? It’s known the a PICC tip may move (usually) downward slightly with arm adduction, but this…?
December 19th, 2019.
Case Description
Progressive thrombotic occlusion of a mechanical mitral valve Initial imaging revealed one immobile (on CT and ultrasound) mechanical valve leaflet. A few days later, the patient experienced a PEA arrest with florid pulmonary edema. At emergency surgery, thrombotic occlusion of the valve was present.
Type A acute aortic syndrome with ascending aortic intramural hematoma and an intimal tear in distal aortic arch. I’ve included excerpts of the operative procedure and post-operative imaging to show the following: replacement of the aortic valve; replacement of the ascending aorta; and insertion of an endovascular stent to occlude the tear — Frozen Elephant Trunk procedure. The stump of a side-arm of the ascending aortic graft—used to perform antegrade cerebral perfusion during the operation—is imaged on the post-operative CT and should not be mistaken for a potential pseudoaneurysm.
December 12th, 2019.
Case Description
Chronic lung disease of prematurity and pneumothorax. The patient presented with a spontaneous pneumothorax. Dysmorphic lungs are present on computed tomography. It’s hard to know exactly what structural abnormalities are present. But the complex of findings is well described in the context of bronchopulmonary dysplasia.
Obstructive RML atelectasis in sarcoidosis. Bronchoscopy (included) shows extrinsic compression of a bronchus, probably from an enlarged contiguous lymph node(s).
Field cancerization phenomenon in non-small cell lung carcinoma. A nodal metastatic RLL adenocarcinoma is present. Careful evaluation of thin sections reveals a multitude of bilateral, multilobar lesions in the spectrum of adenocarcinoma: mostly focal ground glass opacities, some with internal regions of pseudocavitation, and part-solid lesions. Multiple foci of carcinoma in situ are present in the lobectomy specimen.
December 5th, 2019.
Case Description
Slow-flow phenomenon to right inferior pulmonary vein from regional hypoxia due to bronchial disease. It manifests as asymmetric non-opacification of blood in the vein.
Necrotizing mucormycosis in a diabetic patient with a history of pica. This is a dramatic case of a bird’s nest sign and internal cavitation. I wonder about the significance of the history of ingestion of soil by the patient with a psychiatric disorder.
Necrotizing Klebsiella pneumonia with an obstructing tooth in a segmental left lower bronchus. The patient reported aspirating dislodged teeth in the context of a motorcycle crash several years before. The necrotic lobe was removed.
November 21st, 2019.
Case Description
Graft from ascending to proximal descending aorta to bypass a coarctation. This makes for a rather interesting radiograph.
Teaching case of several findings of pneumomediastinum. These are: the double wall sign, the ring-around-the-azygos sign (kinda), and the inelegant appearing left heart sign — which I really made up, when air is present in the mediastinal fat, resulting in a new, well-defined cardiac-air interface .
An extra shocking coil lead in the coronary sinus. This is placed when an additional shocking vector is needed to achieve a defibrillation threshold.
Aortic valve endocarditis resulting in a Valsalva sinus perforation, a phlegmonous abscess, involvement of the aorto-mitral curtain, and communication to the left ventricle. Included excerpts of the Operative Report provide nice correlation.
Protrusion of pancreas through a residual diaphragmatic defect long after childhood correction of congenital diaphragm hernia. The patient’s acute abdominal distress and elevated serum lipase were attributed to this. This is not in your differential diagnosis of pancreatitis! Excerpts of the Operative Report are provided.
November 14th, 2019.
Case Description
Chylothorax as a complication of transhiatal esophagectomy. This was initially managed with a thoracic duct ligation procedure which was unsuccessful. It was then managed by means of transcatheter occlusion using coils and glue via a transabdominal-cysterna chyli approach.
November 7th, 2019.
Case Description
Thoracic (pulmonary) lymphangiomatosis with later development of chylothorax. A surgical lung biopsy revealed findings consistent with “venous” malformation. Given the imaging findings, and the later development of frank chylothorax (a picture of the pleural fluid is included), a lymphatic disorder is clearly present.
The occurrence of a tracheo-esophageal fistula close to the azygos vein in which a catheter is malpositioned and through which multiple chemotherapy infusions were administered over months. This is a perplexing occurrence. It’s hard to avoid the conclusion that there is a causal association.
Vaping-associated lung injury, a spontaneous pneumothorax, and a subpleural parenchymal cyst. This is very similar to Tan’s case (linked here) presented recently in which multiple such subpleural cystic spaces developed with subsequent pneumothoraces.
October 24th, 2019.
Case Description
Multifocal, multilobar segmental bronchial disease in GPA. The trachea is not (or ? minimally) involved. He had a history of chronic sinus disease and renal involvement was diagnosed after admission.
Dotatate PET -positive sclerosing pneumocytoma. This was a surprise as the provisional diagnosis was a carcinoid tumor. I’ve included a Case Report as well as an article about the CT features of this lesion, including a description of an air gap sign, with which I’m not familiar.
October 17th, 2019.
Case Description
Severe MDA-5 antibody-associated lung disease. He presented with a history of a rash and abnormally high CK levels. His presentation was that of acute respiratory failure necessitating mechanical ventilation and veno-venous ECMO. He subsequently developed foci of digital necrosis. This acute respiratory presentation has been reported in this condition.
Right coronary artery to coronary sinus fistula. This was discovered on a CT obtained during surveillance of testicular cancer.
October 3rd, 2019.
Case Description
Vaping-induced lung injury cannabis oil pen. This was a surprise in a 40-year-old person on surveillance for melanoma.
Classic cellular NSIP pattern with surgical lung biopsy confirmation. The patient has Raynaud’s phenomenon but no diagnosed connective tissue disorder.
Typical findings of CTEPH - imaging before and after surgical endarterectomy. The degree of restoration of luminal patency and caliber is impressive.
Pneumothorax ex vacuo from obstructive LUL atelectasis. The context is interesting: atelectasis from placement of endobronchial valves for bronchoscopic lung volume reduction in emphysema.
September 26th, 2019.
Case Description
Left ventricular lateral wall aneurysm. This is a subtle finding on axial CT. Surgical excision was performed.
Very substantial intravascular metastases from colon cancer with an area of pulmonary hemorrhage-infarction. Tumor involves the walls and lumens of the involved vessels with extensive narrowing and occlusions.
Vascular occlusions in small cell lung cancer with peripheral lung hemorrhage. This is analogous to the preceding case but represents direct regional extension from the contiguous tumor.
September 19th, 2019.
Case Description
RUL PAPVR with superior sinus venosus ASD. This was corrected by means of the Warden procedure. Details are provided in the Case Summary.
Retained — and then retrieved— Ray-Tec sponge during cardiothoracic surgery. This was discovered on an intra-operative chest radiograph.
Symmetric opacities produced by the transverse thoracic muscles. These muscles are named portions of the innermost intercostal muscles. These may simulate anterior pleural plaques.
Transmyocardial perforation of a right atrial appendage pacemaker lead. The orientation of the lead is abnormal on the frontal radiograph. Hemopericardium was also present.
September 5th, 2019.
Case Description
Small vessel CTEPH. In this case of chronic pulmonary thromboembolism, very little material was (disappointingly) present in the proximal pulmonary arteries during surgical endarterectomy. This is equivalent to the post-operative classification of Type 3⁄4 disease.
Air-compressor-associated esophageal rupture necessitating partial esophagectomy. It’s not clear what the patient was exactly doing with the compressor in or around his mouth.
Malignant small round cell tumor with the EWSR1 gene rearrangement. The usual diagnosis in this category is the PNET/Ewing’s sarcoma family of tumors.
Septic embolism with large tricuspid valve vegetations on chest CT. The vegetations are readily detectable on this non-gated CT examination
August 29th, 2019.
Case Description
Acute airway obstruction-associated lung edema. This is typically called “negative pressure” lung edema. As is usually the case, this occurred in the context of general anesthesia, and was ascribed to the patient biting down and occluding the endotracheal tube!
Brachiocephalic artery pseudoaneurysm from blunt chest trauma. Other brachiocephalic vessel injuries are present, as well as two small Type 1 aortic mural injuries.
LVAD driveline infection with retrosternal abscess formation. This occurred long after LVAD placement. The pus was drained via a subxiphoid approach.
Pacemaker flipping and withdrawal of leads. There was no twiddling by the patient. This occurred spontaneously because of a very capacious pacemaker pocket and disruption of the suture sleave.
August 22nd, 2019.
Case Description
Fatal thoracic mucormycosis soon after heart transplantation. The early occurrence and severity of this infection were very unusual. Extensive mucor was present with pulmonary vessels (pathology slides included).
Mediastinal paraganglioma. The location in the pretracheal mediastinum is a bit unusual. Otherwise, the findings are typical: an intensely enhancing mass associated with large feeding bronchial arteries.
August 15th, 2019.
Case Description
Vaping-associated acute lung injury. This is the fourth case of vaping-associated acute lung injury we’ve encountered in recent months. As with the others, the presence of lipid-laden macrophages in bronchial lavage fluid was present.
Infectious mediastinal lymphadenitis as a consequence of transbronchial node biopsy for suspected sarcoidosis. The patient was admitted about four weeks after the procedure. The rapid, progressive enlargement of the node was a very important clue to the presence of infection rather than, for example, tumor growth.
Second case of infectious mediastinal lymphadenitis as a consequence of transbronchial node biopsy. In this instance, pericarditis (pericardial effusion) and pleuritis also subsequently developed. Strep. Anginosis was cultured from a blood specimen. This complication occurs in less than 1% of biopsies (in published surveys of biopsy-related complications), but is perhaps underestimated because it is under-diagnosed or not reported.
August 8th, 2019.
Case Description
Vaping-associated lung injury with lipid-laden macrophages in bronchial lavage fluid. Yet another case of vaping-associated lung injury to complement the two cases I presented last time. Lavage fluid eosinophilia is not present. The severity of the injury was mild.
Supra-cristal ventricular septal defect. There is excellent correspondence between the imaging findings and those observed at the time of surgical correction (provided in the Case Summary).
NuPulseVC intravascular assist device in chronic left ventricular failure. This investigational counterpulsation device (akin to that of a conventional IABP) permits the patient to ambulate. It may be an alternative to LVADs in this circumstance.
The use of a left ventricular vent to decompress the distended LV in the context of AV ECMO. The rationale for the use of this strategy is described in this article: PMID—PMC6531683. The small metallic tip in the left ventricle is visible on chest radiography.
Idiopathic plastic bronchitis. Expectorating these large casts (picture included) must be very disturbing!
July 11th, 2019.
Case Description
Vaping-associated lung injury with bronchial lavage fluid eosinophilia. The patient required a period of veno-venous ECMO for acute respiratory failure. He was discharged after 16 days.
Vaping- associated acute lung injury. Another case of this entity, less severe. Like the other, an Oil Red-O stain of the lavage fluid showed lipid material (not glycerin, which is not an oil) in macrophages.
Subpulmonic left pleural fluid. A clue to the presence of this is the abnormal distance between air in stomach and the opacity-lung interface in the basal hemithorax.
June 27th, 2019.
Case Description
Spontaneous waning of opacities of granulomatous-lymphocytic ILD (presumed) in CVID. This phenomenon is known to occur in CVID in the absence of specific treatment.
An anatomic interface between the lateral margin of the ascending aorta and right lung. This is unusual because other structures (SVC; right atrial appendage; mediastinal fat) typically preclude contact of right lung with the ascending aorta.
Expansion of intra-pulmonary lymphoid tissue in relation to bronchovascular bundles in (presumed) sarcoidosis. In this instance, this may simulate filling defects in pulmonary arteries.
Inappropriate use of a reconstruction kernel that is excessively “sharp” during evaluation of ILD This was an “80” kernel on a Siemens scanner. This clearly impedes proper evaluation of the parenchymal abnormalities.
Evolution of opacity of primary coccidioidomycosis during treatment. The opacity is diminished in size and contains a central focus of cavitation. Sometimes, a thin-walled cystic lesion is all that remains.
Pneumothorax ex vacuo in tumor-obstructive right upper lobe atelectasis. Of course, this does not necessitate intervention.
June 13th, 2019.
Case Description
ILD with cystic disease in SLE and anti-synthetase antibody. The images show progression of the pulmonary disease over many years. We do not have pathologic correlation. This is likely non-honeycombing (not UIP-like) cystic disease.
Ascending-to-descending aortic bypass in aortic coarctation. I’ve not seen this before. Aortic luminal stents are also present.
Restrictive ventilatory impairment in ankylosing spondylitis with extensive ankylosis of costovertebral and costotransverse joints. Sometimes it’s particularly important to evaluate the bones when a CT for ILD is performed!
June 6th, 2019.
Case Description
Pneumomediastinum and pneumopericardium in severe blunt chest trauma. The mediastinal and pericardial space communicate (at least in some patients) via the so-called Aperture of Marchand. Marchand described the relevant anatomy and embryologic connection in a classic 1951 article. I’ve included the article and a great educational exhibit from the 2019 meeting of the Society of Thoracic Radiology by Holbert & Oliphant that explicates the relevant anatomy.
Passage of a central venous catheter (left brachiocephalic vein) into the right upper lobe via partial RUL anomalous venous drainage to the SVC. The appearance is disturbing but no harm occurred!.
Appearance of Calypso Beacon Transponders on chest radiography. These transponders are used to facilitate stereotactic ablative radiation therapy of lung cancer. They are placed close to the lesion via electromagnetic navigational bronchoscopy. The Case Summary contains more information about this.
A second case demonstrating these Transponders. Zoom the image to appreciate the structure of these devices.
May 23rd, 2019.
Case Description
Unexpected discovery of tracheo-esophageal fistula in an adult. The patient underwent a right upper lobectomy in infancy for unclear resons. At that time a tracheal bronchus was noted. She has experienced respiratory “symptoms” since then, without an explanation. The fistula was repaired.
Irregularly-shaped calcifications within a primary lung adenocarcinoma. A contralateral synchronous tumor (presumed) is also present.
Primary myocardial capillary hemangioma. This unexpected cardiac tumor was likely responsible for the treated arrhythmia. It was diagnosed by CT-guided biopsy.
Benign intercostal nerve sheath tumor. This was an unexpected imaging finding on a CT performed in the context of blunt chest trauma. It was excised.
Typical imaging presentation of acute pneumocystis pneumonia in a solid organ recipient. I don’t think the chest CT was necessary. The radiographic findings — and context — are typical.
May 16th, 2019.
Case Description
Use of a Gore Cardioform interatrial septal occluder device to diminish aortic valve insufficiency that developed after placement of a left ventricular assist device. Aortic valve incompetence develops in a proportion of patients after implantation of a LVAD. When severe, one means of addressing this is to occlude the valve, in this case with the off-label use of a septal occluder device. It was partly successful.
Negative pressure lung edema consequent on a hanging suicide attempt. Diminished pleural pressure is transmitted to the peri-capillary interstitium. The reduced peri-capillary hydrostatic pressure increases fluid filtration according to the Starling equation.
Progressive fibrotic NSIP in the context of scleroderma. The imaging findings are typical, with severe and progressive traction bronchiectasis in the lower lungs – in particular.
May 9th, 2019.
Case Description
Amiodarone accumulation in the liver. This is the highest-attenuating liver I’ve seen.
AVMs in hereditary hemorrhagic telangiectasia. I’d bet that a flow murmur would be audible on chest auscultation!
Mobile aortic thrombi with emboli to mesenteric arteries. Pulmonary emboli are also present. A coagulopathy is not present.
Another case of mobile aortic thrombi with mesenteric ischemia from emboli. The findings are very similar to the previous case.
Squamous cell carcinoma of the thymus. The imaging findings are indistinguishable from a thymoma.
May 2nd, 2019.
Case Description
Large pericardial cyst in an unusual location in basal left hemithorax. The mesothelial cyst lining is typical of a coelomic cyst.
Dislodged right atrial pacemaker lead. Two clues are present: the vertical orientation of the lead and excessive motion on the lateral projection.
Pneumomediastinum due to the Macklin phenomenon in a patient with asthma. Subpleural interstitial emphysema is present. Substantial bronchial wall thickening and intraluminal mucus is also present.
Anaplastic large cell lymphoma with SVC obstruction. An interesting collateral pathway involves communications between liver surface veins and branches of a portal vein in segment 7 (unusual hot spot location).
April 11th, 2019.
Case Description
Migratory thoracolith. This looks quite a bit like a piece of bone, and presumably comprises a core of fat with peripheral calcium.
Bronchiolitis obliterans and pneumatosis intestinalis after stem cell transplantation. The patient reported mild abdominal pain. She was observed and the pneumatosis resolved over several days. The presence of associated pneumoperitoneum and pneumoretroperitoneum is impressive.
Acute IMH of the ascending aorta (treated surgically) with the subsequent appearance of communicating descending aortic dissection. These forms of acute aortic syndrome may co-exist or appear sequentially. This is not rare.
March 21st, 2019.
Case Description
Fistula between renal collecting system and pleural space late after RF ablation of a renal lesion. Now this is a rare cause of a persistent, “idiopathic” pleural effusion. A smart person measured the creatinine concentration in the pleural fluid: 52 mg/dl.
Iatrogenic diaphragmatic hernia after thoracoabdominal aortic surgery. The first indication of this complication was on chest radiography: air-containing stomach appeared in the lower chest.
Iatrogenic diaphragmatic hernia after transhiatal esophagectomy. Similar to the previous case, air-containing colon appeared in the lower chest after surgery.
March 14th, 2019.
Case Description
Capno-retroperitoneum and -mediastinum after robot-assisted, minimally-invasive renal tumor removal. The carbon dioxide is quickly reabsorbed. The patient was asymptomatic.
Imaging findings of CTEPH with an image showing the material removed during pulmonary surgical endarterectomy. The pre-operative imaging included a perfusion scan and dual-energy CT with pulmonary blood volume maps.
Diffuse pulmonary dendriform ossifications (idiopathic). This is a classic case (CXR and CT) provided by Tan Mohammed, M.D.
Nice teaching case of inversion of pulmonary blood flow in mitral stenosis. Inversion is a consequence of chronic, not acute, pulmonary venous hypertension. An explanatory article is included.
Marginal zone lymphoma discovered as an incidental pulmonary opacity on chest radiography in an elderly female. I’ve included the pathology report of the CT-guided lung biopsy.
Good teaching case of pectus excavatum deformity of sternum. Typical findings are present on frontal chest radiography.
A small endobronchial carcinoid producing subsegmental atelectasis. The slowly growing pulmonary nodule is a subtle finding on chest radiography.
March 7th, 2019.
Case Description
Myeloid leukemia (strong presumptive diagnosis), pleural effusion, lymphadenopathy, and findings consistent with lymphangitic tumor spread. The findings are akin to those we see in lymphangitic carcinomatosis with epithelial tumors. Bone marrow biopsy reveals abnormal myeloid cells. I’ve included an article of direct pulmonary manifestations of leukemias.
Imaging findings of severe constrictive bronchiolitis. I’ve included the results of spirometry. Images from the Expiration Series show corresponding absence of lung deflation because of the severe airflow limitation.
February 28th, 2019.
Case Description
Evolution of pulmonary marginal zone lymphoma in Sjogren syndrome. This evolved over several years. Two previous biopsies revealed LIP only. The diagnostic pathology of lymphoproliferations can be hard, too !
February 21st, 2019.
Case Description
Air in pleural space, pericardial recesses & mediastinum after lung transplantation. The pleural and pericardial membranes may be “disrupted” during lung transplantation, permitting passage of air between these compartments.
Bicuspid aortic valve and bicuspid aortopathy. With a left-right cusp fusion pattern, the blood jet impinges particularly on the anterior-lateral aspect of the ascending aorta, promoting dilatation.
Unexpected, asymptomatic communications between right coronary artery and main pulmonary artery. Coronary artery-to-main pulmonary artery fistulas may involve both left and right coronary arteries.
February 14th, 2019.
Case Description
Obstructive LUL atelectasis with classic radiographic findings. The collapsed LUL is in the anterior and medial upper left hemithorax.
Obstructive LUL atelectasis with a drowned lobe. The volume associated with the airless lobe produces substantial opacity on the frontal and lateral projections.
Obstructive LUL atelectasis with peripheral collapse. This pattern is very unusual. Pleural adhesions presumably keep a portion of the atelectatic lobe in this location.
Incidental finding of strange splenic calcifications on chest radiography. I’ve just learned that this pattern is distinctive for SLE!.
February 7th, 2019.
Case Description
Follicular bronchiolitis found on surgical biopsy. This patient does not have a connective tissue disorder or an immunodeficiency state — the usual associations. It’s a great example of centrilobular, ground-glass opacities.
Intercostal tissue disruption, a rib fracture, and transcostal lung herniation. This is ostensibly from one episode of coughing!.
Rice grain calcifications of cysticercosis as an incidental finding. These are nicely demonstrated in muscle on CT of the abdomen.
January 31st, 2019.
Case Description
Fibrosing lung disease with findings of chronic hypersensitivity pneumonitis on open lung biopsy. Detailed descriptions of the pathology findings by two pathologists are included in the Case Summary.
Fibrosing lung disease with findings of chronic hypersensitivity pneumonitis on open lung biopsy. Excerpts of the pathology report are included.
Chronic fibrosing lung disorder with imaging findings consistent with chronic hypersensitivity pneumonitis. I would present the findings as such at a multidisciplinary case conference.
January 24th, 2019.
Case Description
Type B aortic dissection attributed to blunt chest trauma. I’ve not personally encountered this before. Is it possible that the aortic dissection caused the cyclist to lose control and veer into the path of the vehicle that struck him ? We’ll never know.
Penetrating atherosclerotic ulcer in aortic arch with substantial intramural hematoma in ascending aorta. I’m a bit surprised there isn’t more mural hematoma in immediate proximity to the ulcer. Surgical management consisted of ascending aortic and hemiarch replacement and frozen elephant trunk stent graft placement in distal aortic arch.
Fenestration-related endoleak after surgical management of complications of prior acute aortic syndrome. This is an unusual form of endoleak after complex surgical procedures. It’s worthwhile to read the Case Summary which includes detailed excerpts of operative and endovascular procedures.
January 17th, 2019.
Case Description
Multiple patterns of pulmonary metastases, including cystic lesions, in rectal adenocarcinoma. These were present at the time of initial diagnosis. The occurrence of cavitated and cystic metastases from GI tract, pancreatic, and biliary tract malignancies is often underestimated.
Lung cysts in monoclonal lambda multiple myeloma. The cysts are a consequence of the parenchymal deposition of the immunoglobulin-associated light chains.
Iatrogenic perforation of the trachea during out-of-hospital resuscitation with intubation. It’s surprising that more pneumomediastinum is not present.
Exuberant dystrophic calcifications in mediastinal lymphoma from radiation therapy. Subtle findings of symmetric paramediastinal radiation fibrosis — reticulation and volume loss— are also present.
January 10th, 2019.
Case Description
Intravascular metastases in esophageal cancer. Intravascular tumor expands lobular and a few segmental arteries. The former results in many subpleural vascular tree-in-bud opacities. The use of thin MIP reconstructions enables easier recognition of their morphology.
Nocardia paucivorans opportunistic pneumonia in a patient with CLL on Ibrutinib therapy. The findings are identical to those often seen with other nocardial and invasive fungal infections. This is a relatively recently declared “new” species of Nocardia.
Sternal fracture with partial sterno-manubrial dissociation. This is a nice complement to the case of complete sterno-manubrial dissociation I showed on November 15th last year.
The use of an Ovesco clip to seal an esophageal peroration. This is the first time I’ve encountered the device which has a distinctive appearance.
January 3rd, 2019.
Case Description
Subtle lobulated pleural thickening and fluid as initial presentation of breast cancer. It is often the case that careful examination of coronal and sagittal MPRs more-readily reveals pleural thickening. In this case the primary breast tumor is also visible.
Extranodal B-cell marginal zone lymphoma. The diagnosis was delayed when the focal opacity was first presumed to represent community-acquired pneumonia.
Multiple recurrences of marginal zone lymphoma (in many locations) over many years. The most recent recurrence is in the form of substantial mediastinal tumor in the middle and posterior mediastinum, directly behind the heart, lifting the aorta off the spine.
December 27th, 2018.
Case Description
Episodes of hemoptysis from dilated bronchial submucosal vessels after thrombotic occlusion of pulmonary veins as a complication of ablation procedures for atrial fibrillation. The explanation relates to extensive communications between bronchial and pulmonary veins. I’ve included pertinent articles about such communications with the case, as well as images from bronchoscopy.
Unexpected occurrence of parenchymal and nodal sarcoidosis during surveillance of a rib lesion . The size of the pulmonary lesions, containing air bronchograms is rather impressive. Some would, I think, describe this as “alveolar sarcoid.” Some hint at the so-called sarcoid “galaxy sign.”
Lung involvement (presumed) in a patient with longstanding systemic mastocytosis. The imaging pattern is concordant with that in published Case Reports with pathological confirmation.
December 20th, 2018.
Case Description
Secondary spontaneous pneumothorax from cystic cutaneous angiosarcoma metastases. Some of the metastases have ground glass-attenuating halos, perhaps from hemorrhage.
Chronic hypersensitivity pneumonitis on open lung biopsy. Imaging-pathology concordance is present. Foci of non-subpleural traction bronchiectasis are present.
IgG4-related pulmonary disease. The pathologic diagnosis was initially made on biopsy of a neck lymph node. The imaging findings, waxing and waning, are consistent with a lymphoplasmacytic proliferative process. Pathology images are included in the Case Summary.
Evolution (over years) of MGUS to marginal zone lymphoma with cystic lung lesions. Dramatic cavitation (dissolution of parenchyma) and bronchiectasis develops with the lung opacities.
Cystic lung disease and a solitary nodule of plasmacytoma (kappa light chain-restricted) with amyloid on CT-guided biopsy. The nodule was unexpectedly discovered on abdominal CT.
Cystic lung disease with nodules of amyloid, some associated with calcification or ossification. CT-guided biopsy of a nodule yielded the presence of amyloid. I usually consider the possibility of Sjogren syndrome as an association.
December 13th, 2018.
Case Description
Left SVC with absent right SVC. This is an uncommon occurrence. The hemiazygos vein takes the place of the azygos.
Severe constrictive bronchiolitis in rheumatoid arthritis. This case nicely demonstrates the dilatation of proximal segmental bronchi that may occur in this condition.
Tumoral calcinosis in chronic renal failure. Calcium deposits about the hip joints is also present.
Nocardia cyriacigeorgica opportunistic infection several months after stem cell transplantation for lymphoid leukemia. Extensive, multifocal nodular disease is present.
December 6th, 2018.
Case Description
Untreated Type 3 acute aortic mural injury, being followed. I don’t know why this was not managed with a stent at the time of the injury, but it hasn’t changed in quite a while. The chest radiograph is nice for teaching mediastinal-lung interfaces.
Mural left atrial and pulmonary vein calcifications developing in the context of chronic renal failure. The patient has Alport syndrome and has been on dialysis for many years. The case is also an excellent one for teaching findings of renal osteodystrophy.
A persistent drug abuser with pulmonary septic embolism and embolized vegetation fragments from a prosthetic tricuspid valve. . An interesting finding is a small focus of gas (presumably air) within an embolized vegetation in a left lower lobe pulmonary artery.
November 29th, 2018.
Case Description
Rapid progression of gastric cancer metastases with extensive intra-vascular and intra-airway tumor growth. An extensive vascular tree-in-bud pattern is present. Bronchoscopy confirmed extensive endoluminal tumors in the trachea and proximal bronchi.
Rapid growth of intra-vascular (arterial and venous) metastases, lymphangitic tumor spread, and lung edema in metastatic colon cancer. Tumor cells constituted 3% of cells in a bronchial lavage fluid sample.
Cystic metastases from a gluteal pleomorphic liposarcoma resulting in a pneumothorax . Fluid levels are present in the larger, coalescent pulmonary metastases.
November 15th, 2018.
Case Description
Renal osteodystrophy. This case has all the findings — in multiple locations — that you’re likely to show in a teaching conference: subperiosteal bone resorption in multiple locations, Brown Tumors in ribs, and the Rugger Jersey spine.
Sternomanubrial dissociation from blunt chest trauma. This is the first instance I’ve personally seen of this exceedingly uncommon occurrence. The bones usually fracture. It’s a subtle finding on the lateral projection.
Inflammatory pseudotumor of lung — lymphoplasmacytic type. The presence of the nodule was an unexpected finding on a CT performed in a patient with scleroderma.
November 8th, 2018.
Case Description
Spontaneous waxing-and-waning of opacities over many months in granulomatous-lymphocytic interstitial lung disease (presumed) of CVID. It is likely that this is a manifestation of a lymphoproliferative pulmonary process. Such proliferations vary from follicular bronchiolitis to areas of lymphocytic interstitial pneumonitis (LIP)
Lobar interstitial lung edema in small cell lung cancer. It’s not possible to separate lymphangitic tumor spread from pulmonary venous hypertension in this instance — the right SPV is encased and narrowed by tumor. Both may be present. Patchy foci of FDG-avidity are present in the involved lobe.
Difficult diagnosis of malignant mesothelioma. A VATS procedure was eventually required to secure a pathologic diagnosis. View pleural thickening— even if limited in extent — when it involves mediastinal pleural surfaces with considerable concern.
High-grade pleomorphic spindle cell tumor of the basal left hemothorax traversing the left hemidiaphragm. The presence of substantial rib destruction is also an indication of a very bad actor.
Pulmonary arterial hypertension attributed to methamphetamine abuse. One cannot otherwise distinguish this from many other etiologies encompassed in Group I pulmonary hypertension — on imaging findings alone.
November 1st, 2018.
Case Description
Acute Type B aortic dissection with retrograde extension of intramural hematoma into ascending aorta. This is a variation on a pathologic spectrum and our usual classification scheme. This patient was treated with endovascular stent grafts to exclude tears demonstrated in the descending aorta.
Visibility of pulmonary emboli on a CTPA in which the degree of contrast-opacification of blood is ostensibly insufficient. This refutes oft-expressed dogma: when the attenuation measurement of blood in the pulmonary artery is less than 200 H.U., the examination is “non-diagnostic.” The origin of this erroneous assertion is elusive. The presence of noise (quantum mottle) and the resultant contrast-noise ratio is also relevant to this determination.
The evolution of pulmonary infarcts and non-resolution of embolus in a case of pulmonary embolism. Serial imaging in this patient nicely demonstrates these phenomena. The affected vessel never recanalizes and will forever remain occluded.
October 25th, 2018.
Case Description
Mycobacterial spindle cell pseudotumor as endobronchial mass. This is definitely a new one for me! I’ve included pictures from the bronchoscopy procedure and an article about the entity.
Hypersensitivity pneumonitis with classic bronchial lavage and pathology features. This case shows the value of a proper ILD imaging protocol instead of trying to diagnose an ILD-related disorder on a CTPA examination.
Primary chest wall mesenchymal chondrosarcoma. This is a very bad actor as the extent of rib and vertebral involvement attest.
October 18th, 2018.
Case Description
Early sternal incision dehiscence after cardiac surgery. The sternal wires remained intact as they tore through the left half of the sternum.
Hemidiaphragmatic eventration with fluoroscopy images. It’s important to examine the hemidiaphragms in the lateral projection. With a sniff, the anterior hemidiaphragm moved upward (paradoxical motion); the posterior portion moved downward.
Fibrosing interstitial lung disease with imaging findings of pleuroparenchymal fibroelastosis in the upper lobes. The included pathology report of the open lung biopsy revealed findings consistent with chronic hypersensitivity pneumonitis as well.
Lymphomatoid granulomatosis (EBV-positive) with nodular parenchymal disease and skin involvement. The diagnosis was made on a skin biopsy. Because the patient had been treated with azathioprine for many years (for inflammatory bowel disease), this may be a case of Immunodeficiency-Associated Lymphoproliferative Disease.
October 11th, 2018.
Case Description
Subtle findings of subcarinal lymph node enlargement on lateral chest radiography. The presence of lymphadenopathy was confirmed on CT. Subsequent biopsy revealed metastatic melanoma.
CT halo sign in pulmonary melanoma metastases. Both the solid, central and peripheral, ground-glass components enlarge on tumor progression. Is this really surrounding hemorrhage ?
Acute, very large chest wall hematoma, ostensibly spontaneous. The heterogenous attenuation of the hematoma is pretty typical.
A second companion case of apparently spontaneous chest wall hematoma. The patient was on anti-coagulant therapy.
Discovery of right upper lobe PAPVR and an associated sinus-venosus atrial septal defect on a CTPA for acute pulmonary embolism. Note the dilated pulmonary arteries and enlarged right cardiac chambers from the resultant shunt and pulmonary hypertension.
October 4th, 2018.
Case Description
Acute Type A aortic dissection in Marfan syndrome. Not surprisingly, dilatation of the aortic root is not visible on chest radiography.
Septic embolism with large tricuspid valve vegetations. The vegetations are visible on the relatively delayed images from the concurrent abdominal CT examination. A few embolized fragments are visible in some small pulmonary arteries.
Iatrogenic diaphragm hernia from injury during a tumor-debulking procedure for ovarian cancer. One clue is the absence of the (removed) spleen. Otherwise, one has to know the history and surgical details.
Infected thrombosis of jugular vein and septic embolism as a catheter-related complication. The extent of thrombus progressed over several days. Culture-postive Staph. infection.
September 27th, 2018.
Case Description
Interrupted bolus phenomenon in computed tomography pulmonary angiography. The patient must have inspired at just the most inauspicious moment! The non-opacified IVC-derived bolus is being “chased” by a SVC bolus. The examination was repeated with success.
Primary coccidioidomycosis as a hidden lesion. The left lower lobe opacity is invisible on chest radiography. It was discovered on a CTPA performed for chest pain.
Septal lakes of interstitial (hydrostatic) lung edema. This is a particularly nice example of this phenomenon.
September 13th, 2018.
Case Description
Invasive mucinous adenocarcinoma presenting as bilateral, multilobar nodular and cavitary nodular opacities. Is this the so-called field cancerization phenomenon or a manifestation of common clonal origin of multifocal lung cancers ?
Subglottic tracheal narrowing by granulation tissue soon after an episode (6 days) of endotracheal intubation. I’ve included a description of the endoscopic appearance of the tracheal lumen prior to balloon dilatation.
Subtle radiographic findings in tuberculosis as an AIDS-presenting illness. This is sometimes described as an atypical presentation of TB in an adult. One cannot determine whether this is a primary infection or re-activation of latent (prior) infection.
September 6th, 2018.

This week's cases represent complex findings associated with surgical management of aortic dissection and complications thereof. I've included detailed notes of the Operative Procedures for each case. It's really important to know the details of the surgical procedures performed (or being planned) when interpreting and reporting the CT-angiography examinations. In particular, the state of the false lumen should be reported in detail, including the presence, nature, and locations of residual blood flow into it.

Case Description
Elephant trunk procedure and subsequent TEVAR. This case involved three different staged procedures in the situation of a dilating aortic root and false lumen following a prior ascending aorta replacement for aortic dissection.
Frozen elephant trunk technique in management of Type A aortic dissection. The term frozen refers to the notion that this newer stent graft technique may have “frozen” — supplanted — the conventional elephant trunk surgical procedure; a silly description!
August 30th, 2018.
Case Description
Obstructive lingular atelectasis from small cell cancer. The remaining left upper lobe is aerated. This is a great companion case to that presented by Jeff Kanne: lingula-sparing left upper lobe atelectasis.
Westermark and Palla signs in acute pulmonary embolism. It’s not common to see these classic radiographic signs!
Stenosis at the origin of the innominate artery by calcified atheromatous plaque. I showed this case primarily to demonstrate the location and appearance of the plaque on the lateral projection of the chest. Bovine-arch anatomy is shown on angiography.
August 23rd, 2018.
Case Description
Inter-atrial septal aneurysm. This is an incidentaloma and, typically, a leave-alone finding.
The appearance of inadvertently-injected air in pulmonary arteries. This occurred during the performance of CTA in a trauma victim. In some locations, it is clear that an air-block phenomenon is present, with variable contrast-opacification of blood just behind the air.
Evolution of sub-lobular infarcts in pulmonary embolism. The two lower lobe infarcts are quite small and irregular in shape. The notion of “wedge-shaped” opacities in pulmonary embolism is unsubstantiated dogma. I’ve included an image of infarcts of different shapes and sizes from the classic article by Hampton & Castleman, in which the notion is also refuted.
Caseous calcification in mitral valve annulus. It’s rather florid, but otherwise typical. View it with a bone WW/WL display setting
August 16, 2018.
Case Description
Evolution of ulcer-like projection and intra-mural blood pools in acute intramural hematoma (acute aortic syndrome). The blood pools represent a sequel of transected origins of intercostal arteries - hence, pseudoaneurysms. These are nicely shown on the coronal MPR where the associated intercostals are opacified. These developed in four days.
Rocks of bone in the chest. This is an incidental finding in a patient imaged for prostate cancer. The etiology is not apparent. It’s clearly benign. If you’ve seen this before, let me know!
Pneumomediastinum from the Macklin phenomenon in a tackled football player. This, of course, is analogous to that seen in trauma patients involved in car crashes and the like. His chest was presumably compressed while his glottis was closed with alveolar rupture from momentary alveolar overdistention.
Extensive pleural and extrapleural (subtle extrapleural fat sign) lymphoma. Nodal disease is also present. It’s easy to overlook the pleural membrane tumor adjacent to pleural fluid.
High-altitude pulmonary edema. This young person was descending from 13,000 feet when he began to experience shortness of breath.
August 9, 2018.
Case Description
Recurrent bronchopulmonary aspiration in a patient with a Lap Band. Chest radiographs from 2011 onward reveal esophageal dilatation with air and/or ingested food and fluid, not perceived and reported. The last CT performed in 2018 reveal opacities very consistent with substantial aspiration (subtle bronchiolar opacities are also present). Clinic notes over many years provide strong hints towards the diagnosis. I don’t know why it took so long to make it.
Obstructive atelectasis from an endobronchial polypoid lesion. This case demonstrates three substantive findings: obstructive left upper lobe atelectasis on radiography; pneumothorax ex vacuo (article included); and the causative lesion — including bronchoscopic management and pathology images.
Intimo-intimal intussusception in acute aortic dissection. This case from Seth Kligerman nicely shows back-and-forth prolapse of an intimomedial flap through the aortic valve, particularly on the included cardiac ultrasound. Formation of this involves a circumferential tear. A relevant and distinctive observation is an “empty” ascending aortic lumen between the proximal and distal flaps.
A primary cardiac lymphoma. This second case from Seth shows subtle, initial myocardial thickening from the tumor.
July 26, 2018.
Case Description
Vascular metastases in bladder cancer. Tree-in-bud-type opacities are conspicuous. The margins of some of the involved vessels are “shaggy.” These developed in a short period of time.
Spinal disc injury and lacerated esophagus in a motorbike rider hit by a vehicle. The transmural esophageal laceration anterior to the disc space was confirmed with a contrast esophagram and then surgically repaired. Amazingly, the spinal cord was spared.
Extensive lepidic growth in pulmonary metastases from a biliary tract adenocarcinoma. Many of the lesions have a central solid tumor “core” with a halo of ground glass-attenuating opacity.
July 19, 2018.
Case Description
Necrotizing sarcoidosis with pituitary and lung involvement. The case includes an article in which the pathologist author asserts that necrosis in sarcoidosis is not rare and that we should not make a rigid distinction between “ordinary” sarcoidosis and the necrotizing granulomatous variety. The patient responded well to steroid.
Acute pulmonary embolism with classic opacity of focal hemorrhage in posterior lung adjacent to costophrenic recess. The opacity is difficult to perceive on the lateral projection— not visible on the PA projection.
Smoker’s lung with all the findings you might want to see. I’m sure there’s massive parenchymal and alveolar accumulation of smoker’s macrophages - a nice teaching case of DIP.
July 12, 2018.
Case Description
Rapid lung destruction in CNS and pulmonary coccidioidomycosis. The patient had been in Arizona in December. The neck CTs (performed in the evaluation of “stroke” that was subsequently considered a manifestation of small vessel vasculitis) show the development of apical parenchymal cavitations over three days. Cocci was cultured from bronchial lavage fluid. High serum titers of cocci-specific antibodies was simultaneously demonstrated.
Slow development of a small mediastinal thymoma. This occurred during periodic surveillance imaging in a patient with treated colon cancer.
Right superior accessory fissure. Note the fissure projecting over the spine on the lateral projection. It’s nicely demonstrated on sagittal CT
July 5, 2018.
Case Description
Diffuse pulmonary disease in systemic AL amyloidosis. The distribution of the calcified (or ? ossified) reticulo-nodular opacities is very sarcoid-like, with protein deposition in interlobular septa and the subpleural interstitium. The morphology of many opacities is also akin to that seen with dendriform ossifications. There is also pleural involvement with an instance of spontaneous pneumothorax during the patient’s disease course.
Evolution of infarcts after pulmonary embolism. This case demonstrates two phenomena: large, acute opacities that diminish over time (melting sign) to result in irregularly-shaped (not wedge-shaped — a common misconception about these lesions) subpleural opacities; non-resolution of a large central embolus with occlusive, fibrotic organization in the involved vessel.
Occurrence of a pulmonary artery pseudo-aneurysm within a primary lung cancer after treatment with chemoradiation. The patient presented with hemoptysis. The pseudoaneurysm was occluded with coils.
Primary germ cell tumor of mediastinum. I’ve included graphic summaries of immunohistochemical characterization of these tumors.
June 28th, 2018.
Case Description
Acute eosinophilic pneumonia attributed to a preparation of naltrexone. Serum and bronchial lavage eosinophilia suggested the diagnosis. FDA labelling describes the occurrence of this in clinical trials preceding marketing approval. The patient responded promptly to steroid therapy.
Hyperattenuating lymph nodes in a welder. The attribution of the phenomenon to nodal metal accumulation is compelling.
Retained wood as a consequence of remote penetrating trauma involving a tree. The “mass” was resected revealing residual chips of wood in the lesion. Nice pathology pics are included. A webinar co-presenter suggested ligneothorax for this — I like it!
A nice example of the so-called “tipped-up” variant of right middle lobe collapse. I’ve included a description of the wedge-in-wedge phenomenon and an article describing the tipped-up morphology.
June 14th, 2018.
Case Description
Diffuse pulmonary hyperattenuation in hypersensitivity pneumonitis. View the first CT at the standard lung display setting: WW 1500; WL -500. Note the diffuse “grey lungs,” with a so-called black bronchus sign intimating the substantial difference between the blackness of air in the airways compared to the lungs. If one increases the WL or narrows the WW, the finding will “disappear.” The follow-up CT shows resolution of the abnormality. The patient apparently had several pet birds in his house.
Extension of left thyroid lobe into the chest displacing the trachea rightward. A goiter usually displaces the trachea more superiorly .
June 7th, 2018.
Case Description
Multiple malpositioned pacemaker leads. This is quite a collection for one patient: Extravascular location of a right atrial lead; malpositioned atrial lead in the SVC; trans-apical passage of right ventricular lead (on CT).
Organizing pneumonia (presumed) from transtuzumab (Herceptin). Classic consolidative and ground glass-attenuating opacities with several reverse-halos.
Sputum-postive TB in an AIDS patient. The lung findings on CT are very sparse— in the upper lobes.
Subaortic left brachiocephalic vein. A nice teaching example of this unusual anomaly.
May 31st, 2018.
Case Description
Brachiocephalic artery and aortic mural injuries from multiple, unsuccessful attempts at jugular vein catheterization (presumed). This was an unanticipated finding on the CT obtained for other reasons. An examination of the medical record revealed a description of the five catheterization attempts a few hours before the scan. The actual mechanism of injury is elusive.
Hypersensitivity pneumonitis (presumed) attributed to avian protein. This is a dramatic example of a mosaic attenuation pattern from obstructive small airways disease/air trapping.
Interstitial edema (asymmetric) with septal lakes from mitral valve regurgitation. Images from the transesophageal ultrasound examination are included.
Lateral displacement of the mediastinal-lung interface in the azygo-esophageal recess from esophageal dilatation. The esophagus is distended with ingested food (turkey and mash potato!) as detailed in the endoscopy report in the Case Summary.
May 24th, 2018.
Case Description
Chronic granulomatous disease. The diagnosis is not potentially possible without having a substantial history of repeated bronchopulmonary (and other organs, such as skin) infections.
Mediastinal large B-cell lymphoma. Substantial internal necrosis is present in the mass. The FDG-avid lung lesions are presumably lymphoma, too.
Malignant breast phyllodes tumor invading all four pulmonary veins with extension into the left atrium. A very aggressive tumor, with a lethal course — in this instance.
Severe pericarditis after removal of an interatrial septal occluder device (for ostensible nickel allergy). Substantial pericardial T1-hyperintensity on delayed gadolinium MRI imaging. A total pericardiectomy eventually had to be performed when trials of various anti-inflammatory medications did not successfully suppress the inflammation.
An intercostal-bronchial trunk in the proximal descending aorta potentially simulating aortic mural injury in a trauma victim. Note the “conical” shape of the origin of the vessel, which gives rise to bronchial and intercostal arteries.
May 17th, 2018.
Case Description
Aortic pseudothrombus from black smoke phenomenon. An excellent example of this phenomenon (a mixing of opacified and incompletely opacified blood), which is due to a combination of a short scan time (less than a second), with a distinct contrast-attenuation difference in the opacified distal aortic arch compared to the distal descending aorta (leading contrast edge phenomenon), and relatively slow flow on the inner aspect of the lumen. The area of relatively low attenuation still has attenuation values much higher than thrombus, the latter usually around 30-40 H.U.
Appearing heart sign of pneumomediastinum. I’ve given the observation this inelegant name. Let me know of a better one. The expected convex heart-lung interface (particularly that related to the apical left ventricle) has suddenly “appeared” because of the accumulation of air in the contiguous mediastinal fat, which previously effaced the interface. This complements other, usual signs of pneumomediastinum.
Behcet’s disease with RV clot and pulmonary emboli. Pulmonary artery aneurysms are not present in this case, kindly submitted by Julie Takasugi.
Incidental discovery of a PDA during evaluation of acute aortic syndrome. Note the nice jet of contrast (the white spotlight) entering the left pulmonary artery.
Pulmonary extramedullary hematopoiesis in myelofibrosis (very strong presumption). Note the diffuse FDG-avidity in the lungs on the PET scan.
May 3rd, 2018.
Case Description
Diffuse lymphangitic tumor spread (presumed) from a gastric cancer. This previously healthy patient presented with extensive osseous, nodal, and pulmonary metastases. A tumor was discovered at the gastro-esophageal junction. Diffuse interstitial edema and pleural effusions are present. Diffuse pulmonary FDG-avidity is present on PET-CT.
April 19th, 2018.
Case Description
Familial pulmonary fibrosis. The patient’s mother and two siblings are also affected. Genetic studies (e.g., for telomerase-associated mutations) have not been done. A biopsy has not been performed, but I wouldn’t be surprised if findings of pleuroparenchymal fibroelastosis were present.
Primary mediastinal large B-cell lymphoma. I was concerned that a more-dire diagnosis— such as midline NUT carcinoma— was present.
Smoking-related fibrosis, enlarged airspaces, and massive accumulation of smoker’s macrophages. A correlative lung biopsy report is included. I wish that a multi-disciplinary discussion had occurred. I think that a confident diagnosis of “smoker’s lung” may be made on the basis of the imaging findings.
Incidental finding of a thrombosed systemic artery to the RLL. Leif Jensen made a great observation: a bronchus in the adjacent lobe does not have a companion artery. We’ll call this the lonely bronchus sign. Let me know if you’ve ever seen this phenomenon.
April 6th, 2018.
Case Description
Parenchymal cysts in B-cell chronic lymphocytic leukemia. The (larger) cysts have features typical of those that are consequent on protein (light chains) deposition, seen in a variety of lymphoplasmacytic proliferative disorders.
Incidental discovery of CTEPH-like vascular morphologic findings in the left lower lobe. Substantial luminal narrowing is present with slow flow through the lobe and a “black smoke” phenomenon in the pulmonary veins and left atrium. Careful evaluation of a chest radiograph obtained two years before shows the same vascular attenuation in the left lower lobe.
Hydrostatic lung edema from cardiomyopathy. This is a great teaching case to show: very thick interlobular septa; edematous inter-segmental septum in the LLL; subpleural interstitial edema in relation to interlobar fissures; peri-bronchial fluid cuffs, substantially narrowing bronchial lumens (think cardiac asthma); mediastinal fat edema; nodal edema.
Human metapneumovirus infection in a breast cancer patient on chemotherapy. A nice companion case to that shown by Travis last week! The findings of substantial bronchitis are great for teaching.
March 29th, 2018.
Case Description
Recurrent pyogenic abscesses ascribed to recurrent aspiration episodes. Large, recurrent foci of necrotizing pneumonia occur. Subtle airway findings— intraluminal material in the lumens of small bronchi and bronchioles— are present on some examinations. An organism(s) has never grown in culture.
An interstitial fibrosing disorder. I would describe the pattern as indeterminate for UIP. Classification criteria are here. Areas of fibrosis, with traction bronchiectasis, are present away from the lung periphery and a basal-predominant disease distribution is not present. Sparse foci of air-trapping are present. Pathologic findings on open-lung biopsy revealed findings consistent with UIP.
Another left atrial appendage occluder device. This one is an Amplatzer Amulet device.
March 22th, 2018.
Case Description
An unusual course of a central venous catheter on bedside radiography, causing some consternation. The catheter jogs slightly into a large azygos vein. Additional imaging demonstrates: absence of the intra-hepatic IVC; a small persistent left SVC; and bilobed lungs (Kanne’s Rule : look for concurrent airway and lobation anomalies.)
Left cervico-thoracic sign (of Felson). As expected, a goiter is the cause. The structure that contacts the left upper lobe is the displaced left subclavian artery. The presence of the goiter is also visible on the lateral projection.
Substantial increase in extrapleural fat with evolving adjacent, extensive pleural thickening. I don’t think we know why this happens, but it’s a well-described phenomenon in the context of chronic pleural fluid/thickening.
March 15th, 2018.

Today’s cases are two examples of smoking-related lung disease, particularly Langerhan’s Cell Histiocytosis. The chest radiographs demonstrate the often-very- subtle upper lung-zone reticulation and cystic changes that substantially “under-represent” the extent of disease that is present. Examine the PA projections carefully for an Aunt-Minnie perceptual pattern.

Case Description
First case Florid cystic disease with small solid and cavitated nodules in a 29-year-old smoker. The extent of disease is diminished after smoking cessation.
Second case In addition to the upper lobe cysts, florid parenchymal hyperattenuation is present, undoubtedly representing massive parenchymal accumulation of smoker’s macrophages. Several small, circumscribed cysts are present in the lower lungs. If a lung biopsy were performed, I’d bet that DIP would be described. Of course, DIP is a misnomer.
March 8th, 2018.
Case Description
An accessory hyparterial left upper lobe bronchus An additional small bronchus arises from the distal left main bronchus just before the origin of the LUL bronchus. A graphic demonstrating such accessory bronchi is included. (Case from Julie Takasugi)
Hepatocellular carcinoma with direct extension into IVC and extensive intravascular metastases Numerous intravascular (large) tumor emboli are present. (Case from Julie Takasugi)
Systemic arterial supply to RLL, drainage of pulmonary veins into the azygos, and bilobed right lung A rather strange variation of intralobar sequestration with venous drainage into a systemic vein. Not unexpectedly, lobation anomaly is also present— the Kanne Rule. (Case from Julie Takasugi)
Necrotizing Staph. aureus pneumonia with several small cavitary lesions — Cheerios with halos. The case also demonstrates pneumomediastinum from the Macklin phenomenon (ventilated patient)— septal emphysema; subpleural emphysema; and air in axial connective tissue sheaths are present
March 1st, 2018.
Case Description
CTPA. Scanning too early after contrast administration with incomplete opacification of the pulmonary arteries in a patient with CHF. With our new Siemens Force scanner (0.5-1s scan time) we’ve had to increase the default scan delay (9-10s) on our bolus tracking protocol to achieve proper opacification of the arteries and left heart.
Enlargement of all four parathyroid glands in secondary hyperparathyroidism in CRF. The glands are situated more inferiorly than usual.
Transpleural connections between chest wall veins and pulmonary veins in central venous obstruction A patient with sickle cell disease and venous obstruction attributed to a complication of chronic vein catheterizations. A SVC stent is present, covering the junction of brachiocephalic veins. The veins traverse the pleural space through pleural fluid to enter the lung. Other more-usual collaterals are present as well.
Mounier-Kuhn syndrome A classic case. Embolization procedures (presumably for hemoptysis) were performed previously.