Abdominal Chest Computed Tomography Research Articles

Emphysematous changes as red flag signs preceding rapidly progressive infectious aortic disease: two case reports

BackgroundInfectious aortic disease is a rare and fatal disease, that requires the appropriate intervention. An accurate diagnosis should be promptly established. However, this is difficult because the clinical manifestations of this disease vary and are non-specific.Case presentation(CASE 1) An 87-year-old male, presenting with generalized malaise and weight loss, was admitted for further examination. A chest computed tomography (CT) showed mediastinal emphysema. Empirical intravenous antibiotics were administered to address the non-specific infectious findings in the laboratory data. The treatment was effective, and the patient fully recovered. However, he was in shock due to aortic rupture and marked pseudo aneurysmal formation around the aortic arch day 25 of hospitalization. An emergency total aortic arch replacement was performed, and the patient was discharged. (CASE 2) An 82-year-old male who had undergone Y-graft replacement in the abdominal aorta 15 years previously was admitted due to general malaise and anorexia. Abdominal CT revealed emphysematous changes adjacent to the abdominal aorta. The patient responded favorably to empirical treatment with intravenous antibiotics and was discharged 19 days after admission. Four days after discharge, the patient went into cardiac arrest after an episode of hematemesis. Abdominal CT revealed an enlarged stomach and duodenum, filled with massive high-density contents proximal to the abdominal aorta. He died of hemorrhagic shock despite cardiopulmonary resuscitation.ConclusionsAlthough emphysematous changes are rare, they are red flag signs during the early stage of infectious aortic disease. Thus, physicians should remain vigilant for this kind of critical sign.

Breast Sarcomas, Phyllodes Tumors, and Desmoid Tumors: Turning the Magnifying Glass on Rare and Aggressive Entities.

Breast sarcomas (BSs), phyllodes tumors (PTs), and desmoid tumors (DTs) are rare entities that arise from connective tissue. BSs can be classified as either primary or secondary, whether they develop de novo or after radiation exposure or lymphedema. PIK3CA seems to play an important common role in different BS. Malignant PTs show similar behavior to BSs, while DTs are locally aggressive but rarely metastasize. BSs usually present as unilateral, painless, rapidly growing masses with rare nodal involvement. The diagnosis should be based on magnetic resonance imaging and a core needle biopsy. Staging should comprise a chest computed tomography (CT) scan (except for benign PT and DT), while abdominal and pelvic CT scans and bone scans should be added in certain subtypes. The mainstay of treatment for localized BS is surgery, with margin goals that vary according to subtype. Radiotherapy and chemotherapy can be used as neoadjuvant or adjuvant approaches, but their use in these settings is not standard. Advanced BS should be treated with systemic therapy, consistent with recommendations for advanced soft tissue sarcomas of other topographies. Given the rarity and heterogeneity of these entities, multidisciplinary and multi-institutional collaboration and treatment at reference centers are critical.

Comparison of the duration of generating radiological protocols with keyboard and voice input

BACKGROUND: Speech recognition is becoming increasingly common in the national healthcare system. One of the first specialties to implement this technology on a large scale was radiology. However, the efficiency of voice input and its effect on the length of time required to complete medical records remain unresolved.
 AIM: To assess the efficiency of speech recognition in generating radiological protocols of different modalities and types.
 METHODS: The retrospective study was conducted at the Moscow Reference Center of the Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Department of Health. A total of 12,912 radiological reports on fluorography, mammography, chest computed tomography (CT), contrast-enhanced magnetic resonance imaging (MRI) of the brain, and contrast-enhanced CT of the abdomen and pelvis were included in the study by simple random sampling. The size of all samples exceeded 766 reports, calculated with regard to the size of the general population of over 100,000 reports. The Voice2Med software was used to fill in the radiological protocols. Intergroup comparison was performed using the MannWhitney U-test with a statistical significance level of 0.05.
 RESULTS: The average duration of generating fluorographic protocols in the keyboard and voice input groups was 189.9 s (0:03:09) and 236.2 s (0:03:56), respectively (p 0.0001). For mammographic reports, the duration was 387.1 s (0:06:27) and 444.8 s (0:07:24), respectively (p 0.0001). For radiographic reports, it amounted to 247.8 s (0:04:07) and 189.0 s (0: 03:09), respectively (p 0.0001), and for chest CT, it was 379.7 s (0:06:19) and 382.7 s (0:06:22), respectively (p=0.12). For MRI of the brain, the protocols were generated for 709.9 s (0:11:49) and 559.9 s (0: 09:19), respectively (p 0.0001), and for contrast-enhanced chest, abdominal, and pelvic CT scans, it took 2714.6 s (0:45:15) and 1778.4 s (0:29:38), respectively. Voice input slowed down the preparation time of mammographic and fluorographic protocols. This is due to the use of a structured electronic medical document in medical facilities to describe the results of the examinations. Speech recognition showed the greatest efficiency in generating MRI and CT protocols. Such reports contain a large number of pathological changes, both target and incidental findings, which requires a detailed description by the radiologist in the examination protocol.
 CONCLUSIONS: Speech recognition in generating radiological protocols showed different efficiency depending on the modality and type of the radiological protocol filled in using the voice input system. This approach is optimal for describing CT and MRI scans.

Clinical Analysis of Intestinal Tuberculosis: A Retrospective Study.

This study aimed to summarize and analyze the clinical data of intestinal tuberculosis (ITB) in order to provide guidance for accurate diagnosis and treatment of ITB. This study consecutively included patients with ITB who were admitted to our hospital from 2008 to 2021 and retrospectively analyzed their clinical features. Forty-six patients were included. The most common clinical symptom was weight loss (67.4%). Seventy percent of 20 patients were positive for tuberculin skin test; 57.1% of 14 patients were positive for mycobacterium tuberculosis specific cellular immune response test, while 84.6% of 26 patients were positive for tuberculosis infection T cell spot test. By chest computed tomography (CT) examination, 25% and 5.6% of 36 patients were diagnosed with active pulmonary tuberculosis and with inactive pulmonary tuberculosis, respectively. By abdominal CT examination, the most common sign was abdominal lymph node enlargement (43.2%). Forty-two patients underwent colonoscopy, and the most common endoscopic manifestation was ileocecal ulcer (59.5%), followed by colonic ulcer (35.7%) and ileocecal valve deformity (26.2%). ITB most frequently involved the terminal ileum/ileocecal region (76.1%). Granulomatous inflammation with multinucleated giant cells and caseous necrosis was found via endoscopic biopsies, the ultrasound-guided percutaneous biopsy of enlarged mesentery lymph nodes, and surgical interventions. The acid-fast bacilli were discovered in 53.1% of 32 samples. Twenty-one cases highly suspected of ITB were confirmed after responding to empiric anti-tuberculosis therapy. It was necessary to comprehensively analyze clinical features to make an accurate diagnosis of ITB and aid in distinguishing ITB from diseases such as Crohn's disease and malignant tumors.

Severe Klebsiella pneumoniae pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism: A case report

Klebsiella pneumoniae (K. pneumoniae) is a clinically common Gram-negative bacillus that can cause community- and hospital-acquired infections and lead to pneumonia, liver abscesses, bloodstream infections, and other infectious diseases; however, severe pneumonia caused by hypervirulent K. pneumoniae (hvKp) complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism is rarely seen in the clinical setting and has not been reported in the literature. A 51-year-old man was hospitalized with fever and dyspnea. Persistent mild pain in the middle and upper abdomen began at dawn on the 3rd day following admission and developed into persistent severe pain in the left upper abdomen 8 h later. Based on chest computed tomography (CT), bronchoscopy, bronchoalveolar lavage fluid metagenomic next-generation sequencing, abdominal aortic CT angiography (CTA), and culture of the superior mesenteric artery embolus, adult community-acquired severe hvKp pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism was diagnosed. Notably, he recovered and was discharged from the hospital after receiving effective meropenem anti-infection, endovascular contact thrombolytic, and systemic anticoagulant therapies and undergoing percutaneous thrombus aspiration. Ten days later, the patient returned to the hospital for abdominal CTA examination, which indicated blocked initial common pathway of the celiac trunk and superior mesenteric artery, and local stenosis. Therefore, celiac trunk artery stenting was performed in Chongqing Hospital, and postoperative recovery was good. We report a case of hvKp severe pneumonia complicated by acute intra-abdominal multiple arterial thrombosis and bacterial embolism and suggest that clinicians should consider the possibility of a Gram-negative bacillus infection and conduct effective pathogen detection in a timely fashion when managing patients with severe community-acquired pneumonia before obtaining bacteriologic and drug sensitivity results. At the same time, when patients have severe pulmonary infection complicated by severe abdominal pain, an acute mesenteric artery embolism should be considered to avoid delays in treatment.

Liver resection in a patient with persistent positive PCR test for coronavirus disease 2019 (COVID-19): a case report

BackgroundThe perioperative mortality rate is high in patients with coronavirus disease 2019 (COVID-19), and infection control measures for medical care providers must be considered. Therefore, the timing for surgery in patients recovering from COVID-19 is difficult.Case presentationA 65-year-old man was admitted to a hospital with a diagnosis of moderate COVID-19. He was transferred to our hospital because of risk factors, including heavy smoking history, type 2 diabetes mellitus, and obesity (BMI 34). Vital signs on admission were a temperature of 36.1 °C, oxygen saturation > 95% at rest, and 94% on exertion with 3 L/min of oxygen. Chest computed tomography (CT) showed bilateral ground-glass opacities, predominantly in the lower lungs. Contrast-enhanced abdominal CT incidentally revealed a liver tumor with a diameter of 80 mm adjacent to the middle hepatic vein, which was diagnosed as hepatocellular carcinoma (HCC). After being administered baricitinib, remdesivir, dexamethasone, and heparin, the patient’s COVID-19 pneumonia improved, his oxygen demand resolved, and he was discharged on day 13. Furthermore, the patient was initially scheduled for hepatectomy 8 weeks after the onset of COVID-19 following a discussion with the infection control team. However, 8 weeks after the onset of illness, a polymerase chain reaction (PCR) test was performed on nasopharyngeal swab fluid, which was observed to be positive. The positive results persisted till 10 and 11 weeks after onset. Both Ct values were high (≥ 31) out of 45 cycles, with no subjective symptoms. Since we determined that he was no longer contagious, surgery was performed 12 weeks after the onset of COVID-19. Notably, medical staff wearing personal protective equipment performed extended anatomical resection of the liver segment 8 ventral area in a negative-pressure room. The patient had a good postoperative course, with no major complications, including respiratory complications, and was discharged on postoperative day 14. Finally, none of the staff members was infected with COVID-19.ConclusionsWe reported a case regarding the timing of surgery on a patient with persistently positive PCR test results after COVID-19, along with a literature review.

A Trapped Colon

A Trapped Colon

Misdiagnosis Due to False-Positive Detection of Pneumococcal Urinary Antigen.

IntroductionThe detection of pneumococcal antigens in urine is an alternative to gram staining, and their culture is central to the diagnosis of pneumococcal pneumonia. We present a case of the false-positive detection of urinary Streptococcus species pneumococcal antigen with a BinaxNOW test. This resulted in delayed diagnosis of a liver abscess.Case descriptionA 70-year-old woman presented to the emergency department with a 1-day history of chills and difficulty walking. She had a fever and her physical examination was normal. Non-contrast chest computed tomography (CT) revealed a slight ground-glass opacity in the left lower lobe. Laboratory tests revealed liver injury and elevated C-reactive protein levels. A urinary pneumococcal antigen test was positive, and she was diagnosed with acute bronchopneumonia caused by Streptococcus pneumoniae. She was treated with ceftriaxone. However, abdominal contrast-enhanced CT performed the next day revealed portal vein thrombus and a left lobe liver abscess. Streptococcus constellatus was detected in a puncture specimen of the liver abscess. It was concluded that the positive urinary pneumococcal antigen test was a false-positive owing to Streptococcus infection.DiscussionFalse-positive results might be explained by the presence of C-polysaccharide antigens in the cell wall of S. pneumoniae. The positive urinary antigen test together with the finding of slight ground-glass opacity in the left lung on chest CT initially led to misdiagnosis. False positives may result in misdiagnosis and unnecessary antimicrobial therapy.ConclusionThe overuse of the pneumococcal urinary antigen tests can lead to false positives and misdiagnosis.LEARNING POINTSFalse-positive pneumococcal urinary antigen results may lead to the misdiagnosis of pneumococcal pneumonia caused by Streptococcus pneumoniae and unnecessary antimicrobial therapy.False-positive results can occur in patients with infections caused by other Streptococcus species (e.g., liver abscess caused by Streptococcus constellatus).The optimal use of pneumococcal urinary antigen tests needs to be studied in clinical practice settings.

Weil syndrome coincident with upper gastrointestinal bleeding.

A 48 year old male was referred to our center due to a gastrointestinal bleeding with melena secondary to a Forrest IIb gastric ulcer treated endoscopically. Physical examination revealed bilateral conjunctival suffusion, bradypsychia, and asterixis. Epidemiological history included a trip to Dominican Republic two weeks before, presenting later a flu-like syndrome. He had no history of NSAID use. Laboratory tests showed a normocytic anemia, leukocytosis with neutrophilia, acute renal failure, severe hyponatremia, a predominant direct hyperbilirubinemia, hyperamylasemia, and mild coagulopathy (Table 1). An abdominal ultrasound was performed, with no pathological findings, and a chest-abdominal computed tomography (CT), bilateral diffuse ground glass pulmonary opacities and pleural effusion, mild hepatomegaly, and peritoneal and gastrohepatic ligament lymphadenopathy, with no signs of acute pancreatitis. A second look upper endoscopy revealed a Forrest III gastric ulcer. Gastric biopsies results ruled out malignancy and Helicobacter pylori infection. Due to his recent travel history combined with his characteristic signs and symptoms a clinical diagnosis of leptospirosis was made and empirical antibiotic therapy with meropenem was started. The serology for Leptospira was positive (IgG 1/1600) and antibiotic therapy was de-escalated to ceftriaxone with clinical and analytical remission on day five of his hospital stay with complete radiological resolution at 6 months.

Xanthomatous Pleuritis Associated With Pancreaticopleural Fistula.

Xanthomatous pleuritis is a very rare type of chronic inflammation, with only 3 reports to date.1–3 However, the exact etiology of this disease is unknown. Herein, we present a case of xanthomatous pleuritis that might have been associated with pancreatic pleural effusion. CASE REPORT A 62-year-old male who regularly consumed alcohol (<20 g/day), was a nonsmoker, and had no medical history was referred to our hospital for exertional dyspnea. Laboratory examination revealed leukocytosis (11,200/μL); however, all other findings were normal (C-reactive protein, 0.62 mg/dL; serum amylase, 171 IU/L; serum lipase, 30 IU/L; tumor markers, negative; interferon-gamma release assay, negative). The chest radiograph showed left pleural effusion. Moreover, chest computed tomography (CT) revealed left pleural effusion. We performed thoracoscopy under local anesthesia for drainage and pathologic diagnosis as pleural effusion because of malignancy was considered. Pleural fluid examination revealed bloody exudative (protein, 5.0 g/dL; lactate dehydrogenase, 1264 IU/L; Rivalta reaction, positive; serum total protein, 6.9 g/dL; serum, lactate dehydrogenase 212 IU/L) and high level of amylase (13,355 IU/L). Thoracoscopy of the left thorax revealed diffuse yellow plaque-like deposits in the pleura (Fig. 1). Histology of the left pleural biopsy specimen showed inflammation and foamy cells (Fig. 2). There was no evidence of malignancies and infections, including Mycobacterium. Therefore, we considered the presence of pancreaticopleural fistula and performed further abdominal examinations. An enhanced CT and endoscopic retrograde cholangiopancreatography revealed pancreatic stones, main pancreatic duct dilatation, meandering pancreatic duct, and left pancreaticopleural fistula (Fig. 3). Distal pancreatectomy was performed after thoracic drainage with a chest tube to treat the pancreatic pleural fistula for prevention of pleural effusion recurrence and rule out pancreatic cancer. The surgically resected specimen of the pancreas showed chronic pancreatitis with pancreatic stones and no findings of malignancies. On the basis of these results, xanthomatous pleuritis with pancreaticopleural fistula because of chronic pancreatitis was finally diagnosed. The patient has had an uneventful course without recurrence for more than 4 years.FIGURE 1: A and B, Thoracoscopic image shows diffuse yellow plaque-like deposits in the pleura of the left thorax.FIGURE 2: Biopsy specimen of the pleura with yellow plaque-like deposit shows foamy cells (×400 magnification).FIGURE 3: Endoscopic retrograde cholangiopancreatography reveals meandering pancreatic duct and contrast outflow to the left thoracic cavity (red arrow).DISCUSSION To the best of our knowledge, this is the first report of xanthomatous pleuritis with pancreatic pleural effusion. Xanthomatous pleuritis is a very rare benign type of chronic inflammation, and only 3 cases have been reported in the literature.1–3 Although the exact etiology is uncertain, previous reports2–4 suggested that chronic inflammation, defective lipid transport, and hemorrhage might be the causes of xanthomatous inflammation. In the present case, chronic inflammation because of pancreaticopleural fistula might have caused xanthomatous pleuritis. Furthermore, aberrance of the lipid component of the pancreas might also be a cause of defective lipid transport. In addition, we present the thoracoscopic findings of xanthomatous pleuritis. Thoracoscopy showed diffuse yellow plaque-like deposits in the pleura. This finding was similar to that in a previous report by Bateman et al.3 Xanthoma comprises yellow plaque-like lesions characterized by the presence of lipid-containing histocytes and is commonly found in the gastrointestinal tract.5 The endoscopic finding of xanthoma in the gastrointestinal tract includes yellow spots,6,7 which is very similar to the finding in our case and a previous report.3 Hence, the yellow plaque-like deposits might be the characteristic finding in xanthomatous pleuritis. Physicians should consider the possibility of xanthomatous pleuritis when such thoracoscopy findings are observed. Furthermore, the thoracoscopy finding of xanthomatous pleuritis may indicate the possibility of the presence of pancreatic disease, even though pancreatic disease is not initially considered as a differential diagnosis when physicians examine patients with pleural effusion. Therefore, abdominal examinations, such as abdominal CT, ultrasound, or endoscopic retrograde cholangiopancreatography, should be performed when physicians confirm this thoracoscopy finding. Treatments for xanthomatous pleuritis are yet to be established, although steroids have been used in the previous cases.1,3 Since xanthomatous pleuritis was considered to be associated with pancreaticopleural fistula in the present case, we performed distal pancreatectomy, which led to a favorable outcome. It may be important to find out the underlying causes, such as pancreaticopleural fistula, when physicians diagnose xanthomatous pleuritis. In conclusion, the present case suggests that pancreatic pleural effusion might be a cause of xanthomatous pleuritis, and the thoracoscopic finding of yellow plaque-like deposits in pleura might be the characteristic finding of xanthomatous pleuritis.

Impact of COVID-19 on liver.

The incidence of liver injury after coronavirus disease 2019 (COVID-19) infection ranged from 15%-53%. The mechanism includes direct viral cytopathic effect, cytokinesis, and treatment drug-induced liver injury. The symptoms include nausea, vomiting, diarrhea, and loss of appetite. The laboratory results include increased liver enzyme levels, decreased monocyte count, and longer prothrombin time. The most common imaging findings are hepatomegaly on ultrasound, ground-glass opacity on chest computed tomography (CT), and liver hypodensity and pericholecystic fat stranding on abdominal CT. Patients may also have different presentations and poor outcomes of different liver diseases concomitant with COVID-19 infection. Liver function test (LFT) results should be monitored, and all factors known to cause or predispose liver injury should be investigated while managing the patients. The risks of transfer to an intensive care unit, need for mechanical ventilator support, and acute kidney injury is higher in COVID-19 patients with than without abnormal LFTs. Increased mortality and length of hospital stay are both observed.

Formula for the Cross-Sectional Area of the Muscles of the Third Lumbar Vertebra Level from the Twelfth Thoracic Vertebra Level Slice on Computed Tomography

The purpose of this study was to investigate a means by which to reflect muscle mass using chest computed tomography (CT). A cross-sectional study was conducted with patients aged ≥ 65 years having abdominal and chest CT scans. The formula to predict third lumbar vertebra (L3) cross-sectional area (CSA) of the muscles from the erector muscles of the spine at the twelfth thoracic vertebra (Th12) level slice on CT was created using the five-fold cross-validation method. Correlation between predicted L3 CSA and measured L3 CSA of the muscles was assessed by intraclass correlation coefficients (ICC) and correlation coefficients (r) in the data of the development, and predictability was examined with accuracy and F-values in the validation study. The development study included 161 patients. The developed formula was as follows: −1006.38 + 16.29 × age + 1161.80 × sex (if female, 0; if male, 1) + 55.91 × body weight + 2.22 × CSA of the erector muscles at Th12. The formula demonstrated strong concordance and correlation (ICC = 0.849 [0.800–0.887] and r = 0.858 [0.811–0.894]). The validation study included 34 patients. The accuracy and F-value between predicted CSA and measured CSA were high (accuracy = 0.889–0.944, F-value = 0.931–0.968). We developed a formula predicting CSA at L3 using Th12 CT slice. This formula could be used to assess decreased muscle mass even with chest CT alone.

Evaluation of body composition using computed tomography in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis.

Background/AimsMeasures of body composition, including visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and skeletal muscle area (SMA), are considered important prognostic factors in chronic diseases. The association of these measures with auto-inflammatory disorders, such as anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), remains unclear. We investigated the clinical significance of VAT, SAT, and SMA in patients with AAV.MethodsPatients with AAV subjected to chest computed tomography (CT), abdominal CT, or positron emission tomography-CT on diagnosis of AAV were evaluated. Quantitative assessment of VAT, SAT, and SMA was performed at the third lumbar vertebral level and computed by summing the pixel attenuation for tissue-specific Hounsfield units in the corresponding region. Associations of VAT, SAT, and SMA with clinical and laboratory data and clinical outcome measures were evaluated.ResultsOf the 117 patients, 61 (52.1%) were classified as having microscopic polyangiitis, 28 (23.9%) as granulomatosis with polyangiitis, and 28 (23.9%) as eosinophilic granulomatosis with polyangiitis. VAT significantly correlated with age, weight, body mass index (BMI), and Birmingham Vasculitis Activity Score, whereas SAT correlated with weight, BMI, and creatinine levels. A significant association was found between SMA and age, height, weight, BMI, and the Five-Factor Score. Cox proportional hazards analysis showed that creatinine levels (odds ratio [OR], 1.346; 95% confidence interval [CI], 1.034 to 1.753; p = 0.027) and high VAT (OR, 7.137; 95% CI, 1.343–37.946; p = 0.021) were independently associated with all-cause mortality during follow-up.ConclusionsEvaluation of VAT using CT is useful for estimating disease activity and all-cause mortality in patients with AAV.

Routine Chest Computed Tomography for Staging of Pancreatic Head Carcinoma.

The diagnostic value of routine chest computed tomography (CT) in addition to abdominal CT in workup for pancreatic head carcinoma is unclear. The aim of this study was to determine if routine chest CT revealed significant lesions that altered the management of patients with suspected pancreatic head carcinoma. All Dutch pancreatic cancer centers were surveyed on the use of chest CT in preoperative staging. In addition, a single-center retrospective cohort study was performed including all patients referred with suspected pancreatic head malignancy without chest CT between 2005 and 2016. The primary end point was the proportion of patients in which chest CT revealed clinically significant lesions, leading to a change in management. In 7 of 18 Dutch pancreatic cancer centers (39%), a preoperative chest CT is not routinely performed. In the study cohort, 170 of 848 patients (20%) were referred without chest CT and underwent one by local protocol. Chest CT revealed new suspicious lesions in 17 patients (10%), of whom 6 had metastatic disease (3.5%). Routine use of chest CT in diagnostic workup for pancreatic head carcinoma reveals clinically significant lesions in 10% of patients, being metastases in up to 4%.

COR PULMONALE RESULTING FROM PULMONARY TUMOR MICRO EMBOLI

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pulmonary tumor microemboli is a rare entity, often missed and diagnosed on autopsy. It leads to elevated pulmonary pressures, cor pulmonale and death. We present a case of a young man with dyspnea and sudden right ventricular failure found to have metastatic adenocarcinoma and tumor microemboli on autopsy. CASE PRESENTATION: A 42 year old man with cough, intermittent hemoptysis, dyspnea, night sweats, and 25 pound weight loss for 6 months. He was cachectic appearing and hypoxemic. Chest computed tomography (CT) revealed bilateral ground glass opacities, tree in bud opacities, mediastinal and hilar lymphadenopathy, without pulmonary embolism (PE). Echo showed normal left ventricular ejection fraction, mildly dilated right ventricle with elevated right sided pressures. Infectious workup was negative. He underwent bronchoscopy with endobronchial ultrasound (EBUS) and transbronchial needle aspiration of the subcarinal lymph node. Bronchoalveolar lavage showed numerous AFB. Treatment for both tuberculosis and Mycobacterium avium complex (MAC) was started and he was discharged home while waiting for cytology results. Two days later presented with worsening dyspnea and hypoxemia. CT chest showed progression of lung opacities in the right upper lobe. Final cytology from the needle aspiration showed metastatic adenocarcinoma. Abdominal CT demonstrated gastric wall thickening with retroperitoneal and perigastric lymphadenopathy. On echocardiogram, the RV was dilated with severely reduced systolic function and elevated pressures, without shunting. Patient deteriorated quickly and suffered cardiac arrest, likely sequelae of acute right ventricular failure due to severe pulmonary hypertension. Autopsy revealed extensive tumor cell microthrombi in the pulmonary vasculature, consistent with pulmonary tumor emboli, and lymphangitic carcinomatosis. The gastric body had multiple ulcers with nodular borders, which were consistent with gastric adenocarcinoma with extensive lymphatic involvement. AFB sputum cultures grew MAC. There was no evidence of pulmonary granulomatous infection in the autopsy. DISCUSSION: Pulmonary tumor microemboli are exceedingly rare. The condition has been reported with multiple malignancies but more commonly in gastric adenocarcinoma. The diagnosis often goes unrecognized given vague symptoms at presentation, as in our patient. Obstruction of the pulmonary vasculature with emboli leads to elevated pulmonary pressures and cor pulmonare. RV failure tends to be rapid, thus early identification is necessary. CONCLUSIONS: Pulmonary tumor emboli should be considered in patients with malignancy presenting with hypoxemia out of proportion to their imaging findings and elevated pulmonary pressures. Mortality is high and the majority of the cases are diagnosed post-mortem. Early diagnosis and chemotherapy may improve outcome. Reference #1: Hirata, K., Miyagi, S., Tome, M., Asato, H., Uechi, N., Kunishima, N. Cor Pulmonale due to Tumor Cell Microemboli. Arch Intern Med 1988; 148:2287-2289 Reference #2: Roberts, K., Hamele- Been, D., Saqi, A., Stein, C.A., Cole, R. Pulmonary Tumor Embolism: A Review of the Literature. Am J Med. 2003;115:228 –232. Reference #3: Liang, Y-H., Kuo, S-W., Lin, Y-L., Chang, Y-L. Disseminated microvascular pulmonary tumor embolism from non-small cell lung cancer leading to pulmonary hypertension followed by sudden cardiac arrest. Lung Cancer 72 (2011) 132–135. DISCLOSURES: No relevant relationships by Louis Buja, source=Web Response No relevant relationships by Sujith Cherian, source=Web Response No relevant relationships by Rosa Estrada-Y-Martin, source=Web Response No relevant relationships by Maryam Kaous, source=Web Response No relevant relationships by Michelle McDonald, source=Web Response

Small bowel metastasis from pulmonary rhabdomyosarcoma causing intussusception: a case report

BackgroundRhabdomyosarcoma (RMS), especially primary pulmonary RMS, is an extremely rare type of soft tissue sarcoma in adults. Small bowel is an uncommon site for metastases.Case presentationThis report described an unusual case of jejunum metastasis from primary pulmonary RMS causing intussusception in a 75-year-old man. The patient consulted for 2 weeks of continuous dyspnea. Chest computed tomography (CT) demonstrated a large mass involving the left lower lobe. Transthoracic biopsy confirmed the existence of pleomorphic RMS. Immunohistochemical studies showed positive findings about desmin and MyoD1. The results of gastroscopy, colonoscopy and abdominal CT were all negative. Positron emission tomography/CT demonstrated a fluorodeoxyglucose-reactive large lesion in the left lower lobe without metastatic lesions. The patient received synchronous chemoradiotherapy. After 9 months, the patient presented with intermittent upper abdominal pain with nausea and vomiting. CT showed small bowel dilatation secondary to intussusception. The patient subsequently received laparotomy, and the intussuscepted small bowel segment was resected. Histological examination revealed pleomorphic RMS involving the mucosa, submucosa, and muscular tissues.ConclusionsRMS is highly aggressive and metastatic. The metastatic disease can rapidly progress to cause subsequent complications. The possibility of small bowel metastasis should be considered, although it is extremely rare.

Pneumatoceles in pediatric blunt trauma: Common and benign

IntroductionTraumatic pneumatoceles are reported to be rare in children and to have an uncertain clinical significance. We report a single institution series of traumatic pneumatoceles to better define their frequency and clinical significance. MethodsAfter obtaining approval from the IRB, data were extracted from the trauma registry of a level 1 pediatric trauma center on children diagnosed with a pulmonary contusion (International Classification of Diseases-9th edition diagnosis codes: 861.21 to 861.31) who presented between June, 2006 and September, 2016. Patient demographics, mechanism of injury, injury severity score, diagnosis and procedure codes, length of hospital stay, outcome, imaging techniques and findings with attention to the identification of a pneumatocele, were examined. ResultsOf the 10,229 trauma admission, 204 children were identified as having a pulmonary contusion, 25 of whom (12.3%) were diagnosed with a pneumatocele. Their mean age was 13years (3–17). Seventy-six percent (19) were male. The most common mechanism of injury was a motor vehicle collision (10), followed by falls (6), and sports (5). Sixteen children (64%) suffered a long bone fracture, 12 (48%) an abdominal solid organ injury and 3 (12%) a traumatic brain injury. The mean Injury Severity Score was 17 (9–34). Twenty-three patients presented as transfers. There were no fatalities. The pneumatocele was identified on chest computerized tomography (CT) alone in 15 (60%), on chest CT and chest radiograph (CXR) in 3 (12%), the upper portions of an abdominal CT in 6 (24%) and on CXR alone in 1 (4%). Seven patients were found to have a solitary pneumatocele and 18 patients had 2 or more. The largest pneumatocele was 3.7cm in diameter. Ten children (40%) were admitted to the intensive care unit, 3 of whom required intubation. One patient (4%) had a respiratory complication: pneumonia. Three patients underwent chest tube placement for: pneumothorax, hemothorax and hemopneumothorax. No child underwent intervention specific to the pneumatocele. Seventeen (68%) patients were seen in follow-up in Trauma Clinic and the remainder by another practitioner ranging from 1week to 6months after injury. One child (4%) underwent a follow-up chest CT to rule out a congenital pulmonary malformation 6months after injury and this demonstrated complete resolution of the pneumatocele. ConclusionThe incidence of traumatic pneumatoceles among children with a pulmonary contusion was 12.3% in this series, but is probably higher given that only 24% were visible on radiographs and a small minority of children with pulmonary contusions underwent chest CT. Pneumatoceles are common in children with pulmonary contusions, but are usually small. The majority do not appear to be clinically significant nor require follow-up imaging. Level of evidenceIV.

Anatomical landmarks for safely implementing resuscitative balloon occlusion of the aorta (REBOA) in zone 1 without fluoroscopy

BackgroundResuscitative balloon occlusion of the aorta (REBOA) can maintain hemodynamic stability during hemorrhagic shock after a following torso injury, although inappropriate balloon placement may induce brain or visceral organ ischemia. External anatomical landmarks [the suprasternal notch (SSN) and xiphoid process (Xi)] are empirically used to implement REBOA in zone 1. We aimed to confirm if these landmarks were useful for determining a balloon catheter length for safe implementation of REBOA in zone 1 without using fluoroscopy.MethodWe selected 25 successive adult blunt trauma cases requiring contrast-enhanced chest/abdominal computed tomography (CT) treated at our emergency department (in an urban area of Kyoto city, Japan) between October 1, 2016 and January 31, 2017. We retrospectively evaluated anonymized CT images. We used three-dimensional multiplanar reconstructions to measure the length along the aorta’s central axis, from the bilateral common femoral arteries (FA) to the celiac trunk (CeT) (FA–CeT) and to the origin of the left subclavian artery (LSCA) (FA–LSCA). Volume-rendering reconstruction images were used to measure the external distance from common FAs to SSN (FA–SSN) and to Xi (FA–Xi).ResultFA–LSCA was significantly longer than FA–SSN. FA–CeT was significantly shorter than FA–Xi.DiscussionBased on these results, the REBOA balloon catheter should be shorter than FA–SSN, and longer than FA–Xi to avoid placement outside zone 1. The advantages of this method are that it can rapidly and easily predict a safe balloon catheter length, and it reflects each patient’s individual torso height.ConclusionTo safely implement REBOA, the balloon catheter length should be shorter than FA–SSN and longer than FA–Xi. We believe that these anatomical landmarks are good references for safe implementation of REBOA in zone 1 without radiographic guidance.

Recurrent Intussusception due to Multiple Intestinal Metastases From Lung Adenocarcinoma

Metastasis to the small intestine presents occasionally as multiple lesions and is associated with numerous complications. However, metastasis-induced intussusception in adults is a rare phenomenon. We report a case of recurrent intussusception induced by metastatic lesions from lung cancer. A 54-year-old male was referred to our hospital with intermittent lower right abdominal pain. Chest computed tomography (CT) revealed a mass, suggesting lung cancer, and abdominal CT showed characteristic target-shaped lesions highly suggestive of enteric intussusception in the ileum. The patient underwent segmental resection of the intussuscepted ileum, and analysis of the resected specimen identified a poorly differentiated adenocarcinoma that was pathologically and immunohistologically identical to the lung specimen obtained by percutaneous needle biopsy. Although the symptoms transiently resolved after surgery, intussusception recurred 3 weeks later, and the patient died 28 days after surgery. Multiple metastatic lesions should be considered in adult intussusception, particularly in patients with a history of malignancy.

Duodenal ulcer accompanied by intractable right lateral chest pain (T6/T7 dermatomal segments).

A 48-year-old man who complained of a severe throbbing pain in his right lateral chest was referred to our department. His chest computed tomography (CT) and X-ray, abdominal CT and ultrasonography had revealed no abnormalities. Four days after admission to our ward the patient vomited and he requested upper gastrointestinal (GI) endoscopy: this showed duodenal ulcer. Treatment with omeprazole and sucralfate improved the duodenal ulcer; concurrently, the symptoms of chest pain were relieved.