Inspiratory Chest Research Articles

Visual versus Automated Evaluation of Chest Computed Tomography for the Presence of Chronic Obstructive Pulmonary Disease

BackgroundIncidental CT findings may provide an opportunity for early detection of chronic obstructive pulmonary disease (COPD), which may prove important in CT-based lung cancer screening setting. We aimed to determine the diagnostic performance of human observers to visually evaluate COPD presence on CT images, in comparison to automated evaluation using quantitative CT measures.MethodsThis study was approved by the Dutch Ministry of Health and the institutional review board. All participants provided written informed consent. We studied 266 heavy smokers enrolled in a lung cancer screening trial. All subjects underwent volumetric inspiratory and expiratory chest computed tomography (CT). Pulmonary function testing was used as the reference standard for COPD. We evaluated the diagnostic performance of eight observers and one automated model based on quantitative CT measures.ResultsThe prevalence of COPD in the study population was 44% (118/266), of whom 62% (73/118) had mild disease. The diagnostic accuracy was 74.1% in the automated evaluation, and ranged between 58.3% and 74.3% for the visual evaluation of CT images. The positive predictive value was 74.3% in the automated evaluation, and ranged between 52.9% and 74.7% for the visual evaluation. Interobserver variation was substantial, even within the subgroup of experienced observers. Agreement within observers yielded kappa values between 0.28 and 0.68, regardless of the level of expertise. The agreement between the observers and the automated CT model showed kappa values of 0.12–0.35.ConclusionsVisual evaluation of COPD presence on chest CT images provides at best modest accuracy and is associated with substantial interobserver variation. Automated evaluation of COPD subjects using quantitative CT measures appears superior to visual evaluation by human observers.

Patterns of extension of gastrointestinal stromal tumors (GIST) treated with imatinib (Gleevec®) by 18F-FDG PET/CT

currently it is recognized the usefulness of 18F-FDG PET in assessing response to therapy with imatinib (Gleevec®) in the gastrointestinal tract sarcomas (GIST). To facilitate the follow-up of these studies is important to know the patterns of metastatic spread. The aim of this paper is to describe patterns observed in the 18F-FDG PET/CT. retrospective study included 29 patients who underwent 18F-FDG PET/CT after being diagnosed with unresectable or metastatic GIST. In total, 87 PET/CT studies were performed (1-6 controls per patient) with a mean time of follow-up 6-36 months. We analyzed the location of the lesions evidenced in PET, CT and fusion. Images were evaluated visually and semiquantitatively (SUV). In cases in which has been considered necessary, additional images have been undertaken: PET delayed imaging, intravenous contrast CT and inspiratory chest CT. the most common primary site was the stomach (41%), small bowel (35%), and rectum (24%). Significant changes in the location of metastatic disease between pre-treatment and the monitoring were observed, with the appearance of more extra-abdominal disease. individualization of protocol studies and interpretation of PET, CT and fused images were required for evaluation of treatment response to imatinib. Hybrid 18F-FDG PET/CT provides an accurate determination of the extent of GIST. While the most common metastatic site is the liver and peritoneum, in the following cases are common extra-abdominal disease.

The effect of iterative reconstruction on computed tomography assessment of emphysema, air trapping and airway dimensions

ObjectivesTo determine the influence of iterative reconstruction (IR) on quantitative computed tomography (CT) measurements of emphysema, air trapping, and airway wall and lumen dimensions, compared to filtered back-projection (FBP).MethodsInspiratory and expiratory chest CTs of 75 patients (37 male, 38 female; mean age 64.0 ± 5.7 years) were reconstructed using FBP and IR. CT emphysema, CT air trapping and airway dimensions of a segmental bronchus were quantified using several commonly used quantification methods. The two algorithms were compared using the concordance correlation coefficient (p c) and Wilcoxon signed rank test.ResultsOnly the E/I-ratioMLD as a measure of CT air trapping and airway dimensions showed no significant differences between the algorithms, whereas all CT emphysema and the other CT air trapping measures were significantly different at IR when compared to FBP (P < 0.001).ConclusionThe evaluated IR algorithm significantly influences quantitative CT measures in the assessment of emphysema and air trapping. However, the E/I-ratioMLD as a measure of CT air trapping, as well as the airway measurements, is unaffected by this reconstruction method. Quantitative CT of the lungs should be performed with careful attention to the CT protocol, especially when iterative reconstruction is introduced.Key Points• New techniques in CT allow numerous quantitative measurements of lung function.• Iterative reconstruction influences quantitative CT measurements of emphysema and air trapping.• Expiratory-to-inspiratory ratio of mean lung density and airway measurements are unaffected by iterative reconstruction.• Quantitative lung-CT should be performed with careful attention to the CT protocol.

Mass preserving image registration for lung CT

This paper presents a mass preserving image registration algorithm for lung CT images. To account for the local change in lung tissue intensity during the breathing cycle, a tissue appearance model based on the principle of preservation of total lung mass is proposed. This model is incorporated into a standard image registration framework with a composition of a global affine and several free-form B-Spline transformations with increasing grid resolution. The proposed mass preserving registration method is compared to registration using the sum of squared intensity differences as a similarity function on four groups of data: 44 pairs of longitudinal inspiratory chest CT scans with small difference in lung volume; 44 pairs of longitudinal inspiratory chest CT scans with large difference in lung volume; 16 pairs of expiratory and inspiratory CT scans; and 5 pairs of images extracted at end exhale and end inhale phases of 4D-CT images. Registration errors, measured as the average distance between vessel tree centerlines in the matched images, are significantly lower for the proposed mass preserving image registration method in the second, third and fourth group, while there is no statistically significant difference between the two methods in the first group. Target registration error, assessed via a set of manually annotated landmarks in the last group, was significantly smaller for the proposed registration method.

Air Trapping: A Cause of Heterogeneous Attenuation

Purpose: To investigate important factors affecting the frequency of air trapping through observation of normal lung attenuation, and propose a cause of heterogeneous attenuation. Materials and Methods: In this ethical committee-approved study, a total of 109 patients (30 males, 79 females; mean age, 58.2 years; range, 27 - 81 years) were included. All patients had undergone inspiratory and expiratory chest thin-section computed tomography (CT) examinations and pulmonary function tests. Air trapping on CT images was graded subjectively. Hounsfield units (HU) lung attenuation value and lung volume were measured on CT images. All variables (age, sex, indices of pulmonary function test results, air trapping score, HU value, and rate of change in lung volume) were compared by diagnoses and air trap- ping findings cohorts. The correlation between lung function test results and expiratory HU attenuation were analyzed. Results: Interstitial pneumonia showed higher and bronchiolitis obliterans showed lower HU attenuation at normal and air trapping regions. The variables affecting air trapping findings were age, a ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1.0/FVC), maximal expiratory flow at 50% of forced vital capacity (MEF50), HU attenuation at normal regions, and rate of change in lung volume. Compared with expiratory HU attenuation, significant positive correlation was shown to FEV1.0/FVC and negative correlation to single-breath diffusion capacity for carbon monoxide, which was confirmed by a simple regression analysis. Conclusion: It can be suggested that lung attenuation can increase when fibrosis is advanced, and this is exaggerated when lungs are compressed.

Changes in Central Apnea Index following Pediatric Adenotonsillectomy

To determine if there are changes in the central apnea index (CAI) when pediatric patients undergo adenotonsillectomy for obstructive sleep apnea (OSA). Case series with chart review. Two tertiary children's hospitals. Children between 1 and 16 years of age who underwent adenotonsillectomy for OSA and had both preoperative and postoperative full-night polysomnography (PSG) with CAI greater than 1 on preoperative PSG were eligible for inclusion. Central apnea was defined as the absence of both inspiratory effort and chest wall movement lasting longer than 20 seconds. Criteria for diagnosis of central sleep apnea (CSA) was CAI greater than 1. A total of 101 children with OSA had preoperative and postoperative PSG. Fifteen of these patients had a preoperative CAI greater than 1. The mean age was 67.7 months (SD, 62.7 months). The CAI ranged from 1.1 to 11.1. The mean preoperative CAI was 3.9 (SD, 2.9), while the mean postoperative CAI was 1.9 (SD, 4.8). There was significant improvement (P = .008) of the CAI following adenotonsillectomy. Ninety percent of subjects with mild CSA (CAI between 1 and 5) had postoperative resolution of their disease. There was also significant improvement (P = .004) in the obstructive apnea hypopnea index (AHI), with the mean preoperative AHI of 22.8 (SD, 19.8) decreasing to an AHI of 5.5 (SD, 6.5) postoperatively. Children with OSA and mild CSA on preoperative PSG showed significant improvement in CAI following adenotonsillectomy. Future studies are needed to determine the clinical significance of CSA in children with OSA and to identify treatment strategies.

Stridor and lingual thyroglossal duct cyst in a newborn

To describe the diagnosis and management of lingual thyroglossal duct cyst in newborns. A one-month-old girl presenting with inspiratory stridor and chest wall retraction was referred to our department for management of stridor. Upper airway endoscopy and neck CT scan showed a round mass at the base of the tongue causing upper airway obstruction. Computed tomography showed a well-circumscribed, low-density lesion at the base of the tongue. Endoscopic marsupialization of this lesion was performed under general anaesthesia. Histological examination confirmed the diagnosis of lingual thyroglossal duct cyst. No recurrence was observed 18 months after endoscopic treatment. Lingual thyroglossal duct cyst with airway obstruction is an uncommon aetiology of stridor in newborns with symptoms similar to those of laryngomalacia. The diagnosis is based on laryngoscopy. Surgical endoscopic removal is the treatment of choice. Recurrence after endoscopic treatment is rare.

Volume-monitored chest CT: a simplified method for obtaining motion-free images near full inspiratory and end expiratory lung volumes

Lung inflation and respiratory motion during chest CT affect diagnostic accuracy and reproducibility. To describe a simple volume-monitored (VM) method for performing reproducible, motion-free full inspiratory and end expiratory chest CT examinations in children. Fifty-two children with cystic fibrosis (mean age 8.8 ± 2.2 years) underwent pulmonary function tests and inspiratory and expiratory VM-CT scans (1.25-mm slices, 80-120 kVp, 16-40 mAs) according to an IRB-approved protocol. The VM-CT technique utilizes instruction from a respiratory therapist, a portable spirometer and real-time documentation of lung volume on a computer. CT image quality was evaluated for achievement of targeted lung-volume levels and for respiratory motion. Children achieved 95% of vital capacity during full inspiratory imaging. For end expiratory scans, 92% were at or below the child's end expiratory level. Two expiratory exams were judged to be at suboptimal volumes. Two inspiratory (4%) and three expiratory (6%) exams showed respiratory motion. Overall, 94% of scans were performed at optimal volumes without respiratory motion. The VM-CT technique is a simple, feasible method in children as young as 4 years to achieve reproducible high-quality full inspiratory and end expiratory lung CT images.

Genetic Epidemiology of COPD (COPDGene) Study Design

ABSTRACTBackground: COPDGene is a multicenter observational study designed to identify genetic factors associated with COPD. It will also characterize chest CT phenotypes in COPD subjects, including assessment of emphysema, gas trapping, and airway wall thickening. Finally, subtypes of COPD based on these phenotypes will be used in a comprehensive genome-wide study to identify COPD susceptibility genes. Methods/Results: COPDGene will enroll 10,000 smokers with and without COPD across the GOLD stages. Both Non-Hispanic white and African-American subjects are included in the cohort. Inspiratory and expiratory chest CT scans will be obtained on all participants. In addition to the cross-sectional enrollment process, these subjects will be followed regularly for longitudinal studies. A genome-wide association study (GWAS) will be done on an initial group of 4000 subjects to identify genetic variants associated with case-control status and several quantitative phenotypes related to COPD. The initial findings will be verified in an additional 2000 COPD cases and 2000 smoking control subjects, and further validation association studies will be carried out. Conclusions: COPDGene will provide important new information about genetic factors in COPD, and will characterize the disease process using high resolution CT scans. Understanding genetic factors and CT phenotypes that define COPD will potentially permit earlier diagnosis of this disease and may lead to the development of treatments to modify progression.

Impact of a Rehabilitation Program on Dyspnea Intensity and Quality in Patients with Chronic Obstructive Pulmonary Disease

Background: It has yet to be determined whether the language of dyspnea responds to pulmonary rehabilitation programs (PRP). Objective: We tested the hypothesis that PRP affect both the intensity and quality of exercise-induced dyspnea in patients with chronic obstructive pulmonary disease (COPD). Methods: We studied 49 patients equipped with a portable telemetric spiroergometry device during the 6-min walking test before and 4 weeks after PRP. In a first screening visit, appropriate verbal descriptors of dyspnea were chosen that patients were familiar with during daily living activities. Tidal volume, respiratory frequency, inspiratory capacity, inspiratory reserve volume (IRV) and dyspnea intensity were evaluated by a modified Borg scale every minute during the test. Results: Qualitative descriptors of dyspnea were defined by three different sets of cluster descriptors (a–c) at the end of the exercise test, before and after PRP: a – work/effort (W/E); b – inspiratory difficulty (ID) and chest tightness (CT), and c – W/E, ID and/or CT. The three language subgroups exhibited similar lung function at baseline, and similar rating of dyspnea and ventilatory changes during exercise. The rehabilitation program shifted the Borg-IRV relationship (less Borg at any given IRV) towards the right without modifying the set of descriptors in most patients. Conclusions: Rehabilitation programs allowed patients to tolerate a greater amount of restrictive dynamic ventilatory defect by modifying the intensity, but not necessarily the quality of dyspnea.

Severe episodic dyspnoea and abnormal flow-volume loop

A 78-year-old never-smoking Caucasian woman presented with a 4-month history of persistent dry cough and episodic severe dyspnoea with inspiratory stridor and chest pain. She had visited the emergency department...

Transient Constrictive Pericarditis With Videographic Display of Kussmaul Sign

A 24-year-old white man with no significant past medical history presented with sharp chest pain that increased with inspiration and radiated to his left shoulder and neck. The pain had begun 1 week before presentation. The patient denied accompanying shortness of breath, dizziness, palpitations, edema, or syncope. The patient recalled having had an upper respiratory infection that he presumed was viral ≈2 weeks before this admission. A review of systems was noncontributory. He denied any unusual exposures. He used alcohol occasionally and denied recreational drug use. On examination, he was afebrile with a blood pressure of 110/56 mm Hg, pulse rate of 90 bpm, and normal oxygen saturations. Pulsus paradoxus of 13 mm Hg was measured, and no jugular venous distension was noted. He appeared to be in moderate distress from the pain. Cardiac examination revealed faint heart sounds without a pericardial rub or murmurs. Complete blood count and serum chemistries were within normal …

Air Trapping Detected on End-Expiratory High-Resolution Computed Tomography in Symptomatic World Trade Center Rescue and Recovery Workers

We utilized end-expiratory chest computed tomography (CT) to investigate air trapping (AT) in symptomatic former World Trade Center (WTC) workers, and correlated the findings with clinical, physiological, and exposure-related characteristics. Twenty-nine WTC workers with lower respiratory symptoms were evaluated. Clinical data included symptom inventories, quantitative respiratory symptom scores, WTC dust exposure duration, pulmonary function tests, and inspiratory and end-expiratory high-resolution chest CT scans. The latter were scored quantitatively for AT (by two methods) and interstitial changes, and those scores were correlated with the clinical data. The two AT scoring methods yielded highly correlated results. AT was demonstrated in 25 of 29 patients, with scores ranging from 0 to 24 (mean, 10.6). There was a statistically significant correlation between AT and the duration of dust exposure. AT scores were significantly higher in patients with restrictive lung function data, and in lifetime nonsmokers. Our data suggest that AT from small airways disease may account for some of the reported clinical and pulmonary functional abnormalities in WTC dust-exposed workers, and support the use of high-resolution CT scans in the investigation and characterization of the pulmonary ailments of selected workers.

Dynamic Hyperinflation During Bronchoconstriction in Asthma: Implications for Symptom Perception

The objective of this study was to examine the relationship between respiratory symptom intensity and quality and dynamic lung hyperinflation (DH) during induced bronchoconstriction in asthma. Subjects with asthma (n = 116) underwent baseline spirometry and lung volume measurement followed by high-dose methacholine challenge testing (MCT) [maximum decrease in FEV(1) of 50% from baseline]. Dyspnea intensity (Borg scale) was measured after each dose of methacholine. Qualitative descriptors of breathlessness and functional residual capacity (FRC) were measured at the doses nearest to the provocative concentration of methacholine causing a 20% fall in FEV (PC(20)) and at the highest dose of methacholine (maximum response). FEV(1) decreased by 24.7 +/- 0.7% (mean +/- SEM) at the dose nearest to PC(20) and by 46.1 +/- 1.1% at maximum response. Inspiratory capacity decreased by 0.62 +/- 0.04 L at the dose nearest to PC(20) and 1.06 +/- 0.06 L at maximum response. The descriptor clusters "inspiratory difficulty," "chest tightness," "unsatisfied inspiration," and "work" were selected at the dose nearest to PC(20) but were more frequently selected at maximum response (p < 0.0001). Individuals who reported chest tightness at maximum response had greater airflow obstruction and higher FRC (percentage of predicted) than those who did not report chest tightness. Four dominant qualities of dyspnea in asthma (inspiratory difficulty, chest tightness, unsatisfied inspiration, and work) were reported early in the course of MCT and evolved in parallel, becoming more prevalent at maximum response. Significant DH accompanied even mild bronchoconstriction during MCT in asthma, making it difficult to separate mechanisms of chest tightness from other dominant respiratory sensations.

Neonatal chest wall suspension splint: A novel and noninvasive method for support of lung volume

Surfactant and musculoskeletal immaturity results in lower compliance of the lung relative to the chest wall, with clinical manifestations of low lung volume, marked chest wall retractions (CWR), and thoracoabdominal asynchrony. Inspiratory efforts are dissipated on distorting the chest wall inward rather than recruiting lung volumes. The current study tests the hypothesis that a novel neonatal chest wall suspension splint (SP), designed to provide stability to the compliant chest wall, would reduce inspiratory chest wall retractions and improve lung volumes. Nine preterm infants (29 +/- 1 SE weeks of gestation; 1.59 +/- 0.27 SE kg study weight) were studied at 16 +/- 5 SE days of life at baseline (BL) and following application of the front plate (FP) and the full SP (Hug n Snug Neonatal Chest Splint, Respironics, Inc.). Phase angle of thoracoabdominal motion, CWR, functional residual capacity (FRC), and pulmonary function were evaluated during spontaneous breathing. Compared to BL, there was a significant decrease in anterior CWR (2.21 +/- 0.91 SE vs. 0.25 +/- 0.09 SE mm; P < 0.05), an increase in FRC (16.6 +/- 2.8 SE vs. 27.8 +/- 5.5 SE ml/kg; P < 0.05) and tidal volume (4.8 +/- 1.5 SE vs. 7.3 +/- 1.4 SE ml/kg; P < 0.05), minimal effect on pulmonary compliance (1.98 +/- 0.50 SE vs. 1.72 +/- 0.30 SE ml/cmH2O/kg), and a trend for a decrease in phase angle (128.4 +/- 10.9 SE vs. 111.8 +/- 19.3 SE) with the application of the splint. FRC correlated inversely with severity of CWR across all conditions (P < 0.05, r = -0.68). Phase angle was directly correlated to anterior CWR (r = 0.72; P < 0.05) and correlated inversely with FRC (P < 0.005; r = -0.56). We speculate that by improving CW stability, the use of this splint may reduce the energetic requirements of breathing and, potentially, the need for more invasive ventilatory support in the neonate.

Quantitative air-trapping analysis in children with mild cystic fibrosis lung disease.

The purpose of this study was to compare quantitative computed tomography air trapping (AT) and pulmonary function measurements between subjects with mild cystic fibrosis lung disease (MCF; forced expiratory volume in 1 sec (FEV1) > 70% predicted) and normal age-matched controls. Quantitative AT measurements at different levels of expiration were evaluated. Ten subjects from the MCF group and 10 normal subjects underwent inspiratory and expiratory spirometer-triggered chest high-resolution computed tomography (HRCT) and pulmonary function tests. Six matched CT images were obtained at full inflation and at a lung volume near residual volume (nRV). Quantitative measurements of AT were determined by evaluating expiratory CT lung density and by the percent of segmented lung which demonstrated AT on expiratory scans. Percent AT was evaluated for all lung slices combined (global AT), and also by regional assessment. Additional comparisons of lung density and percent air trapping were made in 10 CF subjects with three matched axial HRCT images at lung volumes corresponding to full inflation, near functional residual capacity (nFRC), and nRV. All measurements of expiratory lung density in CF subjects were significantly lower and % AT significantly higher than normal controls. Significant correlations for all subjects were observed between % global AT and RV/TLC as well as forced expiratory flow between 25-75% of forced vital capacity (FEF(25-75)) % predicted. Pulmonary density measurements and % AT better discriminated differences between groups than PFTs. Measurements made on expiratory scans near FRC showed significantly higher values for AT than those made near RV.

Endometriosis-related pneumothorax: clinicopathologic observations from a newly diagnosed case

thymic masses by indium-111-DTPA-D-pentetreotide scintigraphy. J Nucl Med. 1998;39:634-9. 22. Reisiene T, Bell GI. Molecular biology of somatostatin receptors. Endocr Rev. 1995;16:427-42. 23. Patel YC, Srikant CB. Subtype selectivity of peptide analogs for all five cloned human somatostatin receptors (hsstr 1-5). Endocrinolgy. 1994;135:2814-7. 24. Filosso PL, Ruffini E, Oliaro A, Papalia E, Donati G, Rena O. Long-term survival of atypical bronchial carcinoids with liver metastases, treated with octreotide. Eur J Cardiothorac Surg. 2002;21: 913-7.

Mu-opioid receptor agonist effects on medullary respiratory neurons in the cat: evidence for involvement in certain types of ventilatory disturbances.

Mu-opioid receptor agonists depress tidal volume, decrease chest wall compliance, and increase upper airway resistance. In this study, potential neuronal sites and mechanisms responsible for the disturbances were investigated, dose-response relationships were established, and it was determined whether general anesthesia plays a role. Effects of micro-opioid agonists on membrane properties and discharges of respiratory bulbospinal, vagal, and propriobulbar neurons and phrenic nerve activity were measured in pentobarbital-anesthetized and unanesthetized decerebrate cats. In all types of respiratory neurons tested, threshold intravenous doses of the micro-opioid agonist fentanyl slowed discharge frequency and prolonged duration without altering peak discharge intensity. Larger doses postsynaptically depressed discharges of inspiratory bulbospinal and inspiratory propriobulbar neurons that might account for depression of tidal volume. Iontophoresis of the micro-opioid agonist DAMGO also depressed the intensity of inspiratory bulbospinal neuron discharges. Fentanyl given intravenously prolonged discharges leading to tonic firing of bulbospinal expiratory neurons in association with reduced hyperpolarizing synaptic drive potentials, perhaps explaining decreased inspiratory phase chest wall compliance. Lowest effective doses of fentanyl had similar effects on vagal postinspiratory (laryngeal adductor) motoneurons, whereas in vagal laryngeal abductor and pharyngeal constrictor motoneurons, depression of depolarizing synaptic drive potentials led to sparse, very-low-frequency discharges. Such effects on three types of vagal motoneurons might explain tonic vocal fold closure and pharyngeal obstruction of airflow. Measurements of membrane potential and input resistance suggest the effects on bulbospinal Aug-E neurons and vagal motoneurons are mediated presynaptically. Opioid effects on the respiratory neurons were similar in anesthetized and decerebrate preparations.

Repeatability of quantitative CT indexes of emphysema in patients evaluated for lung volume reduction surgery.

To evaluate the repeatability of quantitative computed tomographic (CT) indexes of emphysema and the effect of spirometric gating of lung volume during CT in candidates for lung volume reduction surgery (LVRS). Initial and same-day repeat routine inspiratory spiral chest CT studies were performed in 29 LVRS candidates (group 1, routine study vs repeat study). In a separate cohort of 29 LVRS candidates, spiral chest CT studies were performed both without and with spirometric gating by using a spirometer to trigger scanning at 90% of vital capacity (group 2, spirometric gating study). In each study, Pearson and intraclass correlation coefficients were calculated to determine the agreement between multiple pairs of whole-lung quantitative CT indexes of emphysema, and mean values were compared with two-tailed paired t tests. Pearson and intraclass correlation coefficients were high for all quantitative CT indexes (all > or = 0.92). No significant differences were found between mean values of quantitative CT indexes in group 1. Variation in quantitative CT results was small but more prominent in group 2 than in group 1. The variation in quantitative CT results was primarily related to differences in lung volume (r(2) as great as 0.83). Repeatability of quantitative CT test results in LVRS candidates is high and unlikely to improve by using spirometric gating.

Cardiac vein thrombosis and haemorrhagic myocardial necrosis; report of a case with review of the literature

A 29-year-old woman, addicted to heroin since the age of 15 years, presented with a 4-day history of acute inspiratory chest pain, dyspnoea and vomiting associated with hypoventilation. She died 3 h after admission to the intensive care unit in spite of active resuscitative measures. The main autopsy findings were limited to the heart, which showed widespread cardiac vein thrombosis, and both ventricles and the atria were associated with multiple areas of haemorrhagic myocardial necrosis. We review the literature of this uncommon pathological entity and discuss its possible pathogenesis.