Kaushik Shahir

Pulmonary Embolism in Pregnancy: CT Pulmonary Angiography Versus Perfusion Scanning

OBJECTIVE The purpose of this study was to evaluate the equivalence of CT pulmonary angiography and perfusion scanning in terms of diagnostic quality and negative predictive value in the imaging of pulmonary embolism (PE) in pregnancy. MATERIALS AND METHODS Between 2000 and 2007 at a university hospital and a large private hospital, 199 pregnant patients underwent 106 CT pulmonary angiographic examinations and 99 perfusion scans. Image quality was evaluated, and the findings were reread by radiologists and compared with the original clinical readings. Three-month follow-up findings of PE and deep venous thrombosis were recorded. RESULTS PE was found in four of the 106 patients (3.7%) who underwent CT pulmonary angiography. The overall image quality was poor in 5.6% of cases, acceptable in 17.9%, and good in 76.4%. Fourteen CT and nine radiographic studies showed other clinically significant abnormalities. Six patients had indeterminate CT pulmonary angiographic findings, three had normal perfusion scans, and none underwent anticoagulation. All perfusion scan findings were normal. There was one incomplete study, and follow-up CT pulmonary angiography performed the same day showed PE. Two of 99 studies (2.02%) showed intermediate probability of the presence of PE; PE was not found at CT pulmonary angiography, but pneumonia was found. PE was found in one postpartum patient 9 weeks after she had undergone CT pulmonary angiography and ultrasound with normal findings. None of the patients died. CONCLUSION CT pulmonary angiography and perfusion scanning have equivalent clinical negative predictive value (99% for CT pulmonary angiography; 100% for perfusion scanning) and image quality in the care of pregnant patients. Therefore, the choice of study should be based on other considerations, such as radiation concern, radiographic results, alternative diagnosis, and equipment availability. Reducing the amount of radiation to the maternal breast favors use of perfusion scanning when the radiographic findings are normal and there is no clinical suspicion of an alternative diagnosis.

A case of tracheal varices: an unusual but important cause of mural nodules in the trachea

Tracheal varices (TV) are uncommon but can be an important source of massive or recurrent haemoptysis. We present a case of TV in a 32-year-old patient with a history of Glenn-Fontan surgery, for congenital tricuspid atresia, and portal hypertension owing to cardiac cirrhosis. We discuss TV presenting as tracheal nodules in the presence of extensive mediastinal collateral circulation.

‘Coronary wrap’: IgG4 related disease of coronary artery presenting as a mass lesion

Our patient is a 68-year male who presented with fatigue. He had a past history of liver transplant 13 years back. As per routine evaluation with computed tomography (CT) scan extensive enhancing soft tissue masses surrounding the left anterior descending (LAD) and circumflex coronary arteries (Fig. 1 thin arrows) noted. A magnetic resonance imaging (MRI) was done to further characterize the abnormality. MRI confirmed CT findings and showed heterogeneously enhancing mass lesion with increased perfusion and underlying aneurysmal dilatation of LAD (Fig. 1 thick arrow). Incidental significant aortic valve stenosis was also noted. Differentials of this indeterminate soft tissue ranged from inflammatory disorder to neoplastic etiology like lymphoma. Cross sectional imaging helped cardiac surgeon to plan the biopsy. Open biopsy was performed which revealed IgG4 related disease.

Intraparenchymal pulmonary lipoma: pathologic-radiologic correlation of a rare presentation of a common neoplasm

We report a rare case of pulmonary intraparenchymal lipoma. Lipomas are benign adipocytic tumors, which are ubiquitous in distribution, particularly in the subcutis and soft tissue. Visceral lipomas, in particular, pulmonary lipomas, are rarely reported. Even rarer are intraparenchymal lipomas, such as this case, of which less than 10 have been reported in the medical literature. The radiologic (computed tomographic scan) findings of pulmonary lipoma may be somewhat difficult to evaluate. In this case, on initial review, the computed tomographic findings were not diagnostic, but retrospective analysis revealed attenuation values suggestive of an adipocytic lesion. A high index of suspicion and careful attention to attenuation values are therefore required for radiologic diagnosis. Excision is necessary for histologic confirmation, which is generally relatively straight forward, although admixture with fibrous tissue and some cytologic atypia may pose diagnostic challenges.

Etanercept and Corticosteroid Therapy for the Treatment of Late-Onset Idiopathic Pneumonia Syndrome

Idiopathic pneumonia syndrome (IPS) is a complication of allogeneic hematopoietic stem cell transplantation (HSCT) that typically occurs within the first 100 days after transplantation. Tumor necrosis factor α (TNF-α) has been shown to be a key mediator of IPS, and the TNF-α binding protein etanercept appeared to improve IPS outcomes in small retrospective and prospective studies. IPS also has been observed to occur later (>100 days) after HSCT; however, little is known about the disease course and whether a TNF-α-based therapeutic strategy is efficacious in these patients. To address this question, we performed a retrospective analysis of 23 patients who underwent HSCT between 2004 and 2016 at our institution who developed late-onset IPS and received treatment with etanercept and high-dose corticosteroids (CS). Ten of the 23 patients (43%) attained a complete clinical response to etanercept and CS. Responses were significantly more likely to occur in patients who did not require positive pressure ventilation at the time of diagnosis. Those who responded experienced a durable survival benefit, with a 2-year overall survival of 67%. In the 13 patients (57%) who did not respond to etanercept and CS, the median overall survival was only 13 days (range, 1 to 60 days). The difference in 2-year overall survival between responders and nonresponders was statistically significant (67% versus 0%; P < .001). These results indicate that late-onset IPS carries high mortality, but that treatment with etanercept and CS has activity and can result in long-term survival in some patients. Prompt diagnosis and early institution of therapy before the need for advanced respiratory support is critical for maximizing responses.

Right ventricular size assessed by cardiovascular MRI may predict mortality after left ventricular assist device placement

Methods Patients were referred for cardiovascular magnetic resonance imaging prior to LVAD placement. We assessed the association of mortality to pre-LVAD right ventricular end systolic volume index (RVESVI), right ventricular end diastolic volume index (RVEDVI), left ventricular ejection fraction (LVEF) by CMR. Right ventricular stroke work index (RVSWI) was determined by preLVAD right heart catheterization.

Dose reduction of 69% for computed tomography pulmonary angiography: reduced z-axis computed tomography pulmonary angiography retains accuracy in those younger than 40 years.

Objective We sought to determine whether reduced scan range (z axis) computed tomography pulmonary angiography (CTPA) technique in 18- to 40-year age group can accurately detect pulmonary embolism (PE) and other important conditions and to quantify the resulting dose reduction. Methods We retrospectively identified 200 patients in the age group of 18 to 40 years who underwent CTPA over a period of 3 years. These included 86 patients with PEs and 114 randomly selected patients negative for PE (control subjects). The scans were modified by reducing the scan coverage by eliminating images above the aortic arch and below the base of the heart. Two blinded experienced radiologists rescored them for PE and incidental and pertinent non-PE findings. Discrepancies between these and the original report were assessed by a third experienced radiologist. Separately, a departmental quality-control project was conducted in 15 patients to assess the dose length product along the z axis across the 3 zones of thorax. Results Pulmonary embolism was diagnosed in all 86 patients. No pertinent additional findings were missed. Only 7 incidental findings were missed (eg, benign thyroid nodules [n = 4], benign adrenal adenoma [n = 1], gallstones [n = 1], and hepatic hemangioma [n = 1]). None affected clinical outcome or management. Dose length product was reduced by a mean of 69% (60%–79%). Conclusions Reduced z-axis CTPA for PE is definitely feasible in 18- to 40-year age group. There is a significant radiation reduction (69%) and hence should be considered in selected subgroups of patients.

A novel computed tomography method to detect normal from abnormal psoas muscle: a pilot feasibility study

Sarcopenia is a syndrome characterized by progressive loss of skeletal muscle which can be detected by computed tomography (CT) by estimating total psoas muscle cross‐sectional area (CSA). Relying on total psoas CSA alone takes into account abnormal muscle and intramuscular fat, both of which may be increased in sarcopenic obesity. We developed a novel CT‐method to identify the proportion of normal to abnormal psoas muscle at the third lumbar (L3) level. The primary objective of our pilot study was to measure inter‐observer agreement between measuring total psoas CSA and proportion of normal and abnormal psoas muscle using a novel CT‐method. We hypothesized total psoas CSA and proportion of normal and abnormal psoas muscle would be reliably quantifiable.

Circulating fibrocytes as biomarkers of impaired lung function in adults with sickle cell disease

Lung injury and fibrosis are common in patients with sickle cell disease (SCD). Fibrocytes, a population of circulating, bone marrow-derived cells, have been linked to development and progression of tissue fibrogenesis and have been implicated in the development of lung fibrosis in preclinical models of SCD. We tested the hypothesis that the levels and activation state of circulating fibrocytes during steady state are associated with abnormal pulmonary function in adults with SCD. In a prospective cohort of steady-state adults with SCD and healthy age- and race-matched control participants, we measured the concentration and activation state of circulating fibrocytes and assessed pulmonary phenotype with pulmonary function tests (PFTs), a respiratory questionnaire, 6-minute walk test, high-resolution chest computed tomography scan, and echocardiogram. Seventy-one adults with SCD and 26 healthy African American control participants were examined. Compared with control participants, patients with SCD demonstrated higher levels of circulating fibrocytes, a significant proportion of which expressed the activation marker α-smooth muscle actin. Within patients with SCD, elevated absolute concentrations of circulating fibrocytes were strongly and independently associated with impaired lung physiology, as measured by PFTs. We conclude that elevated circulating fibrocytes are associated with lung disease in adults with SCD during steady state, consistent with a role for these cells in pathogenesis of lung fibrosis in this disease. Circulating fibrocytes may represent a novel biomarker for progressive pulmonary fibrosis in patients with SCD.

Retroperitoneal lymphangioleiomyoma with lymph node involvement: A pathologic-radiologic correlation of a rare form of myomelanocytic tumor

Lymphangioleiomyomatosis (LAM) is a rare and slowly progressive disorder that usually arises in the lung, affects exclusively women in their childbearing years, and typically presents with progressive dyspnea on exertion and pneumothorax. Infrequently, extra-pulmonary LAM can occur in the retroperitoneum, uterine wall, mediastinum and intraperitoneal lymph nodes. Histologically, LAM is characterized by a proliferation of perivascular epithelioid cells (PEC) that express markers for both melanocytes and smooth muscle cells. We report a case of a peripancreatic retroperitoneal mass that was incidentally discovered on magnetic resonance image (MRI) scan of a 38-year-old female. The morphologic findings and the immunohistochemical staining were consistent with a lymphangioleiomyoma. The radiologic and pathologic correlation along with differential diagnosis of this rare entity is discussed.