M. N. Wiesmayr

Azygos Arch Cannulation by Central Venous Catheters: Radiographic Detection of Malposition and Subsequent Complications

The aim of this study was to determine the frequency of radiographically evident central venous catheter misplacement in the azygos arch and to analyze whether the frequency of azygos arch cannulation is dependent on the anatomical site of catheter insertion. We reviewed 1,287 postprocedural examinations and 3,441 follow-up examinations. Catheters had been inserted through the left (6%) or right (15%) internal jugular veins and through the left (32%) or right (46%) subclavian veins. Radiographs were analyzed for possible catheter malposition in the azygos arch and for complications related to this malposition. Catheter malposition in the azygos arch was seen on 16/1,287 (1.2%) postprocedural radiographic examinations. Of the 16 malpositioned catheters, 11 (69%) had been inserted in the left subclavian vein, three (19%) in the left jugular vein, two (12%) in the right subclavian vein, and none (0%) in the right jugular vein. There was a statistically significant difference in the frequency of azygos arch cannulation between left- and right-sided catheters (p = 0.001). All complications consisted of venous perforations and were seen in three of 16 cases (19%). Azygos arch cannulation is a rare but hazardous central venous catheter malposition that occurs early after catheter insertion and carries a substantial risk for complication. The risk for azygos arch cannulation is substantially increased if catheters are inserted in left-sided veins. Because of the severity of subsequent complications, radiologists should be vigilant in the detection of this rare malposition.

Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients.

Objective: The aim of our study was to illustrate the radiographic spectrum of the intrabronchial malposition of nasogastric tubes and subsequent complications, and to discuss the role of radiography in the detection of such malpositions. Design: Retrospective clinical investigation. Setting: Tertiary care university teaching hospital. Patients and methods: We reviewed chest radiographs of 14 intensive care patients with nasogastric tubes malpositioned in the tracheobronchial tree. The site and anatomic location of the malposition were recorded. Complications due to tube malpositioning were monitored on follow-up radiographs and on computed tomographic examinations, which were available in 4 patients. Results: Nine of 14 nasogastric tubes were inserted in the right and 5 in the left tracheobronchial tree. Tube tips were malpositioned in the lower lobe bronchi (50 %), the intermediate bronchus (36 %), and the main bronchi (14 %). There was perforation of the bronchial system with subsequent pneumothorax in 4 patients. In 4 other patients, pneumonia developed at the former site of the malpositioned tube tip. Radiographic detection of nasogastric tube malpositioning was prompt in 9 patients and delayed in 5 patients. Conclusions: Whereas clinical signs of nasogastric tube malpositioning in intensive care patients may be absent or misleading, chest radiography can accurately detect nasogastric tube malpositions in the tracheobronchial tree, may prevent complications, and avoid the use of further costly or invasive diagnostic techniques.

Update: Abdominal tuberculosis — Unusual findings on CT

To update our knowledge of abdominal tuberculosis as manifested on computed tomography (CT), we reviewed the CT scans of 12 patients with proven abdominal tuberculosis. The nature, range and extent of abdominal involvement was determined. The CT findings were compared to those reported in the literature. The aetiologic agent was Mycobacterium tuberculosis in all patients. One patient had an increased risk because of AIDS. In nine patients, tuberculosis was limited to the abdomen, and three patients had previously unknown thoracic tuberculous disease. Characteristic features in our patients included low density ascites and uncommon patterns of adenopathy. Findings reported to be typical in abdominal tuberculosis were present in only five of our 12 patients. Unusual findings in our patients included solitary and multiple pelvic, adrenal, splenic and hepatic lesions. In six of 12 patients, those findings mimicked malignancy. We conclude that knowledge and early recognition of these unusual manifestations of abdominal tuberculosis should help to optimize clinical management of the disease and avoid misdiagnosis.

Pleurale und pulmonale Veränderungen im Rahmen der rheumatoiden Arthritis

ZusammenfassungLungenveränderungen im Rahmen der rheumatoiden Arthritis stellen einen klinisch bedeutsamen Aspekt dieser in Schüben verlaufenden chronischen Arthropathie dar. Die mit dem Bestehen einer rheumatoiden Arthritis verbundenen pulmonalen Veränderungen können alle anatomischen Teile des Lungenparenchyms, die Pleura sowie Teile des knöchernen Thorax betreffen. Die wichtigsten thorakalen Veränderungen im Rahmen der rheumatoiden Arthritis sind die nekrobiotischen Rheumaknoten, pleurale Veränderungen, das Caplan-Syndrom, die Lungenfibrose, die Bronchiolitis obliterans und medikamentös induzierte Lungenveränderungen. Der vorliegende Artikel beschreibt das Spektrum der Lungenveränderungen, die im Rahmen der rheumatoiden Arthritis vorkommen. Hierbei werden die klinischen und radiologischen Charakteristika dieser Veränderungen vorgestellt. Die Bedeutung der verschiedenen bildgebenden Methoden im diagnostischen Algorithmus wird diskutiert.SummaryPulmonary complications caused by rheumatoid arthritis are a clinically relevant aspect of this chronic arthropathy. Those complications can involve all parts of the thorax, including the lung parenchyma, the pleura, and the thoracic cage. The most common complications are necrobiotic nodules, pleural abnormalities, Caplans syndrome, parenchymal fibrosis, bronchiolitis obliterans, and iatrogenic damage of lung the parenchyma. This article reviews pulmonary abnormalities induced by rheumatoid arthritis and their clinical and radiological findings. In addition, the role of different imaging modalities in the diagnostic work-up of pulmonary complications caused by rheumatoid arthritis is discussed.

Incidental discovery of a nonfunctioning islet-cell tumor 8 years after resection of an insulinoma: primary neoplasm or local recurrence?

Two islet-cell tumors with uncommon radiological presentation were detected in a 48-year-old woman within a period of 8 years. Whereas the first tumor was an unusually large malignant insulinoma, the second (or recurrent) tumor was a non-functioning islet-cell tumor. Both tumors were studied~with with ultrasound and computed tomography.

Computertomographie AIDS-assoziierter Thoraxerkrankungen

ZusammenfassungPulmonale Infektionen und Tumore sind eine wesentliche Todesursache bei Patienten, die am erworbenen Immunmangelsyndrom AIDS leiden. In den meisten Fällen gelingt es, durch Zusammenschau klinischer, radiologischer, labortechnischer und pathohistologischer Befunde das differentialdiagnostische Spektrum erheblich einzuengen oder eine spezifische Diagnose zu stellen. Dennoch wäre eine Beschleunigung des diagnostischen Prozedere wünschenswert, um früher und gezielter therapeutisch wirksam werden zu können. Neben dem konventionellen Thoraxröntgen hat sich die Computertomographie als hilfreich in der Bildgebung AIDS-assoziierter Thoraxveränderungen gezeigt. Ziel dieser Übersicht soll es sein, anhand typischer Beispiele die Einsatzmöglichkeiten der Computertomographie in der Diagnostik AIDS-assoziierter Erkrankungen des Thorax zu beschreiben. Informationen über das Spektrum wichtiger Erreger sowie wichtige differentialdiagnostische Zeichen sind als Ergänzung in Tabellen zusammengefaßt.SummaryPulmonary infections and tumors are a major cause of death in patients with AIDS. The combination of clinical, radiological, laboratory, and pathohistological data helps to narrow the spectrum of differential diagnoses or even allows a specific diagnosis in many patients. Nevertheless, an accurate diagnosis should be obtained as soon as possible during the clinical course of the illness to initiate treatment in time. Computed tomography (CT) has proven to provide promising results in the diagnosis of AIDS-related thoracic diseases. The aim of this paper was to demonstrate the diagnostic capacities of CT in the context of particular AIDS-related thoracic pathologies. Additional information on the spectrum of pathological agents and on differential diagnostic signs is summarized.

Spira-CT bei chronisch-thrombembolischer Lungenerkrankung

ZusammenfassungDie chronisch thrombembolische pulmonale Hypertension (CTEPH) ist ein seltenes Krankheitsbild, das vermutlich eine Folgeerscheinung nach rezidivierenden Pulmonalembolien darstellt. Die chirurgische Pulmonalisthrombendarteriektomie ist heute die Therapieoption der Wahl. Zur Planung dieser Operation ist eine exakte Darstellung der thrombotischen Gefäßwandveränderungen Voraussetzung. Als diagnostischer Goldstandard gilt bis heute die Pulmonalisangiographie. Die Einführung der Spiral-CT ermöglichte nun erstmals nichtinvasiv eine gute Kontrastierung der gesamten Pulmonalarterien und damit eine direkte und suffiziente Darstellung der Thromben in zentralen Pulmonalarterien. Sie ist in der Darstellung der Thromben in den zentralen Pulmonalarterien der Pulmonalisangiographie leicht überlegen, während dessen die Angiographie eine bessere Darstellung der Veränderungen in den Segmentarterien gibt. Die Diagnose der CTEPH ist alleine durch die Spiral-CT im Literaturvergleich in etwa 90 % zu stellen. Sowohl die Literatur als auch unsere eigenen Ergebnisse zeigen, daß bei ca. 80 % der Patienten die Entscheidung über die Operabilität des Patienten allein aufgrund der Spiral-CT Untersuchung möglich ist. Die Spiral-CT ist als nichtinvasive Untersuchung sowohl zum Screening als auch zur postoperativen Verlaufskontrolle geeignet und ermöglicht in Kombination mit der Pulmonalisangiographie eine optimale Operationsplanung.SummaryChronic thromboembolic pulmonary hypertension (CTEPH) is a rare result of recurrent pulmonary embolism and is treated by pulmonary thromboendarterectomy. Knowledge of the exact location of the thrombi is necessary in planning this operation. To date, pulmonary, angiography is the diagnostic imaging gold standard. Since the introduction of spiral CT excellent vascular opacification of the pulmonary arteries has become feasible, and thrombi in the pulmonary arteries can be visualized directly. Spiral CT is superior to angiography in demonstrating thrombi in the central pulmonary arteries, whereas angiography proves superior to CT in the evaluation of abnormalities within segmental arteries. The sensitivity of spiral CT in confirming the diagnosis of CTEPH is reported to be more than 90 %. According to the literature and based on our own results, the decision concerning operability is possible on the basis of spiral CT images in more than 80 % of patients with CTEPH. Spiral CT as a non-invasive tool may be used for CTEPH screening, for postoperative follow-up after pulmonary thrombendarterectomy and, combined with pulmonary angiography, to optimize operation planning.

Broncho-subcutaneous fistula in a patient with reactivation tuberculosis

We report a case of reactivation tuberculosis with the additional complication of a large broncho-subcutaneous fistula in a post-tuberculous lobectomy fibrothorax. The Spiral CT findings of both pathologies are described and the importance of multiplanar reconstruction for establishing the correct diagnosis and planning subsequent surgical therapy is emphasised.