Robert M. Steiner

Infection with Mycobacterium avium complex in patients without predisposing conditions.

Pulmonary disease caused by Mycobacterium avium complex usually occurs in patients with chronic lung disease or deficient cellular immunity, and its prevalence is increasing. We describe 21 patients (mean age, 66 years) with such infection without the usual predisposing factors, representing 18 percent of the 119 patients surveyed. Seventeen women and 4 men were given a diagnosis of M. avium complex from 1978 to 1987, with a stable incidence over the decade, on the basis of pulmonary symptoms, abnormalities on chest films, positive cultures, and in 14, biopsy evidence of invasive disease. Most of the patients (86 percent) presented with persistent cough and purulent sputum, usually without fever or weight loss. The cough was present for a mean of 25 weeks before the correct diagnosis was made. Radiographic patterns of slowly progressive nodular opacities predominated (71 percent); only five patients had cavitary disease at presentation. All patients responded initially to antimycobacterial therapy, but eight eventually relapsed when it was stopped. Four patients died of progressive pulmonary infection caused by M. avium complex. The extent of the initial pulmonary involvement was greater in patients with progressive disease than in those whose condition improved. We conclude that pulmonary disease caused by the M. avium complex can affect persons without predisposing conditions, particularly elderly women, and that recognition of this disease is often delayed because of its indolent nature.

How to differentiate benign versus malignant cardiac and paracardiac 18F FDG uptake at oncologic PET/CT.

Patients undergoing 2-[fluorine 18]fluoro-2-deoxy-d-glucose (FDG) whole-body oncologic positron emission tomography (PET)/computed tomography (CT) are studied while fasting. Cardiac FDG uptake in fasted patients has been widely reported as variable. It is important to understand the normal patterns of cardiac FDG activity that can be seen in oncologic FDG PET/CT studies. These include focal and regional patterns of increased FDG myocardial activity. Focal activity can be observed in papillary muscles, the atria, the base, and the distal anteroapical region of the left ventricle. Regional increased cardiac FDG activity may be diffuse or localized in the posterolateral wall or the base of the left ventricle. Abnormal patterns of cardiac FDG activity not related to malignancy include those associated with lipomatous hypertrophy of the interatrial septum, epicardial and pericardial fat, increased atrial activity associated with atrial fibrillation or a prominent crista terminalis, cardiac sarcoidosis, endocarditis, myocarditis, and pericarditis. Knowledge of these patterns of cardiac FDG activity is important to be able to recognize malignant disease involving the paracardiac spaces, myocardium, and pericardium. With a better understanding of the range of normal and abnormal patterns of cardiac FDG activity, important benign and malignant diseases involving the heart and pericardium can be recognized and diagnosed.

“Tumor Vascularity” in Left Atrial Myxoma Demonstrated by Selective Coronary Arteriography

Atrial myxoma is the commonest of the rare primary heart tumors and one of the few which is curable. Increasing interest in these lesions culminated in a recent symposium on cardiac tumors (8, 9, 14), in which the available literature was summarized in detail. The purpose of this communication is to show previously unreported “tumor vascularity” demonstrated by selective coronary arteriography in a proved case of left atrial myxoma. Case Report A 51-year-old Caucasian male presented with an eight-year history of intermittent dyspnea, orthopnea, ankle edema, and a recent weight gain of 15 lb. Between episodes of failure he was virtually asymptomatic. There was a questionable history of joint symptoms at the age of twelve years, and mild diabetes had been discovered two years previously. Pertinent negative findings included the absence of fever, anemia, or embolic phenomena. Physical examination showed moderate cardiac failure and an apical systolic murmur. The murmur did not alter dramatically with change ...

Patterns of disturbed myocardial perfusion in patients with coronary artery disease

Fifty patients who presented with angina pectoris were studied to examine the disturbances of regional myocardial perfusion during stress. Each patient underwent 16-point precordial mapping of the ECG during an exercise test, and coronary and left ventricular angiography. Regional myocardial perfusion was assessed using an atrial pacing test and a short-lived radionuclide, krypton-81m. Eleven patients had negative exercise tests and uniform increases in myocardial activity of krypton-81m of 98 ± 18.0% during pacing. Ten patients performed 30,000-43,000 J in positive exercise tests. These patients showed abnormal coronary anatomy and increases in myocardial activity of krypton-81m to remote and jeopardized myocardium at the onset of pacing. However, further pacing produced a decrease in activity in the affected segment of 68.0 ± 9.0% accompanied by ST-segment depression and angina. Twelve patients achieved 26,000-32,000 J in positive exercise tests and had significant coronary artery disease. Atrial pacing produced increased activity of krypton-81m to remote myocardium. The jeopardized segment at first showed no change and then a decrease in regional activity of krypton-81m (89.0 ± 17%) accompanied by ST-segment depression and chest pain. Seventeen patients achieved only 7000-22,000 J in positive exercise tests. These patients showed abnormal coronary anatomy and developed decreases in regional activity of krypton-81m to the affected segment of myocardium starting at the onset of atrial pacing and decreasing by 88 ± 7.0% below control. We conclude that different patterns of disturbed myocardial distribution of krypton-81m are present during stress-induced ischemia in patients with coronary artery disease. There was a close temporal relationship between these disturbances and ST-segment depression.

Abdominal Iron Distribution in Sickle Cell Disease: Mr Findings in Transfusion and Nontransfusion Dependent Patients

Objective Our goal was to determine the difference in iron distribution between transfusion dependent (TD) and nontransfusion dependent (NT) patients with sickle cell disease (SCD). Materials and Methods The T2-weighted and T2*-weighted abdominal MR images in nine cases of homozygous SCD were reviewed to determine the distribution of low signal from iron in five TD and four NT patients. Results All eight patients with visualized spleens had decreased splenic signal intensity. One patient who had no history of splenectomy had no visualized splenic tissue. The majority of both groups had renal cortex of low signal intensity that was attributable to iron deposition from intravascular hemolysis and was not correlated with clinical renal abnormalities. None of the NT group had liver or pancreas of low signal intensity, while all five TD patients had decreased liver signal intensity and three of five had decreased pancreatic signal intensity. Conclusion Decreased pancreatic signal intensity can occur in TD patients, perhaps suggesting total body iron overload. Nontransfusion dependent sickle cell patients usually have normal hepatic signal intensity and do not have total body iron overload, even in the presence of renal and splenic iron deposition.

The Radiological Findings in Dermatomyositis of Childhood

Twenty-two children with proved dermatomyositis were followed up for 2 to 14 years. Fourteen recovered from the active inflammatory phase, but varying degrees of crippling and calcinosis universalis subsequently developed. Of these 14, one died of cardiopulmonary and gastrointestinal complications; the remaining 8 had a self-limited course without the development of calcinosis. Spontaneous regression of calcinosis was seen in several patients following the use of disodium etidronate (diphosphonate).

Roentgenographic Demonstration of Intrapulmonary and Pleural Lymphatics During Lymphanqioqraphy

The authors report the demonstration of intrapulmonary and pleural lymphatics during lymphangiography. In a case of bilateral chylothorax the etiology was shown by reflux from the thoracic duct retrograde to visceral pleural lymphatics. Valvular insufficiency in the mediastinal and pulmonary lymphatics was present, a manifestation of a mild form of congenital pulmonary lymphangiectasis. A similar mechanism of reflux into parietal pleural lymphatics occurred in the second case, one of lymphosarcoma.

Total lung capacity by plethysmography and high-resolution computed tomography in COPD

Aim To characterize and compare total lung capacity (TLC) measured by plethysmography with high-resolution computed tomography (HRCT), and to identify variables that predict the difference between the two modalities. Methods Fifty-nine consecutive patients referred for the evaluation of COPD were retrospectively reviewed. Patients underwent full pulmonary function testing and HRCT within 3 months. TLC was obtained by plethysmography as per American Thoracic Society/European Respiratory Society standards and by HRCT using custom software on 0.75 and 5 mm thick contiguous slices performed at full inspiration (TLC). Results TLC measured by plethysmography correlated with TLC measured by inspiratory HRCT (r = 0.92, P < 0.01). TLC measured by plethysmography was larger than that determined by inspiratory HRCT in most patients (mean of 6.46 ± 1.28 L and 5.34 ± 1.20 L respectively, P < 0.05). TLC measured by both plethysmography and HRCT correlated significantly with indices of airflow obstruction (forced expiratory volume in 1 second/forced vital capacity [FVC] and FVC%), static lung volumes (residual volume, percent predicted [RV%], total lung capacity, percent predicted [TLC%], functional residual capacity, percent predicted [FRC%], and inspiratory capacity, percent predicted), and percent emphysema. TLC by plethysmography and HRCT both demonstrated significant inverse correlations with diffusion impairment. The absolute difference between TLC measured by plethysmography and HRCT increased as RV%, TLC%, and FRC% increased. Gas trapping (RV% and FRC%) independently predicted the difference in TLC between plethysmography and HRCT. Conclusion In COPD, TLC by plethysmography can be up to 2 L greater than inspiratory HRCT. Gas trapping independently predicts patients for whom TLC by plethysmography differs significantly from HRCT.

Single breath-hold pulmonary magnetic resonance angiography. Optimization and comparison of three imaging strategies.

RATIONALE AND OBJECTIVES.Ultrafast gradient-recalled-echo techniques for obtaining high-quality pulmonary magnetic resonance angiograms within a single breath-hold were optimized. METHODS.Fourteen subjects were imaged with both the body coil and a phased-array surface coil, using three gradient-recalled-echo pulse sequences: 1) two-dimensional sequential; 2) two-dimensional interleaved; and 3) volumetric acquisitions. Image quality was assessed with varied flip angle, receiver bandwidth, slice thickness/number, and matrix size. Cardiac compensation diminished ghost artifacts in the interleaved sequence.Individual sagittal sections and maximum intensity projections were reviewed RESULTS.Pulmonary magnetic resonance angiograms acquired with volumetric and two-dimensional interleaved gradient-recalled-echo pulse sequences benefit greatest from intravenous gadolinium and result in greater pulmonary arterial visualization than traditional time-of-flight techniques. Phased-array coils result in improved vessel detection. CONCLUSIONS High-quality breath-held pulmonary magnetic resonance angiography can be obtained with an intravcnous contrast-enhanced gradient-recalled-echo acquisition; however, image quality is dependent on the pulse sequence.

Radiographic Evaluation of Patients with Schistosomiasis

Plain films of the abdomen in advanced states of schistosomiasis reveal massive splenomegaly without evidence of splenic calcification. The liver may be enlarged in the early stages but ultimately decreases and becomes small. Ascites is evident in far advanced disease. Chest films are negative in the early stages, but in advanced disease, dilated pulmonary arteries, right ventricular enlargement, and dilatation of the azygous vein may be recognized. Granulomata are seen as multiple small rounded densities scattered throughout both lung fields. The routine barium swallow will reveal unsuspected esophageal varices. Nine patients were studied preoperatively by panhepatic angiography and 14 post-operatively following splenorenal shunt. Thrombosis of the shunt and hepatic encephalopathy were common postoperative complications.