What's your line?

A resident put in a left subclavian line and maybe went a little too far. An xray shows that it went into the right atrium and into the IVC and up to the IVC filter. When it was removed (with help from vascular), the filter had migrated up 2 vertebrae... Click image to enlarge. It is a bit dark.

41 year old with HIV and fever

This is a 41 year old man with AIDS, CD4 below 10, who presented with shortness of breath and fever. He was admitted to a general ward but trasnferred to the unit a few days later for tachypnea. On the general floor, his vitals were normal except for some tachycardia. He was 97% on 2 l NC. CXR:



a full workup was done to look for infectious source.
sputums: AFB negative x 3, fungal negative. PCP negative (no PCR, no bacteria
CSF - negative for infection.

What kinds of things could be causing these findings and what would you do?

Pulmonary infiltrates

This is a 77-year-old woman who presented with significant cough, dyspnea and hypoxemia and was found to have pulmonary infiltrates. She has been started on aggressive good antibiotic therapy, but continued to have an elevated white blood cell count, dyspnea and cough so we were consulted. No previous label of COPD; never smoked; no heart disease; no odd exposures.

She had not been able to produce significant amounts of sputum. She was also found to be hyponatremic with significant fluctuation of her sodium during her initial hospital stay. Urine and serum Osms were consistent with some SIADH and she improved with fluid restriction. Unremarkable U/A and normal renal function.

She then developed some respiratory distress, mild hemoptysis, worsening hypoxemia and had to be intubated and had the changes seen on the second CxR. (Some cuts from the CT from that day are included).

What would you want to know/do next?

Cavitary mass

86 year old man with history of dementia brought by his caretaker for mental status changes and lethargy. He lives in an assisted living facility, but has no TB risk factors otherwise (He has his own apartment-like structure, but I beleive there is a common area).

His CT:



There was no hilar or mediastinal adenopathy.
The thickest wall area on that lesion was 4-5 mm.

Someone placed a PPD and it was 11 mm. It was reportedly negative 6 months ago.
He is not productive of sputum, so 3 gastric lavages were done and they were all negative. What would you do next? Are you worried about active tb? Here are my thoughts
1. How sensitive is gastric lavage for afb?
2. location of the cavitary mass is not where tb should be.
3. is he a ppd converter, or was he anergic or are we seeing a booster effect
4. His family does not want an aggressive w/u for cancer, but on the other hand one would not want to send someone home to hospice with active tb....

Where is Waldo (or the line)?

As ICU co-directors we get to see some unusual situations. This line was reportedly a "little traumatic" going in and there is no good blood return from any of the ports. I enlarged the segment of interest and crudely followed the trajectory. Where is the line going?

Digging for gold

This nice woman with mild asthma lost a tooth crown and aspirated it as she was about to have lunch.

Check out the CxR. It was lodged at the first branching of the R bronchus intermedius with the smooth side (the shiny top of the crown) up towards us. Unfortunately I was using an optic (as opposed to digital, I know they are all "optic") scope and couldn't take a picture. I did snap a picture of the crown after removal with the basket on the side.

We did not have a bronch basket handy so an OR gallstone basket was just the perfect sixe.

Radiology Friday

This patient has a pleural effusion. Which fissure (and which side) is this?

Halleliujah

From Arenberg:
"In celebration of the fact that the IT people in the Department of Radiology at the University of of Michigan have recognozed that their department exists to provide films for other doctors to look at, and have finally made it into the 21st centry by providing consistent, relaible online access to films for the unwashed masses (read: non-radiologists)...I hereby submit this film of an unfortunate man with a history of cancer."

Radiology monday

This 72 year old man is asymptomatic and had a routine chest xray as part of a yearly exam from his primary care physician.

Follow-up to Radiology Thursday

Jennings picked up on the Left mediastinal mass. The patient could not stand up for the lateral so a CT was obtained:

Radiology Thursday

We were consulted on this 82 y/o man for an abnormal CxR.
What is your DDx?

collapsed RML

Check out Jeff's post below.

I hate to answer a question with another question, Jeff but I have had this similar case. This is a 65 y/o woman, no significant TOB Hx with recurrent partial LLL collapse. She has had LLL CAP 3 times (see above) and though the pneumonias clinically all resolve (they have been over ~ 5years) she always has a residual partial LLL collapse. She was bronch'ed in 2001, 2002 and I have re-bronch'ed her in 2005. Her airway though a little narow with some dynamic collapse looks normal and biopsies and Cxs were also all negative.
Other than encouraging pulmonary clearance, chest P&PD, etc. would you do anything else?

Radiology Friday. 20 year old female

20 year old presents with cough. What's the abnormality and what's the diagnosis? (Hint: it is not the calcified granuloma that is circled, that would be too easy.)


Need a hint? click here.

Click hint #2.

Click here for one last hint.

Final diagnosis to be posted Monday.

Quick show & tell

Nice view of an azygous "lobe" with severe bullous emphysema.

Follow-up to Wednesday Radiology - Case 2

'Can't hide anything from these smart people.
Check out the CT (unenhanced because Creat is 2.0). We did not feel like biopsying the "mass" either...

Radiology Wednesday - Case 2

We were called by one of the cardiologist for this abnormal CxR. How would you approach the radiographic abnormality?

Radiology Wednesday

This was submitted by D Arenberg:
This is a contrast chest CT. What's the differential diagnosis?