Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: March Cases

Adult Chest X-Rays Of The Month
Travis Barlock, MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Chest X-Ray Mastery Project
March 2021

Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

50-Year-Old
Female With
HIV Presenting
With
Dyspnea And
Fever.

Diagnosis: Miliary Tuberculosis
50-Year-Old
Female With
HIV Presenting
With
Dyspnea And
Fever.

50-Year-Old
Female With
HIV Presenting
With
Dyspnea And
Fever.
Hospital Day 2.

50-Year-Old
Female With
HIV Presenting
With
Dyspnea And
Fever.
Hospital Day 3.

Miliary Tuberculosis
In 1700, Dr. John Jacob Manget coined the term miliary tuberculosis
(derived from the Latin word millarius, meaning related to the millet
seed of the Pennisetum typhoides plant). This described the
resemblance of gross pathological findings to that of innumerable
millet seeds in size and appearance.
Pennisetum typhoides

Brain
Lung Spleen

Open in a separate window
Fig. 1
Chest radiograph (postero-anterior view) (A) and chest CT (lung window) (B) showing classical miliary pattern.
Ta
R
The Term “Miliary” Can Also Be Used To Describe The Classic
Radiographic Pattern Seen On Chest X-Ray And On Chest CT.

• In 1%-2% of TB cases, there is systemic dissemination of Mycobacterium
tuberculosis into the vascular system. This results from the inability of the
host immune system to control the infection.
• Multi-organ involvement is the rule, and without treatment miliary TB is
uniformly fatal.
• Seen more frequently in infants, the elderly and the immunocompromised.

The Development Of Miliary Tuberculosis:
Small Mycobacterium tuberculosis droplets are
deposited in the alveoli (1) where host-pathogen
interactions occur. 70% of exposed individuals do not
get infected (2), whereas 30% develop infection (3).
Infection is contained (latent) in 90% of individuals (4),
and the remaining 10% will develop progressive primary
TB (5). During this phase lympho-hematologic
dissemination to various organs (6) can cause miliary
TB. Latent TB has a 10% risk of reactivation, resulting in
post-primary TB (7). By contrast, in HIV-infected
patients, the risk of TB reactivation is extremely high, at
≈10%/year. Massive dissemination during reactivation
in this population (8) can result in miliary TB with
multisystem involvement.

Multisystem Involvement
• Tuberculous pneumonia the typical “1st finding” that alerts clinicians
• Liver, spleen, kidneys
• CNS involvement ominous
• Eye findings (choroid tubercles) are pathognomonic
• Skin findings may be seen, especially in patients with co-incident HIV

Ophthalmoscopic Image Of Choroid Tubercles (arrows), Pathognomonic For Miliary TB.
Resources How To
Journal List Indian J Med Res v.135(5); 2012 May PMC3401706
Indian J Med Res. 2012 May; 135(5): 703–730. P
Advanced Journal list
US National Library of Medicine
National Institutes of Health
PMC

HIV [+] Male With Miliary TB And Papulonodular Cutaneous Lesions.

Cutaneous Lesions In A Child With Miliary TB.
miliary TB (Fig. 3). These include erythematous macules and papules (tuberculosis miliaria cutis) .
Fig. 3
Clinical photograph of a child showing cutaneous lesions of miliary tuberculosis (Kind courtesy: Dr M. Ramam,
4
Resources How To
Journal List Indian J Med Res v.135(5); 2012 May PMC3401706
Indian J Med Res. 2012 May; 135(5): 703–730. P
Advanced Journal list
US National Library of Medicine
National Institutes of Health
PMC

Aim To determine clinical & laboratory features in patients with military TB.
Methods Retrospective review of 263 patients (54% male, mean age 44, range 16-89)
from 15 tertiary hospitals in Turkey between 1981 and 2015.

Immunosuppression
An Important Risk.

Open in a separate window
Fig. 1
Chest radiograph (postero-anterior view) (A) and chest CT (lung window) (B) showing classical miliary pattern.
Ta
R
Chest X-Ray And CT Scan: Classic Pattern In A Young Patient With Miliary TB.

Other Recent Cases Of Miliary
Tuberculosis Here At CMC.
We Would Like To Thanks Dr. Michael Leonard From The Division
of Infectious Disease, in the CMC Department of Internal
Medicine, For Providing These Cases And His Expert Input.

50-Year-Old
Peruvian
Female Cough
And Fever.

50-Year-Old
Peruvian
Female Cough
And Fever.
Hospital Day 7

50-Year-Old
Female With
HIV Presenting
With
Dyspnea.
The Patient Is
Intubated And
Then Becomes
Unstable.

50-Year-Old
Female With
HIV Presenting
With
Dyspnea.
The Patient Is
Intubated And
Then Becomes
Unstable.
Diagnosis: Tension Pneumothorax

50-Year-Old
Female With
HIV Presenting
With
Dyspnea.
CXR After Tube
Thoracostomy.

68-Year-Old
Female In
Respiratory
Failure
AFB +++

68-Year-Old Female In Respiratory Failure.

55-Year-Old
With Dyspnea
And
Respiratory
Failure.
AFB +++

55-Year-Old With Dyspnea And Respiratory Failure.

Embedded References
Mert A. Miliary tuberculosis. Epidemiological and clinical analysis of a large case series from a
moderate to low tuberculosis endemic country. Medicine Open. 2017; 96:1-7.
Sharma SK. Miliary tuberculosis: a new look at an old foe. Journal of Clinical Tuberculosis and Other
Mycobacteria Disease. 2016; 3:13-27.
Sharma SK. Miliary tuberculosis: new insights into an old disease. Lancet Infectious Disease. 2005.
Volume 5. www.infection.thelancet.com.

73-Year-Old
Female With
Weakness And
Fatigue.

Diagnosis: Mediastinal mass
73-Year-Old
Female With
Weakness And
Fatigue.

Needle Biopsy: Reactive Adenopathy (Known 1º Endometrial Cancer).
73-Year-Old
Female With
Weakness And
Fatigue.

Our Patient’s Lesion Is In The Middle Mediastinum

51-Year-Old
Male Presents
With Chest
Pain Five Hours
After An
Endoscopy And
Stricture
Dilatation.

Diagnosis: Esophageal Perforation With Pneumopericardium [arrows].
51-Year-Old
Male Presents
With Chest
Pain Five Hours
After An
Endoscopy And
Stricture
Dilatation.

51-Year-Old Male
Presents With Chest Pain
Five Hours After An
Endoscopy And Stricture
Dilatation.
Mediastinal Emphysema

Esophageal Perforation Repaired With Surgery And Esophageal Stenting.

Follow-Up CT Esophagram Without Evidence Of Contrast Leak.

Follow-Up CT Esophagram With Evidence Of Contrast Leak.

Esophageal Perforation: Etiologies
• Iatrogenic causes the most common:
• Endoscopic dilatation of strictures and achalasia
• Foregut surgery
• Anti-reflux surgery
• Spontaneous rupture related to sudden increases in abdominal pressure:
• Persistent retching or vomiting (Boerhaave’s syndrome)
• Weight-lifting, blunt trauma
• Ingestion of caustic liquids
• Perforation in the setting of malignancy

Esophageal Perforation
Signs And Symptoms
Mackler’s Triad: emesis, chest
pain, cervical emphysema Cervical: 15%
Thoracic: 75%
Abdominal: 15%
Distribution
Cervical neck pain, dysphagia, dysphonia
Thoracic chest pain, dyspnea
Abdominal abdominal pain, peritonitis

Aim To assess the etiology, management, and outcomes of esophageal
perforation over a 28-year period, and to characterize optimal treatment
options.
Methods Retrospective clinical review of all patients treated for esophageal
perforation at a tertiary referral hospital in Madrid, Spain between 1987 and
2015 (n=57).

Main Results
Etiologies
Endoscopic instrumentation
Surgical procedure
Swallowed foreign body
Spontaneous rupture
Tumoral perforation
35%
21%
21%
19%
4%
Management
Surgical treatment
Conservative (Abx + TPN)
Endoscopic treatment
Endoscopic + surgery
67%
14%
12%
7%
90-Day Mortality1
Surgical treatment2
Conservative (Abx + TPN)2
Endoscopic + surgery
Endoscopic treatment
32%
38%
25%
0%
1Mortality highest in patients with tumoral perforation.
2No statistical difference in mortality.

Embedded References
Esophageal Perforation
Vicente AP. Management of Esophageal Perforation: 28-Year Experience in a Major Referral Center.
The American Surgeon. 2018; 84:684-689.
Mert A. Watkins JR. Endoluminal Therapies for Esophageal Perforations and Leaks. Thoracic Surgery
Clinics of North America. 2018; 28:541-554.

68-Year-Old
Female With A
Chronic Left
Sided Pleural
Effusion
Presents With
Worsening
Shortness Of
Breath.
Diagnosis: Pneumomediastinum

Diagnosis: Pneumomediastinum
Diagnosis: Complete Left Lung Collapse
68-Year-Old
Female With A
Chronic Left
Sided Pleural
Effusion
Presents With
Worsening
Shortness Of
Breath.

Same Patient,
Following A
Bronchoscopy
Which Showed
Mucus Plugging.
Improved LUL
Aeration
Persistent
LLL Effusion

27-Year-Old
Male Brought To
The ED Following
An Opioid
Overdose. He
Wakes Up After
Naloxone
Reversal But
Becomes
Dyspneic And
Hypoxic During
His ED Stay.

Diagnosis: Naloxone-Related Pulmonary Edema
27-Year-Old
Male Brought To
The ED Following
An Opioid
Overdose. He
Wakes Up After
Naloxone
Reversal But
Becomes
Dyspneic And
Hypoxic During
His ED Stay.

Naloxone-Induced
Non-Cardiogenic
Pulmonary Edema
• Rare and thought to occur in 0.2-3.6% of patients
(based on data from elective post-operative
anesthetic reversal).
• Mostly reported in patients with co-existing cardiac
disease and/or in young adults with obstructive sleep
apnea.
• Thought to be caused by catecholamine release
which antagonizes the mu-opioid receptors in the
adrenal medulla; leading to increased pulmonary
blood volumes and pressures, and increased capillary
permeability.
Recommendation: Use the lowest effective dose of
naloxone!
Jiwa, Nasheena et al. “Naloxone-Induced Non-Cardiogenic
Pulmonary Edema: A Case Report.” Drug Safety - Case Reports
vol. 5,1 20. 10 May. 2018, doi:10.1007/s40800-018-0088-x

Aim To determine whether administration of higher doses of naloxone for the treatment of
opioid overdose is associated with increased pulmonary complications.
Methods Retrospective, observation study of 1,831 patients treated with naloxone by the City
of Pittsburgh EMS. “High-dose” naloxone was defined as a total administration
exceeding 4.4 mg.

Main Results:
• Patients receiving high dose naloxone were 62% more likely to have a pulmonary complication
(42% versus 26% absolute risk; odds ratio 2.14; 95% CI 1.44 to 3.18).
• When the initial dose of naloxone exceeded 0.4 mg, there was an increased risk of pulmonary
complications (27% versus 13% absolute risk; odds ratio 2.57; 95% CI 1.45 to 4.54).
• Pulmonary edema occurred in 1.1% of patients.
Recommendation: Use the lowest effective dose of naloxone!

Pulmonary Edema
Review
• Cardiogenic (high pulmonary capillary pressure):
• Left heart failure
• Mitral regurgitation
• Aortic stenosis
• Myocardial pathology (Cardiomyopathy, Myocarditis)
• Non-cardiogenic (increased capillary permeability):
• Neurogenic pulmonary edema
• High altitude pulmonary edema
• Reperfusion pulmonary edema
• Re-expansion pulmonary edema
• Overdose (heroin, methadone, fentanyl,l naloxone)
• Salicylate toxicity
• Drugs (amiodarone, immunosuppressives)
• Pulmonary embolism
• Eclampsia
• Viral infections
• Pulmonary veno-occlusive disease
• Transfusion related acute lung injury (TRALI)

What Should You
Look For
On Chest X-Ray?
Pulmonary Interstitial Edema
• Kerley B lines
• Peribronchial cuffing
Pulmonary Alveolar Edema
• “Bat wing” pattern
• Air bronchograms
Cardiomegaly
Pulmonary Vascular Engorgement
Vascular cephalization

70-Year-Old
Male Presents
With Shortness
Of Breath And
Back Pain. EKG
Showed ST
Depression In
The Anterior
Leads.

Bilateral Pulmonary Infiltrates Right >>> Left.
70-Year-Old
Male Presents
With Shortness
Of Breath And
Back Pain. EKG
Showed ST
Depression In
The Anterior
Leads.

70-Year-Old
Male Presents
With Shortness
Of Breath And
Back Pain.
Hospital Day 2
Worsening
Hypoxia And
Vasopressor
Requirements.

70-Year-Old
Male Presents
With Shortness
Of Breath And
Back Pain.
Hospital Day 2
Worsening
Hypoxia And
Vasopressor
Requirements.
Exam Reveals A
3/6 Systolic
Murmur. ECHO
Confirms
Severe MR.

Diagnosis: Mitral Regurgitation With Right-Sided Pulmonary Edema.
70-Year-Old
Male Presents
With Shortness
Of Breath And
Back Pain.
Severe Mitral
Regurgitation.

Unilateral Pulmonary Edema
• 2% of cardiogenic pulmonary edema cases
• Causes:
• Severe mitral regurgitation (MR) the most common
• Re-expansion pulmonary edema
• Pulmonary vein occlusion
• Right-to-left shunt
Mechanism: In patients with severe MR, the regurgitant blood jet is directed
towards the right pulmonary vein, causing unilateral right-sided overload.

45-Year-Old
With Acute,
Severe Mitral
Regurgitation
And Unilateral
(Right-Sided)
Pulmonary
Edema.

Embedded References
Unilateral Pulmonary Edema
Inotani S. Unilateral cardiogenic pulmonary edema. Journal of Cardiology Cases. 2018; 17:85-88.
Handagala R. Unilateral pulmonary edema: a case report and review of the literature. Journal of
Medical Case Reports. 2018; 12:219. doi.org/10.1186/s13526-018-1739-3.
Attias D. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral
pulmonary edema. Circulation. 2020; 122:1109-15. doi.10.1161/circulationaha.109.934950.

56-Year-Old
Female On The
Ventilator
Develops Acute
Hypoxemia.

Diagnosis: Acute Respiratory Distress Syndrome (ARDS)
56-Year-Old
Female On The
Ventilator
Develops Acute
Hypoxemia.

56-Year-Old
Female On The
Ventilator
Develops Acute
Hypoxemia.
Diagnosis: Acute Respiratory Distress Syndrome (ARDS);
Ventilator Acquired Pneumonia.

After 1 Week Of Lung Protective Ventilation
And Antibiotics.

Day Of Hypoxemic
Event
1 Week
Later

The Trial Was Stopped Early Because Mortality
Was Lower In The Low Tidal Volume Group.

Known Strategies
To Prevent
Ventilator
Acquired
Pneumonia (VAP).
• The VAP bundle:
• Elevation of the head of the bed (30–45 degrees)
• Daily “sedation vacations” and assessment of the
readiness to extubate
• Peptic ulcer disease prophylaxis
• Venous thromboembolism prophylaxis
• Oral chlorhexidine
• Continuous aspiration of subglottic secretions via the ETT
• Other interventions:
• Avoid routine changing of humidified ventilator circuits,
• Periodic draining and discarding condensate collecting in
the ventilator tubing and,
• Changing the heat-and-moisture exchangers (HMEs) when
they showed mechanical malfunction or became visibly
soiled.

Summary Of Diagnoses This Month
 Miliary tuberculosis
 Mediastinal mass
 Esophageal perforation and pneumomediastinum
 Mucus plugging and left lung collapse
 Naloxone associated pulmonary edema
 Unilateral pulmonary edema in the setting of mitral regurgitation
 ARDS and ventilator-acquired pneumonia

Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: March Cases

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