Posttraumatic pulmonary pseudocyst: a rare complication of blunt chest trauma

Posttraumatic pulmonary pseudocyst is a rare cavitary lesion lacking an epithelial lining, which develops within the pulmonary parenchyma after blunt chest trauma. Such pseudocysts develop most commonly in children and young adults. The clinical course is usually benign with spontaneous resolution of the radiologic manifestations within 2 to 4 months after trauma. A young male injured in a motor vehicle accident, sustaining a posttraumatic pulmonary pseudocyst, is presented here.     

Traumatic pulmonary pseudocysts: CT findings

Traumatic pulmonary pseudocyst constitutes an uncommon, though well recognized, manifestation of closed chest trauma. It is usually encountered in young patients, whose compliant chest wall permits the transmission of great compressive forces to the lung parenchyma and the laceration of the latter. Traumatic pulmonary pseudocyst is usually detected during the imaging evaluation of multi-injured patients with the use of computed tomography, as it is often not apparent in the initial supine anteroposterior chest radiographs. We present 5 cases of trauma patients, in whom we detected the presence of multiple traumatic pulmonary pseudocysts during the imaging evaluation of blunt chest trauma with the use of computed tomography.     

Mediastinal pancreatic pseudocyst

The extension of a pancreatic pseudocyst into the mediastinum is a difficult clinical and radiographic diagnosis. The chest roentgenogram reveals a retrocardiac mass in a patient with nonspecific upper abdominal and chest complaints. Usually there is a preceding history of alcoholism or pancreatitis. The upper gastrointestinal series often demonstrates typical displacement of the distal esophagus anteriorly and to the left. The value of computed tomography is illustrated. Correct preoperative diagnosis is important for proper surgical treatment, since a mediastinal pseudocyst is best managed without thoracotomy.     

A case of mediastinal pancreatic pseudocyst with hemoptysis successfully treated with total parenteral nutrition]

A 51-year-old man with chronic alcohol-related pancreatitis was admitted to our hospital complaining of hemoptysis. A chest X-ray film revealed a ground-glass opacity in the left lower lung field and a bronchoscopic examination revealed bleeding from the left lower lobe bronchus. Chest multi detector-row CT demonstrated a cystic mediastinal mass along the esophagus from the pancreatic tail reaching the carina. No pleural effusion was found. Based on the clinical and radiographic features, we diagnosed mediastinal pancreatic pseudocyst. After four weeks of the treatment of pancreatitis with total parenteral nutrition, hemoptysis was disappeared and the serum amylase level normalyzed. The follow-up CT scan showed that the cystic mediastinal mass had disappeared completely. Mediastinal pancreatic pseudocyst accompanied by hemoptysis is very rare. We suggest that mediastinal pancreatic pseudocyst also should be considered in the differential diagnosis of alcoholics with hemoptysis.     

Treatment of chronic pancreatitic pleural effusion by percutaneous catheter drainage of abdominal pseudocyst

A 53-year-old man entered the hospital with a large, right chronic pancreatitic pleural effusion. Computed tomographic examination of the abdomen and chest demonstrated a pancreatic pseudocyst that had extended into the mediastinum. After conventional closed-chest tube thoracotomy drainage failed to empty the pleural space, percutaneous abdominal pseudocyst drainage was instituted using computed tomographic guidance. The pleural effusion cleared promptly, and the pancreatic pseudocyst resolved gradually over seven weeks. Following termination of pseudocyst drainage, the patient has remained well for over two years with no recurrence of pancreatitis, pseudocyst, or pleural effusion. In contrast, three earlier patients with a chronic pancreatitic effusion managed conventionally had a complicated hospital course and required surgical intervention; two had recurrent pancreatitis following hospital discharge. Percutaneous catheter placement was unsuccessful in one of these three and, in retrospect, was infeasible in the other two. It is recommended that thoracoabdominal computed tomography be performed in all patients with a chronic pancreatitic pleural effusion, and that percutaneous abdominal catheter drainage be attempted in all patients with an accessible pancreatic or mediastinal pseudocyst. Such treatment may relieve respiratory insufficiency, minimize the risk of empyema or fibrothorax, and may promote pseudocyst closure without the need for surgery.     

The role of the chest X-ray in the evaluation of chronic severe heart failure: things are not always as they appear

The chest x-ray has become a standard clinical test to aid in the evaluation of patients with chronic severe heart failure. To evaluate just how useful this tool is in the routine assessment of pulmonary venous hypertension secondary to heart failure, we compared the radiologist's interpretation of the chest x-ray with hemodynamic data obtained from right heart catheterization in a group of patients undergoing protocol evaluation of an experimental treatment for heart failure. Of 23 patients with pulmonary venous hypertension (pulmonary capillary wedge pressure greater than 20 mmHg) and a complete data base, only 11 had chest x-rays showing evidence of pulmonary venous congestion or interstitial or alveolar edema. The sensitivity of the chest x-ray in selecting patients with a pulmonary capillary wedge pressure over 20 mmHg in this setting was only 48%. In other studies, where the radiologist was aware that his or her reading was being compared to hemodynamic assessments, the sensitivity of the chest film has approached 85%. We feel our analysis more closely parallels routine clinical practice. Clinicians should be aware that the chest x-ray may not be a very sensitive tool for the assessment of pulmonary hemodynamics in patients with severe heart failure.     

Mediastinal pseudocyst associated with chronic pleural effusions

We present a patient who had chronic, bilateral pleural effusions without evidence of parenchymal, retrocardiac or mediastinal masses. A CAT scan of the abdomen and chest revealed the extension of a large abdominal pseudocyst through the diaphragm into the posterior mediastinum. The pseudocyst resolved with conservative management.     

Suspicion of pulmonary embolism in outpatients: nonspecific chest pain is the most frequent alternative diagnosis

OBJECTIVES: Several recent studies have focused on identifying clinical predictors of embolism. However, although pulmonary embolism is ruled out in 70-85% of the patients in whom it is suspected, data on the clinical characteristics and discharge diagnosis of such patients are scarce. Our aim was to evaluate whether clinical characteristics would allow predicting alternative diagnoses other than pulmonary embolism thereby ruling out venous thromboembolism. DESIGN: Retrospective analysis. SETTING: Emergency centres of two teaching and general hospitals. SUBJECTS: A total of 1090 consecutive outpatients admitted for clinically suspected pulmonary embolism and a diagnosis established by a validated algorithm and a 3-month follow-up. OUTCOMES: Discharge diagnoses of patients in whom pulmonary embolism was ruled out were identified and regrouped into two categories: (i) nonspecific chest pain and (ii) diagnosis other than pulmonary embolism. Predictive accuracy of clinical and laboratory variables for diagnosing nonspecific chest pain was assessed by univariate and multivariate analysis. RESULTS: In patients without pulmonary embolism, nonspecific chest pain (parietal chest pain, chest pain of unknown origin and pleuritis) was the most frequent discharge diagnosis (n = 334, 31% of the entire cohort, 43% of the patients without pulmonary embolism). Other patients without pulmonary embolism had a wide variety of diagnoses, of which the most frequent were bronchopneumonia (6.0% of the entire cohort) and heart failure (5.2%). In the multivariate analysis, seven variables were strongly associated with nonspecific chest pain: younger age (below 40 years), female gender, respiratory rate below 20 min(-1), heart rate below 100 min(-1), and absence of recent immobilization, dyspnoea and haemoptysis. Two of the 24 patients in whom all those characteristics were present had pulmonary embolism (8%, 95% CI 3-22%). CONCLUSIONS: The most frequent discharge diagnosis in emergency ward patients in whom pulmonary embolism is ruled out is nonspecific chest pain. A clinical model did not allow to predict nonspecific chest pain with enough accuracy to rule out pulmonary embolism without further testing. Whether a more precise characterization of chest pain might allow an accurate identification of such patients deserves further study.     

Mediastinal pancreatic pseudocyst with recurrent pleural effusion. Demonstration by endoscopic retrograde cholangiopancreatogram and subsequent computed tomography scan.

Mediastinal pseudocysts of internal pancreatic fistulas are rare as a cause of bilateral pleural effusions even in relapsing pancreatitis. We describe a 38-year-old man with recurrent bilateral pleural effusion as a complication of a pancreatic pseudocyst. Extension of a pancreatic pseudocyst into the posterior mediastinum was clearly identified by endoscopic retrograde cholangiopancreatogram and subsequent computed tomography scan of the abdomen and chest, and the complication was successfully treated by surgical management. We stress the importance of definite assessment of the communication of pancreatic pseudocyst with mediastinum in patients with pancreatitis who develop recurrent pleural effusions.     

Pancreatic Pleural Fistula: Demonstration by Computed Tomography after Endoscopic Retrograde Pancreatography

A case of chronic pancreatic pleural effusions is reported. The effusions were massive in the right chest at first and became bilateral. Endoscopic retrograde pancreatography showed a pancreatic pleural fistula toward the diaphragm. Computed tomography after endoscopic retrograde pancreatography revealed the entire course of the fistula and a mediastinal pseudocyst. Computed tomography and the operative fistulogram did not show immediate leakage of the contrast medium from the mediastinal pseudocyst.     

A rare complication of chronic pancreatitis: pancreatico-pleural fistula

Pleural effusion is a rare complication of chronic pancreatitis. We report a case observed in a 39-year-old patient hospitalized for dyspnea and pain in the lower left thorax. Chest x-ray revealed left pleural effusion. The exudative pleural fluid contained a very high amylase level. CT-scan revealed a pseudo-cyst of the tail of the pancreas extending into contact with the diaphragm and the chronic pancreatitis lesions. Medical treatment associating thoracic drainage, somatostatin analog, and antibiotics was unsuccessful. Thoracoscopic pleural decortication was performed. The patient then developed pneumonia involving the left base. A new antibiotic regimen was delivered and the pseudocyst was drained percutaneously under CT guidance. The clinical course was favorable at six months with partial involution of the pseudocyst and regression of the pulmonary images.     

9例变应性支气管肺曲菌病误诊为肺结核临床分析

目的探讨变态反应性支气管肺曲菌病(ABPA)的临床特点及误诊为肺结核的原因。方法分析9例误诊为肺结核的ABPA的临床表现、发病、影像学表现、诊断和治疗的特点及误诊原因。结果 9例病例均有慢性咳嗽、咳痰,5例有胸闷、喘息,所有病例长时间的误诊。胸部CT显示:单侧和(或)两侧片状浸润影,呈游走,中心性支气管扩张,外周血嗜酸粒细胞增高,血清总IgE高,烟曲菌抗原皮内试验呈速发反应阳性。9例患者用激素及伊曲康唑治疗后症状改善,X线影像学明显吸收。结论 ABPA与肺结核有相似的临床表现和胸部X线影像学表现,临床医生应提高对ABPA的认识。     

Digital tomosynthesis of the chest

Digital tomosynthesis is a technique that generates an arbitrary number of section images of a patient from a single pass of the x-ray tube. It is under investigation for application to a number of clinical detection tasks, and has recently been implemented in commercial devices for chest radiography. Tomosynthesis provides improved visibility of structures in the chest, such as pulmonary nodules, airways, and spine. This review article outlines the components of a typical tomosynthesis system, and presents examples of improved pulmonary nodule detection from a clinical trial in human subjects. Possible implementation strategies for use in chest imaging are discussed.     

Mediastinal Pancreatic Pseudocyst

Mediastinal extension of pancreatic pseudocysts is uncommon. Frequent presenting complaints include chest pain and shortness of breath. Dysphagia is rare. A patient with mediastinal pseudocyst causing dysphagia is presented. The role of gray-scale ultrasound as a reliable means of diagnosis is discussed.     

涂阴肺结核的诊断与治疗

目的总结涂阴肺结核临床诊断与治疗经验。方法分析2008年-2009年我所治疗的887例涂阴肺结核患者的临床资料。结果临床症状、胸部X线检查（包括胸部CT扫描）、PPD试验、抗结核治疗有效、血结核抗体阳性是诊断本病的主要手段,直接面视下DOTS是确保涂阴肺结核治愈的重要方法。结论涂阴肺结核的诊断有一定的困难,以不住院化疗为主,医护人员直接面视下DOTS。     

围术期26例不典型肺栓塞临床分析及早期诊断的探讨

目的探讨围术期急性肺栓塞的不典型病例特点。方法回顾性分析26例围术期具有不典型症状急性肺栓塞的临床资料。结果 26例急性肺栓塞围术期患者,发生肺栓塞时晕厥、呼吸困难急促、胸闷胸痛、神志或意识改变等症状的发生率分别为31%、54%、19%、27%。结论围术期急性肺栓塞常以不典型症状为表现,易与其基础疾病相混淆,对有上述症状的患者应高度警惕,尽快完善CVP监测、D-二聚体定量测定、床旁心血管彩超,条件允许者行双源CT肺动脉造影可早期诊断肺栓塞。     

An unusual cause of acute cor pulmonale – Significance of the ‘continuous diaphragm sign’

A patient presented with chest pain and clinical features of acute right heart failure. Initial work up revealed the presence of severe PAH. Acute pulmonary embolism is the commonest and most life-threatening cause for acute cor pulmonale. Even though the clinical picture suggested pulmonary embolism, a subtle sign was missed from the first chest X-ray taken in the emergency department. However on reanalysis the ‘continuous diaphragm sign’ later guided us towards the diagnosis. Our case represents one of the first reports of a rare etiology for acute cor pulmonale – hypersensitivity pneumonitis. Right ventricular dysfunction was caused by an acute rise in pulmonary artery pressures as well as by the compressive effects of pneumomediastinum. We emphasize the role played by a good quality chest X-ray early in the management of acute chest pain syndromes. However pulmonary embolism should be ruled out conclusively before redirecting attention to less malignant conditions.     

Diagnosis of pulmonary arteriovenous malformation by ultrafast chest computed tomography in Rendu-Osler-Weber syndrome with cerebral ischemia--a case report.

Pulmonary arteriovenous malformations occur in 15-20% of patients with Rendu-Osler-Weber syndrome and can be the source of paradoxical emboli causing cerebral ischemia, septic emboli leading to brain abscesses, or polycythemia causing hyperviscosity and cerebral ischemia. The diagnosis of these malformations may be elusive, since classic clinical or radiologic findings may be absent in some patients. The authors report a patient with Rendu-Osler-Weber syndrome with cerebral ischemia who had normal findings from a pulmonary examination and chest roentgenogram. An ultrafast computed tomography scan of the chest demonstrated, however, a pulmonary arteriovenous malformation in the right upper lobe that was successfully resected. Ultrafast computed tomography of the chest is a relatively noninvasive method of screening for a pulmonary arteriovenous malformation in a patient with Rendu-Osler-Weber syndrome and otherwise unexplained neurologic symptoms.     

获得性免疫缺陷综合征合并肺结核临床特征与T细胞亚群的相关性分析

目的 探讨获得性免疫缺陷综合征合并肺结核(AIDS/PTB)双重感染的类型,影像特征及临床表现为PTB菌阴及菌阳时,患者T细胞亚群计数的差异及意义.方法 回顾性分析93例AIDS/PTB双重感染患者的类型,影像特征及临床表现分别为PTB菌阴及菌阳时,检测其T细胞亚群水平并进行统计学比较.结果 ①CD4+细胞计数与结核病的发病率成反比,当CD4+＜50×106/L时,结核的发病率明显上升(67.74%,63/93).②影像特征不典型的PTB病例CD4+T细胞计数为(47.79±32.17)×106/L,影像特征典型的PTB病例CD4+T细胞计数为(95.3456±64.89)×106/L.二者之间CD4+T细胞计数差异有统计学意义(P＜0.01).③不同临床表现患者CD4+T细胞计数差异有统计学意义,PTB菌阴组患者明显高于PTB菌阳组患者(P＜0.02),CD8+T细胞计数比较差异无统计学意义(P＞0.05).结论 AIDS/PTB感染患者临床特征与其T细胞亚群计数相关.     

Chronic necrotizing pulmonary aspergillosis complicated by a cavitary lesion caused by Pulmonary Mycobacterium-avium complex disease

A 66-year-old woman who had undergone one year's treatment for pulmonary nontuberculous mycobacterial disease due to Mycobacterium avium (rifampicin, ethambutol, clarithromycin, streptomycin-->levofloxacin) five years earlier was admitted to our hospital because of continuous fever and a newly detected abnormal chest shadow, which was like a fungus ball in the right upper lobe on chest computed tomography in the giant cavitary lesion caused by pulmonary Mycobacterium-avium complex (MAC) disease. A diagnosis of chronic necrotizing pulmonary aspergillosis (CNPA) complicated by pulmonary MAC disease was made because Aspergillus niger was isolated from several sputum specimens, anti-aspergillus antibody was positive, and clinical symptoms such as fever, were disclosed with the radiological finding of a fungus ball-like shadow and an infiltration shadow around the cavity. The patient had received various forms of antifungal chemotherapy, but the clinical effect had been poor. Since then, she had been slowly worsening. Although mycetomas, with the typical appearance of a fungus ball on a chest radiograph, have been reported to easily form in cavitary lesions caused by previous pulmonary tuberculosis, we believe, as illustrated by the present case, that they could also form in such lesions caused by pulmonary MAC disease, since the frequency of pulmonary nontuberculous mycobacterial disease has recently been increasing in comparison with that of pulmonary tuberculosis.