Infarto pulmonar: signos que no debemos dejar pasar en TC de tórax sin contraste / Pulmonary infarction: the signs that we must not miss in chest CT without contrast

Resumen El infarto pulmonar (IP) resulta de la oclusión de las arterias pulmonares distales que generan isquemia, hemorragia y finalmente necrosis del parénquima pulmonar, siendo la causa más frecuente la embolia pulmonar (EP). El diagnóstico oportuno de IP permite el inicio precoz del tratamiento y el respectivo manejo de sostén, disminuyendo así la morbimortalidad asociada. El objetivo de esta revisión es remarcar la importancia de identificar aquellos signos, que en la tomografía computada (TC) sin contraste son altamente sensibles y específicos para el diagnóstico de IP. La TC de alta resolución constituye el método que más información aporta, pudiendo observar signos clásicos de IP como la opacidad en forma de cuña, opacidad con radiolucencia central y el signo del vaso nutricio; así como signos con alto valor predictivo negativo para IP, como la opacidad consolidativa con broncograma aéreo, sugestivo de otras patologías, ya sean infecciosas o tumorales.

Abstract Pulmonary infarction (PI) results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage, and necrosis of the pulmonary parenchyma. The most common cause of pulmonary infarction is pulmonary embolism (PE). Early diagnosis of PI allows early initiation of treatment and supportive care, thus reducing the associated morbidity and mortality. This review aims to highlight the importance of identifying signs that are highly sensitive and specific for the diagnosis of PE even without IV contrast. High-resolution computed tomography (CT) is the method that provides the most information, as it observes classic signs of PI such as wedge-shaped opacity, central lucencies in peripheral consolidation, and the feeding vessel sign, as well as signs with high negative predictive value such as consolidating opacity with air bronchogram that are suggestive of other pathologies, whether infectious or tumoural.

Infarto pulmonar cavitado en mujer con lupus eritematoso sistémico asociado a síndrome antifosfolípido

Tanto lupus eritematoso sistémico como el síndrome antifosfolípido son enfermedades autoinmunes con potencial tromboembólico, sobre todo por la presencia de anticuerpos trombogénicos. El pulmón es un lugar común donde suele asentarse un trombo y generar una tromboembolia, a veces con posterior infarto y cavitación. Existen pocos estudios que informen un infarto pulmonar cavitado en un paciente con lupus asociado a síndrome antifosfolípido. Presentamos el caso de una mujer de 24 años con síntomas generales y lesión pulmonar derecha cavitada. Fue tratada inicialmente como infección tuberculosa o fúngica. La analítica y las imágenes orientaron y diagnosticaron lupus asociado a síndrome antifosfolípido, complicado con tromboembolismo pulmonar que luego pasó a cavitarse. La paciente mejoró considerablemente con anticoagulantes, corticoides y ciclofosfamida.

Both systemic lupus erythematosus and antiphospholipid syndrome are autoimmune diseases with thromboembolic potential, especially due to the presence of thrombogenic antibodies. The lung is a common place where a thrombus usually settles and generates a thromboembolism, sometimes with subsequent infarction and cavitation. There are few studies reporting cavitary pulmonary infarction in a patient with lupus associated with antiphospholipid syndrome. We present the case of a 24-year-old woman with general symptoms and cavitated right lung lesion. She was initially treated as tuberculous or fungal infection. Laboratory tests and images guided and diagnosed lupus associated with antiphospholipid syndrome, complicated by pulmonary thromboembolism that later became cavitated. The patient improved considerably with anticoagulants, corticosteroids, and cyclophosphamide.

Clinical and 18F-FDG PET/CT imaging features of hilar tumor pulmonary infarction / 中华核医学与分子影像杂志

Objective:To investigate the clinical manifestations and 18F-FDG PET/CT imaging features of hilar tumor pulmonary infarction. Methods:From July 2016 to June 2021, 49 patients (40 males, 9 females; age 32-81 years) with hilar tumor pulmonary infarction who underwent PET/CT and enhanced CT in the second Hospital of Shandong University and Shandong Cancer Hospital and Institute, Shandong First Medical University were retrospectively enrolled. All patients were diagnosed by imaging follow-up or pathology. Clinical features and 18F-FDG PET/CT imaging features were analyzed. Results:A total of 108 infarcts were found in 49 patients by 18F-FDG PET/CT. Small cell carcinoma was the most common hilar tumor (67.35%, 33/49). The most common clinical manifestations of hilar tumor pulmonary infarction were cough (69.39%, 34/49) and hemoptysis (34.69%, 17/49). Pulmonary infarction was mainly multiple (69.39%, 34/49), and multiple lung lobes might be involved. The CT morphology of infarcts was wedge-shaped (46.30%, 50/108) or patchy (53.70%, 58/108), and the density was mainly bubble consolidation (61.11%, 66/108). There were 91 (84.26%, 91/108) infarcts showing FDG hypermetabolism, with the SUV max of 1.48-6.62, and the hypermetabolism mode was rim sign (36.11%, 39/108) or heterogeneous hypermetabolism (48.15%, 52/108). Nineteen patients (38.78%, 19/49) were complicated with pulmonary vein involvement, and 26 patients (53.06%, 26/49) had ipsilateral pleural effusion. Conclusions:Hilar tumor pulmonary infarction is characterized by cough. It is helpful for the diagnosis of hilar tumor pulmonary infarction in patients with hilar tumor when wedge-shaped, bubble consolidation, rim sign and heterogeneous hypermetabolism lesions are found in 18F-FDG PET/CT images.

Enfoque del paciente con cavitación pulmonar / Approach to the patient with lung cavitation / Enfoque do paciente com cavitação pulmonar

Cavitation is a common finding in lung images, secondary to infectious, inflammatory, tumor, and autoimmune conditions, the former being the most common cause in all levels of care and geography. The diagnostic approach must be judicious, integrating the image, with the patient's medical history, personal history, and exposures, as well as the time of evolution of the symptoms; which are key elements for the approach. It is always essential to integrate the clinical findings with the laboratory and the pathology in order to reach an accurate diagnosis and timely treatment, since the isolated image is not enough, given the multiple etiologies described and variety of presentation that make this radiological sign only a premise to the confirmation of an underlying disease.

Una cavitación es un hallazgo común en imágenes pulmonares, secundaria a condiciones infecciosas, inflamatorias, tumorales y autoinmunes, siendo las primeras la causa más común en todos los niveles de atención y geográficos. El abordaje diagnóstico debe ser riguroso, integrando la imagen con la historia clínica del paciente, sus antecedentes personales y exposiciones, así como el tiempo de evolución de los síntomas; estos son elementos clave para el enfoque. Siempre es fundamental integrar los hallazgos clínicos con el laboratorio y la patología para llegar a un diagnóstico preciso y a un tratamiento oportuno, pues la imagen aislada no es suficiente, dadas las múltiples etiologías descritas y la variedad de presentación que hacen de este signo radiológico solo una premisa a la confirmación de una enfermedad subyacente.

Uma cavitação é uma descoberta comum em imagens pulmonares, secundária a condições infecciosas, inflamatórias, tumorais e autoimunes, sendo as primeiras a causa mais comum em todos os níveis de atenção e geográficos. A abordagem diagnóstica deve ser rigorosa, integrando a imagem com a história clínica do paciente, seus antecedentes pessoais e exposições, assim como o tempo de evolução dos sintomas; estes são elementos chave para o enfoque. Sempre é fundamental integrar as descobertas clínicas com o laboratório e a patologia para chegar a um diagnóstico preciso e a um tratamento oportuno, pois a imagem isolada não é suficiente, dadas as múltiplas etiologias descritas e a variedade de apresentação que fazem deste signo radiológico só uma premissa à confirmação de uma doença subjacente.

Lung cavities in chronic thromboembolic pulmonary hypertension

OBJECTIVES: Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension (PH) that arises from obstruction of the pulmonary vessels by recanalized thromboembolic material. CTEPH has a wide range of radiologic presentations. Commonly, it presents as main pulmonary artery enlargement, peripheral vascular obstructions, bronchial artery dilations, and mosaic attenuation patterns. Nevertheless, other uncommon presentations have been described, such as lung cavities. These lesions may be solely related to chronic lung parenchyma ischemia but may also be a consequence of concomitant chronic infectious conditions. The objective of this study was to evaluate the different etiologies that cause lung cavities in CTEPH patients. METHODS: A retrospective data analysis of the medical records of CTEPH patients in a single reference PH center that contained or mentioned lung cavities was conducted between 2013 and 2016. RESULTS: Seven CTEPH patients with lung cavities were identified. The cavities had different sizes, locations, and wall thicknesses. In two patients, the cavities were attributed to pulmonary infarction; in 5 patients, an infectious etiology was identified. CONCLUSION: Despite the possibility of being solely associated with chronic lung parenchyma ischemia, most cases of lung cavities in CTEPH patients were associated with chronic granulomatous diseases, reinforcing the need for active investigation of infectious agents in this setting.

Incidence and morphological characteristics of the reversed halo sign in patients with acute pulmonary embolism and pulmonary infarction undergoing computed tomography angiography of the pulmonary arteries / Incidência e características morfológicas do sinal do halo invertido em pacientes com tromboembolismo pulmonar agudo e infarto pulmonar submetidos a angiotomografia de artérias pulmonares

ABSTRACT Objective: To determine the incidence of the reversed halo sign (RHS) in patients with pulmonary infarction (PI) due to acute pulmonary embolism (PE), detected by computed tomography angiography (CTA) of the pulmonary arteries, and to describe the main morphological features of the RHS. Methods: We evaluated 993 CTA scans, stratified by the risk of PE, performed between January of 2010 and December of 2014. Although PE was detected in 164 scans (16.5%), three of those scans were excluded because of respiratory motion artifacts. Of the remaining 161 scans, 75 (46.6%) showed lesions consistent with PI, totaling 86 lesions. Among those lesions, the RHS was seen in 33 (38.4%, in 29 patients). Results: Among the 29 patients with scans showing lesions characteristic of PI with the RHS, 25 (86.2%) had a single lesion and 4 (13.8%) had two, totaling 33 lesions. In all cases, the RHS was in a subpleural location. To standardize the analysis, all images were interpreted in the axial plane. Among those 33 lesions, the RHS was in the right lower lobe in 17 (51.5%), in the left lower lobe in 10 (30.3%), in the lingula in 5 (15.2%), and in the right upper lobe in 1 (3.0%). Among those same 33 lesions, areas of low attenuation were seen in 29 (87.9%). The RHS was oval in 24 (72.7%) of the cases and round in 9 (27.3%). Pleural effusion was seen in 21 (72.4%) of the 29 patients with PI and the RHS. Conclusions: A diagnosis of PE should be considered when there are findings such as those described here, even in patients with nonspecific clinical symptoms.

RESUMO Objetivo: Verificar a incidência do sinal do halo invertido (SHI) associado a infartos pulmonares (IP) relacionados ao tromboembolismo pulmonar (TEP) agudo, identificado por angiotomografia (angio-TC) de artérias pulmonares, e demonstrar as principais características morfológicas do SHI. Métodos: Foram avaliadas 993 angio-TCs, após estratificação de risco clínico para TEP entre janeiro de 2010 e dezembro de 2014. TEP foi encontrado em 164 pacientes (16,5%), sendo que três exames foram descartados devido a artefatos de movimentação respiratória. Dos 161 exames restantes, em 75 (46,6%) foram identificadas imagens compatíveis com IP, totalizando 86 lesões; o SHI foi observado em 33 (38,4% dos pacientes) dessas lesões. Resultados: Dos 29 pacientes com lesões características de IP com o SHI, 25 pacientes (86,2%) apresentavam lesão única e 4 (13,8%), lesão dupla. Todas as imagens compatíveis com SHI eram de localização subpleural. Para padronizar a análise, todas as imagens foram interpretadas no plano axial. Em relação à distribuição lobar das 33 lesões, o SHI estava localizado no lobo inferior direito, em 17 (51,5%); no lobo inferior esquerdo, em 10 (30,3%); na língula, em 5 (15,2%) e no lobo superior direito, em 1 (3,0%). Áreas de baixa atenuação no interior dos IPs com o SHI foram observadas em 29 das 33 lesões (87,9%). O SHI apresentava formato ovalado em 24 (72,7%) dos casos e formato arredondado, em 9 (27,3%). Derrame pleural foi encontrado associado aos IP com o SHI em 21 pacientes (72,4%). Conclusões: O achado de imagens com essas características, mesmo em pacientes com sintomatologia inespecífica, deve alertar para a possibilidade do diagnóstico de TEP.

Infected pulmonary infarction case report / Infarto pulmonar infectado. reporte de caso

ABSTRACT Introduction: Pulmonary infarction occurs in 29% to 32% of patients with pulmonary thromboembolism (PTE). The infection of a pulmonary infarction is a complication in approximately 2 to 7% of the cases, which makes it a rare entity. Case Presentation: 49-year-old woman with pleuritic pain in the left hemithorax that irradiated to the dorsal region, associated with dyspnea and painful edema in the left lower limb of two days of evolution. Two weeks prior to admission, the patient suffered from a left knee trauma that required surgical intervention; however, due to unknown reasons, she did not receive antithrombotic prophylaxis. Physical examination showed tachycardia, tachypnea and painful edema with erythema in the left leg. After suspecting a pulmonary thromboembolism, anticoagulation medication was administered and a chest angiotomography was requested to confirm the diagnosis. The patient experienced signs of systemic inflammatory response, and respiratory deterioration. A control tomography was performed, suggesting infected pulmonary infarction. Antibiotic treatment was initiated, obtaining progressive improvement; the patient was subsequently discharged, and continued with anticoagulation medication and follow-up on an outpatient basis. Conclusions: Pulmonary infarction is a frequent complication in patients with PTE. Therefore, infected pulmonary infarction should be suspected in patients with clinical deterioration and systemic inflammatory response. The radiological difference between pulmonary infarction and pneumonia is not easily identified, thus the diagnostic approach is clinical, and anticoagulant and antimicrobial treatment should be initiated in a timely manner.

RESUMEN Introducción El infarto pulmonar ocurre entre un 29 y un 32% de pacientes con tromboembolismo pulmonar (TEP). Por su parte, la infección de un infarto pulmonar complica aproximadamente del 2 al 7% de los casos, lo que hace que el infarto pulmonar infectado sea una entidad poco frecuente. Descripción del caso Mujer de 49 años con dolor pleurítico en hemitórax izquierdo, irradiado a región dorsal, asociado a disnea y edema doloroso de miembro inferior izquierdo de dos días de evolución. Dos semanas antes de su ingreso la paciente sufrió trauma de rodilla izquierda, el cual que requirió intervención quirúrgica; sin embargo, por motivos desconocidos, no recibió profilaxis anti trombótica. En el examen físico se encontró taquicardia, taquipnea y edema doloroso con eritema en pierna izquierda. Al existir alta sospecha de tromboembolia pulmonar se inició anticoagulación y se solicitó angiotomografía de tórax, con la cual fue posible confirmar el diagnóstico. Durante su evolución, la paciente experimentó signos de respuesta inflamatoria sistémica, deterioro respiratorio. Se realizó tomografía de control sugestiva de infarto pulmonar infectado. Se inició antibiótico y la paciente mejoró de forma progresiva; después de esta mejora, fue dada de alta para continuar anticoagulación y seguimiento ambulatorios. Conclusiones El infarto pulmonar es una complicación frecuente en pacientes con TEP. Por lo tanto, debe sospecharse infarto pulmonar infectado en pacientes con deterioro clínico y respuesta inflamatoria sistémica. La diferencia radiológica entre infarto pulmonar y neumonía no es fácil de identificar, su enfoque diagnóstico es clínico y el tratamiento anticoagulante y antimicrobiano debe iniciarse de manera oportuna.

A Case Report: Cavitary Infarction Caused by Pulmonary Tumor Thrombotic Microangiopathy in a Patient with Pancreatic Intraductal Papillary Mucinous Neoplasm

Pulmonary tumor embolism is commonly discovered at autopsy, but is rarely suspected ante-mortem. Microangiopathy is an uncommon and distinct form of simple tumor pulmonary embolism. Here, we present a 52-year-old male with tumor thrombotic microangiopathy and pulmonary infarction, which might have originated from intraductal papillary mucinous tumor of the pancreas. Multiple wedge-shaped consolidations were found initially and aggravated with cavitation. These CT features of pulmonary infarction were pathologically confirmed to result from pulmonary tumor thrombotic microangiopathy.

A Case of Pulmonary Artery Sarcoma Presented as Cavitary Pulmonary Lesions / 결핵및호흡기질환

Pulmonary artery sarcoma (PAS) is a rare, poorly differentiated malignancy arising from the intimal layer of the pulmonary artery. Contrast-enhanced chest computed tomography (CT) is a good diagnostic modality that shows a low-attenuation filling defect of the pulmonary artery in PAS patients. An 18-year-old man was referred to our hospital for the evaluation and management of cavitary pulmonary lesions that did not respond to treatment. A contrast-enhanced CT of the chest was performed, which showed a filling defect within the right interlobar pulmonary artery. The patient underwent a curative right pneumonectomy after confirmation of PAS. Although lung parenchymal lesions of PAS are generally nonspecific, it can be presented as cavities indicate pulmonary infarcts. Clinicians must consider the possibility of PAS as well as pulmonary thromboembolism in patients with pulmonary infarcts. So, we report the case with PAS that was diagnosed during the evaluation of cavitary pulmonary lesions and reviewed the literatures.

A Case of Pulmonary Infarction Caused by Diffuse Alveolar Damage Confirmed by Open-Lung Biopsy / 대한내과학회지

We report a case of a 63-year-old man with adult respiratory distress syndrome and pulmonary infarction. The patient presented with fever, dyspnea, pleuritic chest pain, and acute respiratory failure, and we applied mechanical ventilation and steroid therapy. Pulmonary infarction and diffuse alveolar damage were confirmed by open-lung biopsy. Diffuse alveolar damage activated the blood coagulation system, resulting in thrombosis in the pulmonary vasculature. After anticoagulation therapy, the patient improved rapidly. We report a rare pulmonary infarction caused by diffuse alveolar damage confirmed by open-lung biopsy.

A Case of Pulmonary Infarction Caused by Diffuse Alveolar Damage Confirmed by Open-Lung Biopsy / 대한내과학회지

We report a case of a 63-year-old man with adult respiratory distress syndrome and pulmonary infarction. The patient presented with fever, dyspnea, pleuritic chest pain, and acute respiratory failure, and we applied mechanical ventilation and steroid therapy. Pulmonary infarction and diffuse alveolar damage were confirmed by open-lung biopsy. Diffuse alveolar damage activated the blood coagulation system, resulting in thrombosis in the pulmonary vasculature. After anticoagulation therapy, the patient improved rapidly. We report a rare pulmonary infarction caused by diffuse alveolar damage confirmed by open-lung biopsy.

A Case of Acute Pulmonary Thromboembolism after Taking Tadalafil / 결핵및호흡기질환

Tadalafil is a phosphodiesterase-5 inhibitor (PDE5I), which is widely used to treat erectile dysfunction. Although PDE5Is have excellent safety profiles, and most of the side effects are mild, rare serious adverse events have been reported in association with PDE5Is. Thrombosis is one of those events, and a few previous reports have suggested the association of PDE5Is with thrombosis. We report the case of a 61-year-old male who developed pulmonary embolism combined with pulmonary infarction directly after taking tadalafil. Both the patient and the physician suspected tadalafil as the culprit drug, as the patient was in an otherwise healthy condition. However, after extensive evaluation, we noticed that factor VIII levels were elevated. Prior reports suggesting the association between thrombosis and PDEIs either lack complete information on coagulation factors, or show inconsistencies in their results. Physicians should operate caution prior to accepting the diagnosis of adverse drug reaction.

Sequestro extralobar com hemotórax secundário a infarto pulmonar / Extralobar pulmonary sequestration with hemothorax secondary to pulmonary infarction

O sequestro pulmonar é uma malformação incomum, representando 0,5-6 por cento de todas as malformações pulmonares, sendo geralmente diagnosticado na infância. Dos dois tipos de sequestro pulmonar, intralobar e extralobar, este último é o menos freqüente. O presente relato descreve o caso de um paciente do sexo feminino, de 32 anos, com quadro de dor toracoabdominal e achados de radiografia e TC de tórax revelando consolidação e derrame pleural. A conduta inicial com toracocentese evidenciou hemotórax. A seqüência diagnóstica através da videotoracoscopia permitiu o diagnóstico de sequestro extralobar e a consequente conduta de conversão para toracotomia para ressecção da lesão com ligadura segura do pedículo vascular intercostal.

Pulmonary sequestration is an uncommon condition that accounts for 0.5-6 percent of all pulmonary malformations and is typically diagnosed in childhood. Of the two forms of pulmonary sequestration, intralobar and extralobar, the latter is less frequently encountered. The current report describes the case of a 32-year-old female patient with chest and abdominal pain. Imaging (chest X-rays and CT scans of the chest) revealed consolidation and pleural effusion. The initial thoracocentesis revealed hemothorax. Subsequent diagnostic video-assisted thoracoscopy revealed extralobar pulmonary sequestration. Consequently, the therapeutic decision was to make the conversion to thoracotomy in order to resect the lesion and safely ligate the intercostal vascular pedicle.

A Pulmonary Nodule due to Pulmonary Infarction Diagnosed by Video-Assisted Thoracoscopy

We report a pulmonary infarction in 68-year-old man who was referred for an asymptomatic pulmonary nodule in chest radiography. Computed tomography (CT), positron emission tomography (PET), and transthoracic needle aspiration suggested suspicion for malignancy. Video-assisted thoracoscopic surgery (VATS) was performed for histologic diagnosis. Our case is a pulmonary nodule due to pulmonary infarction diagnosed by VATS in Korea.

A Further Study of Diagnosis and Differential Diagnosis of Pulmonary Infarction / 实用放射学杂志

Objective To improve the ability in the diagnosis and differential diagnosis of pulmonary infarction.Methods 20 cases of pulmonary infarction,proved by clinical course and symptoms(such as:acute onset of chest distress,shortness of breath and dyspnea,drastic chest pain,hemoptysis and low fever,etc),all had frontal and lateral X-ray films taken more than once;among them 14 cases had chest CT scans;4 cases had SPECT studies,and 9 cases had echocardiograms.Results 3 cases had pulmonary infarction in the upper lobe;5 cases in the middle lobe;and 12 cases in the lower lobe.Among them,6 cases were of multi-lobar distribution.2 cases had radiological signs of hilar amputation;13 cases showed conicalshaped consolidation of lung segments or lobes;7 cases had mottling shadows;15 cases had pleural effusion;14 cases had localized pleural thickening;2 cases were with cor pulmonale of acute onset;elevation of hemidiaphram was shown in 15 cases,and disciform atelectasis was seen in 5.Conclusion Diagnosis of pulmonary infarction can be made in time and accurately,provided radiological signs are to be dealt with in the light of clinical features.

A Case of Pulmonary Infarction Probably Related with Henoch-Schönlein Purpura

We report a case of pulmonary infarction probably related with Henoch-Schönlein purpura, which presented with purpura on both lower extremities in a 27-year-old woman. The purpura had developed 4 days previously and it had no itching or tend'erness. She complained of mild fatigue, chest tightness, but no dyspnea or hemoptysis. On routine examination, chest radiography showed a poorly defined nodular opacity on the left lung field, and it was diagnosed by a follow up chest CT as a pulmonary infarction secondary to pulmonary vasculitis.

Massive Intraoperative Pulmonary Thromboembolism - A case report / 대한마취과학회지

Pulmonary thromboembolism is more common in medical than in surgical wards. However, it can occur in the postoperative period especially in those undergone orthopedic surgery of the hip or knee. We had an opportunity to give witness in a law court the relation between the pulmonary infarction and general anesthesia, which case had been occurred in a local clinic. A case of pulmonary thromboembolism with infarction m a 28 year-old male is presented which developed at the near of surgery and died 1 hour after surgery of the maxillary open reduction with a plate-wire fixation. Anesthesia was performed under the general nasotracheal with Halo-O2. No case has been yet reported. Diagnosis was made by autopsy.