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Confluence of Pulmonary Veins Simulating a Pulmonary Mass
DISCUSSION
The syndrome of mucoid impaction of the bronchi associated with asthma or chronic bronchitis was first described in ten patients by Shaw' in 1951. In a review of6ndings in 85 patients (including Shaw's ten cases), Urschel et all found that asthma and a productive cough were present in most, and fever, chest pain, expectoration of plugs, and hemoptysis were less commonly associated. In addition to asthma and bronchitis, bronchial atresia, adenoma, carcinoma, tuberculosis, and bronchocentric granulomatosis have been described as resulting in mucoid tmpaction.!" Hinson et al6 first described the association of asthma with a hypersensitivity reaction to Aspergillus fumigatus, now referred to as allergic bronchopulmonary aspergillosis (ABPA).6 Large areas of consolidation lasting one to six weeks were described, as well as transient lobar collapse. The hallmark of the lung abnormality was proximal bronchiectasis associated with mucous plugs that could be recurrent. The diagnosis of ABPA is further supported by skin test reactivity to Aspergillus antigens as well as evidence of eosinophilia, IgG precipitins to Aspergillus antigens, and increased IgE levels in serum." In the patient described, each of these tests used to support a diagnosis of ABPA was negative and computed tomography of the chest revealed normal bronchial size. Chest roentgenographic findings that suggest mucoid impaction include predominantly upper lobe segmental bronchial obstruction with involvement of second-order bronchi." Densities may be bilateral, elliptical, rounded or oval, with smooth margins, as noted in the present case. When branching bronchi are impacted they have a "cluster of grapes" or gloved finger appearance.v" When adjacent bronchi are involved, they produce a V- or V-shaped density with the apex pointing to the hilum. Air or mucous bronchograms may be present, and lobar as well as complete lung collapse have been described." The bilateral recurrence of well-circumscribed densities on chest roentgenograms in a patient with asthma is characteristic of ABPA with proximal bronchiectasis. While bronchography is the diagnostic study of choice to detect proximal bronchiectasis, it is not without risk, and computed tomography of the chest has been shown to be valuable in excluding bronchiectasis, as demonstrated in this case. 9 Response to bronchodilators without the need for steroids is consistent with the absence of a hypersensitivity reaction to Aspergillus. Recurrent mucoid impaction producing bilateral chest roentgenographic densities may occur in the absence of ABPA. The appropriate clinical presentation along with serologic studies and computed tomography permit the exclusion of ABPA, thus avoiding the need for prolonged therapy with oral corticosteroids. REFERENCES
bronchial obstruction. Diagn Radiol 1979; 133:9-16 6 Hinson K~ Moon AJ, Plummer NS. Broncho-pulmonary aspergillosis. Thorax 1952; 7:317-33 7 PepysJ, Riddell ~ Citron KM, Clayton YM, Short EI. Clinical and immunologic signmcance of aspergillus. Am Rev Respir Dis 1959; 80:167-80 8 Carlson ~ Martin JE, Keegan JM, Dailey JE. Roentgenographic features of mucoid impaction of the bronchi. AJR 1966; 96:94752 9 Pang jA, Hamilton-Wood C, Metreweli C. The value of computed tomography in the diagnosis and management of bronchiectasis. Clio Radiol 1989; 40:40-4
Confluence of Pulmonary Veins Simulating a Pulmonary Mass· Bertram Levin, M.D.
Conftuence of the pulmonary veins commonly appears on the frontal view of the chest and generally is easily recognized as such. On plain 81m tomography, computerized tomography, and pulmonary angiography, the anatomy of convergence of pulmonary veins prior to common entry into the left atrium is clearly displayed. In this report, attention is called to the occasional appearance of conftuence of the pulmonary veins on the lateral view of the chest as a clearly circumscribed round opacity mimicking a lung or mediastinal mass. (Cheat 1990; 98:1025-26)
T
he shadow cast by the convergence of pulmonary veins is frequently present on frontal views of the chest. On occasion, there may be concern whether this shadow is indeed the confluence, an enlarged left atrium, or a paraspinal mass. The correct assessment is generally not difficult; there is no support for a paraspinal mass or enlarged left atrium on lateral views. Oblique tomograms of the chest often show the confluence en face; it appears as a round opacity into which the pulmonary veins lead and is readily identified as a convergence of pulmonary veins and may be seen on either side. Computerized tomography clearly demonstrates convergence of the pulmonary veins when present, as do pulmonary angiograms. Proto and Speckman' have noted that a "pulmonary vein on end can simulate a coin lesion of the lung. '"The pulmonary vein on the roentgenogram shown to illustrate their point was not round as one would expect a "coin" lesion to be, and in fact, converging pulmonary veins could be seen reaching to the mass density. Though the picture was not ideal (most unusual for these authors), the point made is a valid one. Keats- likewise noted that confluence of pulmonary veins may, in the lateral projection, have a somewhat nodular configuration. "" In his illustrative photographs, the shadows are more stellate than round and appear more vascular than tumorous. However, pulmonary veins as they converge to enter the left atrium, may indeed appear as a clearly round mass opacity in the lateral view of the chest U
1 Shaw RR. Mucoid impaction of the bronchi. J Thorac Surg 1951; 22:149-63 2 Urschel HC, Paulson DL, Shaw RR. Mucoid impaction of the bronchi. Ann Thorac Surg 1966; 2:1-16 3 Fanta CH. Clinical aspects of mucus and mucous plugging in asthma. J Asthma 1985; 22:295-301 4 Katzenstein AL, Liebow AA, Friedman PJ. Bronchocentric granulomatosis, mucoid impaction and hypersensitivity reactions to fungi. Am Rev Respir Dis 1975; 111:497-537 5 Felson B. Mucoid impaction (inspissated secretions) in segmental
*From the Department of Diagnostic Radiology, Michael Reese Hospital and Medical Center" Chicago. Reprint requests: Dr. Levin" Department of Radiology" 2 Blum" Mtchael Reese MedicalCenter; 29th and Ellis,. Chicago60616 CHEST I 98 I 4 I OCTOBER, 1990
1025
FJ<:UIIE 3 . A 76-year-old man with lateral view showing confluence en face (arrows) as a round opacity, It was very faintly evident on the frontal view.
and might be mistaken for a pulmonary or mediastinal mass if one is not aware of this "watch-out-for." When the shadow of the confluence of the pulmonary veins is also seen on the frontal view, that finding supports the correct diagnosis when it appears in the lateral view as a round mass-like shadow. However, it is not unusual for the confluence shadow not to appear on the frontal view and yet appear on the lateral view. It is in these instances that one might mistake the round shadow as a lung or mediastinal mass that is somehow obscured in the frontal view. This report is submitted to call attention to the possibility of erring in the interpretation of the shadow of the pulmonary veins in the lateral view of the chest. Illustrative examples are presented (Fig 1 to 3) from the many the author has seen. REFERENCES FI<:UIIE IA (ul111er). A 67-year-old man with lateral view showing the confluence en face (arrows) ;L~ a round opaque shadow. The frontal view did not show the pulmonary vein confluence . B (lower). Sli~htly off-lateral view shows the pulmonary veins (arrlJws) heading toward the eoniluence which is not seen head-on.
Proto AY. Speckman JM . The left lateral view of the chest . Met! Radiogr Photogr 1979; 55:2 2 Keats TE. An atlas of normal roentgen variants that may simulate disease, 4th ed. Chicago: Year Book Medical Publishers, 1988
Cyclosporine and Chronic Sarcoidosis* Ernest L. Yc"k, M .B.B .Ch ., F.C .C .P.; Thaoisakdi Kooithaconu», M.D.; S. E Fbul Man, M.D., f:C .C .P.; Anthony S. Rebuck, M.D ., EC.C.P.; and Brian j. Sproule, M.D ., f:C .C.P.
Two patients with progressive sarcoidosis who had poor responses and side effects from corticosteroid therapy were treated with cyclosporine. Cyclosporine suppressed conventional markers of inflammation and there was clinical improvement in one patient, but the disease recurred when
FI<:UIIE 2. A 79-year-old woman with lateral view showim; eonlluence (arrows) a 4 em diameter round opacity, The frontal view did not show the confluence of veins.
1026
*Fmm the Division of Pulmonary (Drs . York, Man, and Sproule) and Nephrology Medicine (Dr. Kovithavongs), University of AIherta, Edmonton, Alberta, Canada, and the Division of Respiratory Medicine (Dr. Rebuck), Toronto Western Hospital, Toronto, Ontario, Canada. Reprint requests: Dr. York, 2E-I39 Walter Mocken::ie Centn', Ellmonton, Alberta, Canada T6G 2B7 Cyclosporine and Chronic sarcoidosis (York at al)
The syndrome of mucoid impaction of the bronchi associated with asthma or chronic bronchitis was first described in ten patients by Shaw' in 1951. In a review of6ndings in 85 patients (including Shaw's ten cases), Urschel et all found that asthma and a productive cough were present in most, and fever, chest pain, expectoration of plugs, and hemoptysis were less commonly associated. In addition to asthma and bronchitis, bronchial atresia, adenoma, carcinoma, tuberculosis, and bronchocentric granulomatosis have been described as resulting in mucoid tmpaction.!" Hinson et al6 first described the association of asthma with a hypersensitivity reaction to Aspergillus fumigatus, now referred to as allergic bronchopulmonary aspergillosis (ABPA).6 Large areas of consolidation lasting one to six weeks were described, as well as transient lobar collapse. The hallmark of the lung abnormality was proximal bronchiectasis associated with mucous plugs that could be recurrent. The diagnosis of ABPA is further supported by skin test reactivity to Aspergillus antigens as well as evidence of eosinophilia, IgG precipitins to Aspergillus antigens, and increased IgE levels in serum." In the patient described, each of these tests used to support a diagnosis of ABPA was negative and computed tomography of the chest revealed normal bronchial size. Chest roentgenographic findings that suggest mucoid impaction include predominantly upper lobe segmental bronchial obstruction with involvement of second-order bronchi." Densities may be bilateral, elliptical, rounded or oval, with smooth margins, as noted in the present case. When branching bronchi are impacted they have a "cluster of grapes" or gloved finger appearance.v" When adjacent bronchi are involved, they produce a V- or V-shaped density with the apex pointing to the hilum. Air or mucous bronchograms may be present, and lobar as well as complete lung collapse have been described." The bilateral recurrence of well-circumscribed densities on chest roentgenograms in a patient with asthma is characteristic of ABPA with proximal bronchiectasis. While bronchography is the diagnostic study of choice to detect proximal bronchiectasis, it is not without risk, and computed tomography of the chest has been shown to be valuable in excluding bronchiectasis, as demonstrated in this case. 9 Response to bronchodilators without the need for steroids is consistent with the absence of a hypersensitivity reaction to Aspergillus. Recurrent mucoid impaction producing bilateral chest roentgenographic densities may occur in the absence of ABPA. The appropriate clinical presentation along with serologic studies and computed tomography permit the exclusion of ABPA, thus avoiding the need for prolonged therapy with oral corticosteroids. REFERENCES
bronchial obstruction. Diagn Radiol 1979; 133:9-16 6 Hinson K~ Moon AJ, Plummer NS. Broncho-pulmonary aspergillosis. Thorax 1952; 7:317-33 7 PepysJ, Riddell ~ Citron KM, Clayton YM, Short EI. Clinical and immunologic signmcance of aspergillus. Am Rev Respir Dis 1959; 80:167-80 8 Carlson ~ Martin JE, Keegan JM, Dailey JE. Roentgenographic features of mucoid impaction of the bronchi. AJR 1966; 96:94752 9 Pang jA, Hamilton-Wood C, Metreweli C. The value of computed tomography in the diagnosis and management of bronchiectasis. Clio Radiol 1989; 40:40-4
Confluence of Pulmonary Veins Simulating a Pulmonary Mass· Bertram Levin, M.D.
Conftuence of the pulmonary veins commonly appears on the frontal view of the chest and generally is easily recognized as such. On plain 81m tomography, computerized tomography, and pulmonary angiography, the anatomy of convergence of pulmonary veins prior to common entry into the left atrium is clearly displayed. In this report, attention is called to the occasional appearance of conftuence of the pulmonary veins on the lateral view of the chest as a clearly circumscribed round opacity mimicking a lung or mediastinal mass. (Cheat 1990; 98:1025-26)
T
he shadow cast by the convergence of pulmonary veins is frequently present on frontal views of the chest. On occasion, there may be concern whether this shadow is indeed the confluence, an enlarged left atrium, or a paraspinal mass. The correct assessment is generally not difficult; there is no support for a paraspinal mass or enlarged left atrium on lateral views. Oblique tomograms of the chest often show the confluence en face; it appears as a round opacity into which the pulmonary veins lead and is readily identified as a convergence of pulmonary veins and may be seen on either side. Computerized tomography clearly demonstrates convergence of the pulmonary veins when present, as do pulmonary angiograms. Proto and Speckman' have noted that a "pulmonary vein on end can simulate a coin lesion of the lung. '"The pulmonary vein on the roentgenogram shown to illustrate their point was not round as one would expect a "coin" lesion to be, and in fact, converging pulmonary veins could be seen reaching to the mass density. Though the picture was not ideal (most unusual for these authors), the point made is a valid one. Keats- likewise noted that confluence of pulmonary veins may, in the lateral projection, have a somewhat nodular configuration. "" In his illustrative photographs, the shadows are more stellate than round and appear more vascular than tumorous. However, pulmonary veins as they converge to enter the left atrium, may indeed appear as a clearly round mass opacity in the lateral view of the chest U
1 Shaw RR. Mucoid impaction of the bronchi. J Thorac Surg 1951; 22:149-63 2 Urschel HC, Paulson DL, Shaw RR. Mucoid impaction of the bronchi. Ann Thorac Surg 1966; 2:1-16 3 Fanta CH. Clinical aspects of mucus and mucous plugging in asthma. J Asthma 1985; 22:295-301 4 Katzenstein AL, Liebow AA, Friedman PJ. Bronchocentric granulomatosis, mucoid impaction and hypersensitivity reactions to fungi. Am Rev Respir Dis 1975; 111:497-537 5 Felson B. Mucoid impaction (inspissated secretions) in segmental
*From the Department of Diagnostic Radiology, Michael Reese Hospital and Medical Center" Chicago. Reprint requests: Dr. Levin" Department of Radiology" 2 Blum" Mtchael Reese MedicalCenter; 29th and Ellis,. Chicago60616 CHEST I 98 I 4 I OCTOBER, 1990
1025
FJ<:UIIE 3 . A 76-year-old man with lateral view showing confluence en face (arrows) as a round opacity, It was very faintly evident on the frontal view.
and might be mistaken for a pulmonary or mediastinal mass if one is not aware of this "watch-out-for." When the shadow of the confluence of the pulmonary veins is also seen on the frontal view, that finding supports the correct diagnosis when it appears in the lateral view as a round mass-like shadow. However, it is not unusual for the confluence shadow not to appear on the frontal view and yet appear on the lateral view. It is in these instances that one might mistake the round shadow as a lung or mediastinal mass that is somehow obscured in the frontal view. This report is submitted to call attention to the possibility of erring in the interpretation of the shadow of the pulmonary veins in the lateral view of the chest. Illustrative examples are presented (Fig 1 to 3) from the many the author has seen. REFERENCES FI<:UIIE IA (ul111er). A 67-year-old man with lateral view showing the confluence en face (arrows) ;L~ a round opaque shadow. The frontal view did not show the pulmonary vein confluence . B (lower). Sli~htly off-lateral view shows the pulmonary veins (arrlJws) heading toward the eoniluence which is not seen head-on.
Proto AY. Speckman JM . The left lateral view of the chest . Met! Radiogr Photogr 1979; 55:2 2 Keats TE. An atlas of normal roentgen variants that may simulate disease, 4th ed. Chicago: Year Book Medical Publishers, 1988
Cyclosporine and Chronic Sarcoidosis* Ernest L. Yc"k, M .B.B .Ch ., F.C .C .P.; Thaoisakdi Kooithaconu», M.D.; S. E Fbul Man, M.D., f:C .C .P.; Anthony S. Rebuck, M.D ., EC.C.P.; and Brian j. Sproule, M.D ., f:C .C.P.
Two patients with progressive sarcoidosis who had poor responses and side effects from corticosteroid therapy were treated with cyclosporine. Cyclosporine suppressed conventional markers of inflammation and there was clinical improvement in one patient, but the disease recurred when
FI<:UIIE 2. A 79-year-old woman with lateral view showim; eonlluence (arrows) a 4 em diameter round opacity, The frontal view did not show the confluence of veins.
1026
*Fmm the Division of Pulmonary (Drs . York, Man, and Sproule) and Nephrology Medicine (Dr. Kovithavongs), University of AIherta, Edmonton, Alberta, Canada, and the Division of Respiratory Medicine (Dr. Rebuck), Toronto Western Hospital, Toronto, Ontario, Canada. Reprint requests: Dr. York, 2E-I39 Walter Mocken::ie Centn', Ellmonton, Alberta, Canada T6G 2B7 Cyclosporine and Chronic sarcoidosis (York at al)