Drs. Milam and Thomas's CMC X-Ray Mastery Project: October Cases

Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
October 2019

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

33 Year Old
Previously
Healthy Male
With A History Of
Nicotine/THC
Vaping Presents
With Severe
Dyspnea &
Hypoxia
Bilateral Airspace
Disease On CXR
Diagnosis?

E-Cigarette Associated Pneumonitis
33 Year Old
Previously
Healthy Male
With A History Of
Nicotine/THC
Vaping Presents
With Severe
Dyspnea &
Hypoxia

33 Year Old With A History Of Vaping Presents With Severe Dyspnea
E-Cigarette Associated Pneumonitis

E-Cigarette
Associated
Pneumonitis
3 Days Later
Symptoms
Improved

Published On September 6, 2019, at NEJM.org

E-Cigarette Associated Lung Injury
• Between 2017 and 2018, the prevalence of e-cigarette use increased
from 11.7% to 20.8% amongst U.S. high school students.
• Pulmonary illnesses related to e-cigarettes have been reported, but
no larger series have been described previously.
• In July 2019, the Wisconsin Department of Health Serves received
reports of pulmonary disease associated with vaping.
• The authors describe the demographic and outcome characteristics of
53 patients; representing the largest published case series to date.

Demographic Characteristics (n=53)
Median age 19 (16-53)
Male sex 83%
White race 82%
Reported nicotine use 61%
Reported THC use 80%
Reported nicotine & THC use 44%

Symptoms Reported On Presentation
Median duration of symptoms 6 days (0-61)
Any Respiratory Symptoms
Shortness of breath
Chest pain
Cough
Hemoptysis
98%
87%
55%
83%
11%
Subjective fever 81%
Chills 58%
Nausea 70%
Vomiting 66%

Vital Signs At Presentation
Temperature >38° C 29%
Heart rate >100 beats/min 64%
Respiratory rate >20 breaths/min 82%
Oxygen saturation:
≥95%
89-94%
≤88%
31%
38%
31%

Initial Laboratory Results
WBC >11000/mm3 87%
WBC >80% neutrophils 94%
ESR >30 mm/hr 93%
Initial Radiographic Finding
Abnormal chest X-ray 91%
Abnormal chest CT 100%
Bilateral infiltrates on CT 100%

Treatment
Antibiotics during hospitalization 90%
Steroids during hospitalization 92%
IV steroids during hospitalization 83%
Clinical Course
Hospitalization 94%
Non-invasive ventilation 36%
Endotracheal intubation 32%
Death 1/53 (2%)

Published On September 6, 2019, at NEJM.org
Identical To Our Patient!

The Vapors Are Viscous!
E-cigarette liquids have been shown to contain a variety of chemicals
that may have adverse health effects:
• Propylene glycol
• Glycerin
• Polycyclic aromatic hydrocarbons
• Volatile organic and inorganic chemicals
• Toxic metals
• Flavoring compounds that may cause adverse effects

Monitoring The Future Survey™
National survey of 8th, 10th and 12th graders assessing vaping trends:
2017
2018
2019
43,703
44,482
43,531
Prevalence of use more than doubled between 2017 and 2019!

n integrated view of the
ydiseaseoutbreak since
ted online information
ncluding news aggrega-
and validated official
assified the data by dis-
me.3
Figure1 shows the
ed and suspected cases
ease from vaping over
States. The first 8 sus-
ed byour onlinemining
g) on July 25, 2019, in
8, a total of 119 con-
eshad been detected in
more than doubled by
ing a total of 288 cases
ptember 11, cases had
nning 39 states and the
compoundsof e-cigaretteliquids, adulteration of
devices with tetrahydrocannabinol (THC)–based
oilsor vitamin E, and useof black market vaping
products.1,4
Findingsfrom thisreport suggest that
vaping-associated pulmonary disease cases have
reached epidemic proportions. Incident cases con-
tinueto rise. Further surveillanceis necessary to
monitor the development and spread of this vap-
ing-related outbreak.
Yulin Hswen, M.P.H., Sc.D.
John S. Brownstein, Ph.D.
Innovation Program, Boston Children’sHospital
Boston, MA
yuh958@mail.harvard.edu
Disclosure forms provided by the authors are available with
thefull text of thisletter at NEJM.org.
This letter was published on September 20, 2019, at NEJM.org.

Sm oking & Tobacco Use
Outbreak of Lung Injury Associated with E- Cigarette
Use, or Vaping
Posted Septem ber 19, 2019 at 12:00pm ETPosted Septem ber 19, 2019 at 12:00pm ET
Electronic cigarettes – or e-cigarettes — are also called vapes, e-hookahs, vape pens, and electronic nicotine deliver
systems (ENDS).
CDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and otherCDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and other
clinical and public health partners are investigating a m ultistate outbreak of lung injury associated withclinical and public health partners are investigating a m ultistate outbreak of lung injury associated with
e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use.e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use.
Key Facts about E-Cigarette Use, or Vaping
Sm oking & Tobacco Use
Outbreak of Lung Injury Associated with E- Cigarette
Use, or Vaping
Posted Septem ber 19, 2019 at 12:00pm ETPosted Septem ber 19, 2019 at 12:00pm ET
CDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and otherCDC, the U.S. Food and Drug Adm inistration (FDA), state and local health departm ents, and other
clinical and public health partners are investigating a m ultistate outbreak of lung injury associated withclinical and public health partners are investigating a m ultistate outbreak of lung injury associated with
e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use.e-cigarette product (devices, liquids, re fill pods, and/or cartridges) use.
Key Facts about E-Cigarette Use, or Vaping

There are 530* cases of lung injury reported from 38 states and 1 U.S. territory. Seven deaths have been confirmed
in 6 states.
CDC has received complete sex and age data on 373 of 530 cases.
Nearly three fourths (72%) of cases are male
Two thirds (67%) of cases are 18 to 34 years old
16% of cases are under 18 years and 17% are 35 years or older
All reported cases have a history of e-cigarette product use or vaping.
Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette
products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-
cigarette products containing only nicotine.
What we know
We do not yet know the specific cause of these lung injuries. The investigation has not identified any specific e-
cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.
What we don’t know
What CDC recommends
There are 530* cases of lung injury reported from 38 states and 1 U.S. territory. Seven deaths have been confirmed
in 6 states.
CDC has received complete sex and age data on 373 of 530 cases.
Nearly three fourths (72%) of cases are male
Two thirds (67%) of cases are 18 to 34 years old
16% of cases are under 18 years and 17% are 35 years or older
All reported cases have a history of e-cigarette product use or vaping.
Based on initial data from certain states we know: Most patients have reported a history of using e-cigarette
products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-
cigarette products containing only nicotine.
What we know
We do not yet know the specific cause of these lung injuries. The investigation has not identified any specific e-
cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.
What we don’t know
What CDC recommends

49 Year Old From
Mexico Presents
With One Month
Of A Persistent
Cough

49 Year Old From
Mexico Presents
With One Month
Of A Persistent
Cough
Circular Lesions Of The Left Upper Lobe

49 Year Old From
Mexico Presents
With One Month
Of A Persistent
Cough Apical
Cavitary
Lesions
What Is This?

49 Year Old From
Mexico Presents
With One Month
Of A Persistent
Cough
Tuberculosis
Apical
Cavitary
Lesions

Tuberculosis Epidemiology In The U.S. 2017
• In 2017, the incidence of TB in the U.S. (2.8 cases per 100,000) was
the lowest since national surveillance began in 1952.
• The rate of TB among non-U.S.-born persons was 15 times the rate
among U.S.-born persons.
• The top five countries of birth of non-U.S.-born persons with TB were
Mexico (19%), Philippines (12.3%), India (9.4%), Vietnam (8.3%), and
China (6.3%).
• Persons who received a diagnosis of TB ≥10 years after arriving in the
U.S. accounted for 45% of all TB cases among non-U.S. born persons.

Tuberculosis Epidemiology In The U.S. 2017
• For those born in the United States, TB incidence was the highest
among Native Hawaiian/Pacific Islanders (5.6 cases per 100 000
persons), followed closely by American Indian/Alaskan Natives (4.0
cases per 100 000 persons).
• Individuals experiencing homelessness accounted for 4.1% of TB
cases, while 3.3% occurred among individuals who were incarcerated,
and 1.6% occurred among residents of long-term care facilities.

Background
• Patients with TB risk factors are often cared for at busy urban
hospitals with long wait times and crowded waiting rooms
• The ED is a high-risk are for M. tuberculosis transmission
• Most EDs do not have CDC-compliant TB isolation facilities
• Admitted pneumonia patients with and without TB may have long ED
wait times
• It is desirable to accurately differentiate pneumonia patients at very
low risk for TB from those for whom TB needs to be considered

Design
• Prospective case series conducted at 11 (EMERGEncy ID NET) academic
urban EDs with a combined volume of 900,000
• Participants were ED patients admitted with a diagnosis of pneumonia
or suspected TB
• The main outcome measure was derivation and validation of a sensitive
clinical decision instrument to identify patients not having TB (and not
requiring isolation) according to clinical data an chest radiographs.

Results
• Of 5,079 patients, 224 (4.4%) had pulmonary TB according to sputum
cultures or tissue staining.
• Instrument derived to predict which patient do not have TB:
No TB Or [+] PPD History Nonimmigrant Not Homeless
Not Recently Incarcerated No Recent Weight Loss No Cavitary Or Apical
Infiltrate On Chest X-Ray
NPV: 99.7[95% CI 99.1-99.9] Sensitivity: 96.4 [95% CI 91.9-99.9]

Conclusions
• The absence of all decision instrument criteria was highly predictive of
the absence of TB
• The decision instrument is not difficult to apply and it does not expend
additional resources in the ED
• Identifying low-risk patient may help preserve precious isolation beds
for higher risk patients

What About The CXR?
*Notice the high RR of TB associated with cavitation and apical infiltrate on CXR!
*
*

Punch Line?
• ALWAYS think about TB in your pneumonia patient who:
• Has a prior history of TB and/or a prior [+] PPD
• Is foreign born (see MMWR slides), homeless, and/or recently incarcerated
• Provides a history of non-volitional weight loss
• ALWAYS think about TB in your pneumonia patients with apical
and/or cavitary infiltrates on chest X-ray
When all of these historical and CXR finding are absent you can use a
validated clinical decision instrument to confidently conclude that
your pneumonia patient is not at significant risk for TB, and therefore
will not require respiratory isolation precautions.

IV Drug User With Cough, Fever, Chills

IV Drug User With Cough, Fever, Chills
RLL Abscess

Air-Fluid Level: If It’s Flat There’s Air In There!

43 Year Old With
3 Weeks Of
Progressive Right
Arm & Neck
Swelling

43 Year Old With
3 Weeks Of
Progressive Right
Arm & Neck
Swelling
What Is
This?

43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling
Lung
Mass
Compressed
Superior
Vena Cava

43 Year Old With 3 Weeks Of Progressive Right Arm & Neck Swelling
Lung
Mass
Compressed
Superior
Vena Cava
Superior Vena Cava Syndrome

Anatomy And Physiology:
• Obstruction by the superior vena cava caused by either extrinsic
compression, i.e.: masses in the middle and anterior mediastinum
(tumor, infectious process, adenopathy, aortic aneurysm…), or
intrinsic obstruction, i.e.: thrombosis.
• Collateral flow to the inferior vena cave or azygous vein is established.
• Edema of the head, neck and upper extremities results.
• The severity of symptoms depends on the degree of obstruction and
the speed of onset.

Etiologic Factors:
Overall
Thrombosis And Non-Malignant Causes
Increased use of catheters and pacemakers
35%
Malignant Causes
Non-small cell lung cancer
Small-cell lung cancer
Lymphoma
Metastatic
Cancer
50%
25%
10%
10%
65%

Anatomic Swelling:
Edema Manifestations
Scalp/Face/Arms Physically striking but usually of little
consequence
Eyes Visual symptoms
Brain Headaches, confusion, encephalopathy
Larynx Stridor, hoarseness, airway obstruction

65 Year Old
Presents With 3
Months Of
Dysphagia

65 Year Old
Presents With 3
Months Of
Dysphagia
What Is This?

65 Year Old Presents With 3 Months Dysphagia

65 Year Old Presents With 3 Months Dysphagia
Large Goiter Compressing The Trachea

Summary Of Diagnoses This Month
 E-cigarette associated lung injury
 Pulmonary tuberculosis
 Lung abscess
 Left spontaneous pneumothorax
 Right lung mass and Superior Vena Cava Syndrome
 Goiter

Drs. Milam and Thomas's CMC X-Ray Mastery Project: October Cases

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