Presentation
History of COPD and lung decortication for pleural empyema. Presents with severe dyspnea requiring intubation. CT to rule out pulmonary embolism.
Patient Data
Ill-defined linear areas of filling defects within the middle and lingular pulmonary arteries with extensive traction bronchiectasis with lobar consolidation in the same territory. These pseudo-filling defects are flow artifacts and may be misdiagnosed as true emboli.
During the venous phase, there is a fill-in of the previous filling defects, confirming their artifactual nature.
Bronchial artery enlargement with a left-right bronchial trunk arising from the medial aspect of the aortic arch, and a left bronchial artery arising from the anterior aspect of the descending aorta.
Pulmonary trunk dilatation, measuring up to 42 mm, in keeping with pulmonary hypertension.
Moderate volume left pleural effusion with associated lower lobes consolidations and lung atelectasis, suggestive of infectious pneumonia.
Centrilobular nodules (tree in bud pattern), with diffuse bronchial wall thickening and mosaic attenutation, suggestive of bronchiolitis in the left lower lobe.
Heterogenous enhancement of the lung parenchyma within the pulmonary consolidations with hypovascular areas. There is no pulmonary abscess.
Diffuse pulmonary emphysema. Endotracheal tube in situ.
Compared to the previous CT:
the pseudo-filling defects in the middle lobe and lingula are better seen in this CT. They are ill-defined with a "smoke" appearance
there are no consolidations and lung collapse in the left lower lobe. There is less bronchiolitis and no pleural effusion which make the most likely diagnosis infectious pneumonia
Case Discussion
Features of a bronchial artery collateral inflow due to bronchial pulmonary shunting in a setting of regional pulmonary hypertension. This artifact disappeared on the venous phase, but to directly visualize the reverse flow, an aortic angiogram can be performed1.
The regions involving this artifact demonstrate extensive traction bronchiectasis and sequelae from pleural empyema and lung decortication.
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