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Case 219

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A 35 year-old male presented with coughing, night sweats, dyspnea and heart palpitations in the past 10 months. During the last three months he also complained of weight loss of about 10kg, hemoptysis, worsening dyspnea and desaturation as well as retrosternal pain during breathing. The chest X-Ray was unremarkable and a computed tomography angiography was inconclusive. A ventilation/perfusion scintigraphy with 99mTc-Phytate/MAA was obtained.

Based on the image and on the clinical picture, which of the following is the most likely diagnosis?

a) Lung Tuberculosis

25%

b) Bacterial Pneumonia

25%

c) Pulmonary embolism

25%

d) Lung cancer

25%
   

Image analysis

 

Image 1: Ventilation/perfusion scintigraphy with 99mTc-Phytate/MAA showing high probability of pulmonary embolism (PE). At the ventilation study one can observe a homogenous distribution of the material in both lungs. However, in the perfusion study, there is an uneven distribution of the material (arrows), markedly low in the posterior and anterior segments of the upper right lobe, anterior segment of the inferior left lobe, inferior right lobe and left lung basis.

Highlights

- The PE classic triad: dyspnea, chest pain and hemoptysis;

- The ventilation/perfusion scintigraphy with 99mTc-Phytate/MAA presents:

  •         - bigger accuracy than CT angiography for peripheral arterial findings;

  •         - lower radiation doses than CT angiography and do not uses iodine-based contrast;

  •         - lower availability since it depends on the radioisotopes half-life;

  •         - may be done during pregnancy due to the low doses of radiation.

References

- Morton K A, Clark P B. Diagnostic imaging nuclear medicine. Amrsys Inc, 2007.

- The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of The EuropeanSociety of Cardiology. 2014 ESC Guidelines on the diagnosis and management of acute pulmonaryembolism. European Heart Journal (2014) 35, 3033-3080 doi:10.1093/eurrheartj/ehu283.

- Simal C. Medicina Nuclear. Folium 2012.

- Volpe G J, Joaquim L F, Dias L B A, Menezes M B, Moriguti J C. Tromboembolismo pulmonar. Medicina (Ribeirão Preto) 2010;43(3): 258-71

Authors

Cairo Adriane Mendes Junior, fifth year medical student at the Federal University of Minas Gerais.

E-mail: cairoamjr[at]gmail.com

 

Julio Boriollo Guerra, fifth year medical student at the Federal University of Minas Gerais.

E-mail: juliobguerra[at]gmail.com

 

Gabriel Rodrigues de Carvalho, fifth year medical student at the Federal University of Minas Gerais.

E-mail: grc3008[at]yahoo.com.br

 

Gabriela Neves Vaz, fifth year medical student at the Federal University of Minas Gerais.

E-mail: gabi.neves[at]live.com

 

Gabriela Maria Mendonça Chaves, fifth year medical student at the Federal University of Minas Gerais.

E-mail: gabriela.mmc[at]hotmail.com

 

Guilherme da Silva Oliveira Stefano, fifth year medical student at the Federal University of Minas Gerais.

E-mail: guiso.med[at]gmail.com

Supervisor

Viviane Santuari Parisotto Marino, Adjunct Professor of Nuclear Medicine at the Federal University of Minas Gerais.

E-mail: viviane[at]medicina.ufmg.br

Translated by

Bárbara de Queiroz e Bragaglia, sixth year medical student at UFMG.

E-mail: barbara.bragaglia[at]gmail.com

Revisors

Fellype Borges, Daniela Braga, André Guimarães and Bárbara Queiroz.

Commentics

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