Pulmonary infarct caused by dislodged phlebolith

Case contributed by Dr Matt Skalski

Presentation

IV drug abuser with shortness of breath.

Patient Data

Age: 25
Gender: Male
Modality: X-ray

The heart is moderately enlarged.

In the right middle lobe there is an opacified region near the midline, anteriorly. No calcification or air bronchograms are observed. 

Modality: Annotated image

The opacified area is outlined by the blue dotted line. 

There is a peripherally calcified structure within one of the segmental pulmonary arteries to the anterior right middle lobe with a distal wedge shaped area of reticularly opacified lung tissue. No evidence of significant airspace collapse. 

Modality: Annotated image

The phlebolith is indicated by the blue arrow. 

Case Discussion

The findings in this case are typical for a right middle lobe infarct; however, in this case it is secondary to an endovascular calcified structure within the adjacent vessel.  This may represent a congolomerate of cutting material such as talc, but given that it is more calcified periperhally, with a central medullary cavity, it is favored to represent a phlebolith. Presumably, given the patient's history of IV drug abuse, he may have dislodged a stable phlebolith into the venous system where it was able to travel back to and through the heart to embolize the lung. Quite bizarre.

This case is courtesy of Dr. Aaron Schein of USC, who generously shared it with me.

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Case Information

rID: 34314
Case created: 14th Feb 2015
Last edited: 18th Sep 2015
System: Chest
Inclusion in quiz mode: Included

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