PMC3928753_01
PMC3928753_02
(a) Chest X-ray (PA view) showed bilateral infiltrates with collapse consolidation of right lower lobe. (b) Computed tomography chest shows centrilobular nodules with tree-in-bud appearance in right lower lobes and anterior segment of right upper lobe (shown with arrows). Right hilar lymphadenopathy was present. Collapse with consolidation of right lower lobe with active bronchiolitis of right lower and anterior segment of right upper lobe was noted
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F1
Chest X-ray showed bilateral infiltrates with collapse consolidation of right lower lobe [Figure 1a]. Computed tomography of chest [Figure 1b] showed centrilobular nodules with the tree-in-bud appearance in the right lower lobes and anterior segment of right upper lobe (shown with arrows).
99 mTc sulfur colloid gastro esophageal reflux (GER) scintigraphy ([a] dynamic and [b] high resolution static images) showed grade III GER with an abnormal tracer accumulation at the carinal level, which corresponds to the site of esophageal out pouching in barium swallow imaging performed the day after GER scan (shown with an arrow). ("OC" denotes oral cavity and "S" for stomach)
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F2
Barium swallow showed smooth transit of barium through the esophagus confirming absence of any esophageal atresia. There was evidence of small contrast filled out pouching at the level of carina (marked as esophageal out pouching). There was no stricture or hold up of contrast in esophagus. On distending the stomach (marked as S), reflux of contrast was noted into esophagus (up to the level of suprasternal notch) confirming grade III gastro esophageal reflux
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F3
Barium swallow [Figure 3] was subsequently performed, which showed smooth transit of barium through the esophagus thus confirming the absence of any esophageal atresia.
PMC3928753_03
Tc methylene diphosphonate whole body scintigraphy showed no vertebral hot spots or limb anomalies. Incidentally crossed fused ectopic kidneys were identified with suspicious hydroureter and distal obstruction (shown by arrows). Bone abnormalities reported in VACTERL cases on literature survey are polydactyl, multiple costovertebral defects and limb anomalies such as tibial aplasia/hypoplasia, clubfoot, hallucal deficiency
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F4
99mTc MDP, methylene diphosphonate whole body scintigraphy [Figure 4] was requested as patient also had complaints of intermittent pain in left side of chest.