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Weekly Chest CasesArchive of Old Cases

Case No : 1235 Date 2021-06-21

  • Courtesy of Jooae Choe, Hye Jeon Hwang, Kyung-Hyun Do / Asan medical center
  • Age/Sex 38 / F
  • Chief ComplaintAbnormal findings detected on chest CT scan for staging work up for rectal cancer History: depression, suicidal attempt (14 years ago)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Diagnosis With Brief Discussion

Diagnosis
Paraquat intoxication
Radiologic Findings
Fig. 1. Chest posteroanterior radiograph showing parenchymal distortion with bronchiectasis and linear opacities in both upper lung zones and band-like linear opacities along the subpleural (peripheral) areas of the upper to lower zones of both lungs.
Figs. 2–4. Computed tomography (CT) scans showing traction bronchiectasis with parenchymal distortion involving the central portion of both upper lung zones and linear continuous subpleural band-like opacities involving the upper to lower zones of both lungs.
Figs. 5 and 6. CT scans taken 14 years prior when the patient attempted suicide by ingesting paraquat. Diffuse ground-glass opacities involving both lungs with subpleural consolidation in the right lower lobe are seen, suggesting pulmonary injury from acute paraquat poisoning.
Brief Review
Paraquat (PQ; N,N'-dimethyl-4,4'-bipyridinium dichloride) is a highly toxic organic material that was previously used as an herbicide. Paraquat has toxic effects on the lungs, liver, and kidneys. Death from paraquat poisoning is primarily caused by progressive pulmonary damage and respiratory failure. In the past, paraquat intoxication was a serious public health problem, with an estimated annual incidence of 2000 toxic ingestions associated with a mortality rate of 60%–70% in some Asian countries. Paraquat is a widely used suicide agent in developing countries because of its widespread availability, low toxic dose, and relatively low cost. It is currently banned in many countries, including South Korea. The prognosis is generally associated with the degree of exposure. The toxic effects of paraquat result from oxygen radicals that destroy the cell membrane. Organ-specific damage to the lungs is caused by both lower concentrations of antioxidants and higher concentrations of oxygen within the lungs. Early pathologic findings in the lung include edema-related thickening of the alveolar walls, hemorrhage, and inflammatory cell infiltration. Some of the alveoli become filled with fluid and large amounts of fibrin. Late pathologic findings include pulmonary fibrosis and microcysts. The most common pattern on computed tomography (CT) in acute paraquat poisoning is ground-glass attenuation, mostly bilateral and diffuse in distribution. Consolidation and irregular lines can also be observed on CT. On follow-up scans, the ground-glass attenuation changes to consolidation with bronchiectasis. Additional irregular lines and traction bronchiectasis can also be observed. In this case, the patient survived and showed the fibrotic sequelae of paraquat-induced lung injury.
Please refer to
Case 784, Case 594, Case 356, Case 196,
References
1. Lee SH, Lee KS, Ahn JM, et al. Paraquat poisoning of the lung: thin-section CT findings. Radiology. 1995 Apr;195(1):271-4. doi: 10.1148/radiology.195.1.7892484. PMID: 7892484.
2. Im JG, Lee KS, Han MC, et al. Paraquat poisoning: findings on chest radiography and CT in 42 patients. AJR Am J Roentgenol. 1991 Oct;157(4):697-701. doi: 10.2214/ajr.157.4.1892020. PMID: 1892020.
3. Zhang H, Liu P, Qiao P, et al. CT imaging as a prognostic indicator for patients with pulmonary injury from acute paraquat poisoning. Br J Radiol. 2013;86(1026):20130035.
Keywords

No. of Applicants : 92

▶ Correct Answer : 60/92,  65.2%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Korea University Guro Hospital , Korea (South) LEE SEOKYOUNG
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - Other , Korea (South) HYEJIN YANG
  • - , Korea (South) HYEYOUNG CHOI
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
  • - Inje University Haeundae Paik Hospital , Korea (South) HYUNGIN PARK
  • - , Italy PAOLO BALDASSARI
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
  • - Chungbuk National University Hospital , Korea (South) JIYUN KANG
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - Chungbuk National University Hospital , Korea (South) YOUNGHUN JEON
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - Gifu University Hospital , Japan Yo Kaneko
  • - VDC, HYDERABAD , India KARTHIK RAYASAM
  • - , Japan KANAE TAKAHASHI
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Other , Korea (South) MINSU KIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Seoul National University Hospital , Korea (South) SE WOO KIM
  • - CHU Lille , France PAUL LEBERT
  • - , Japan HIROAKI ARAKAWA
  • - Chungbuk National University Hospital , Korea (South) PARK JUN HYEON
  • - Columbia asia refferal hospital,Bengaluru , India PRAVIN KUMAR M
  • - Osmania Medical College, Hyderabad , India PURUSHOTHAMA RAO TUMMALA
  • - TB centre kasaragod. , India rikhy krishnan
  • - Asan Medical Center , Korea (South) BYUNGSOO IM
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Other , Korea (South) KYU-CHONG LEE
  • - Gifu University Hospital , Japan KEITA FUJIMOTO
  • - Nishida Hospital , Japan SHOJI OKUDA
  • - Apollo Hospitals , India SHRUTHI P
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - , India SUSHMITHA JAKKA
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - , Japan KAZUMA TERAUCHI
  • - Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
  • - National Center for Global Health and Medicine , Japan TOMOKI IMOKAWA
  • - Private sector , Greece VASILIOS TZILAS
  • - Columbia asia radiology group , India VIKHYATH SHETTY Y
  • - , Japan YUKI HAYASHI
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 1/92,  1.1%
  • - , Korea (South) EUNJIN LEE
▶ Semi-Correct Answer : 11/92,  12.0%
  • - , Japan HIROAKI ARAKAWA
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Seoul National University Bundang Hospital , Korea (South) SOWON JANG
  • - Asan Medical Center , Korea (South) EUNJI CHOI
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Osaka University , Japan AKINORI HATA
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - McGill , Canada MUTAZ ADNAN KHAIRO
  • - Samsung Medical Center , Korea (South) KYOWON GU
  • - Kyoto University Hospital , Japan SATOSHI IKEDA
  • - Kyoto university , Japan AKIHIKO SAKATA
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Current Editor : Eui Jin Hwang, M.D., Ph.D Email : weeklychestcases@gmail.com

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