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5: Diagnostic Imaging

David T. Schwartz

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    AMA Citation
    Schwartz DT. Schwartz D.T. Schwartz, David T.Diagnostic Imaging. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. Hoffman R.S., Howland M, Lewin N.A., Nelson L.S., Goldfrank L.R. Eds. Robert S. Hoffman, et al.eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1163&sectionid=65089434. Accessed October 15, 2018.
    MLA Citation
    Schwartz DT. Schwartz D.T. Schwartz, David T.. "Diagnostic Imaging." Goldfrank's Toxicologic Emergencies, 10e Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. Hoffman R.S., Howland M, Lewin N.A., Nelson L.S., Goldfrank L.R. Eds. Robert S. Hoffman, et al. New York, NY: McGraw-Hill, 2015, http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1163&sectionid=65089434.

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INTRODUCTION

Diagnostic imaging can play a significant role in the management of many patients with toxicologic emergencies. Radiography can confirm a diagnosis (eg, by visualizing the xenobiotic), assist in therapeutic interventions such as monitoring gastrointestinal (GI) decontamination, and detect complications of the xenobiotic exposure (Table 5–1).180

TABLE 5–1.Xenobiotics with Diagnostic Imaging Findings
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TABLE 5–1. Xenobiotics with Diagnostic Imaging Findings
Xenobiotic Imaging Studya Finding
Amiodarone Chest Phospholipidosis (interstitial and alveolar filling), pulmonary fibrosis
Asbestos Chest Interstitial fibrosis (asbestosis), calcified pleural plaques, mesothelioma
Beryllium Chest Acute: Airspace filling; chronic: hilar adenopathy
Bisphosphonates Skeletal Increase bone density, insufficiency fractures femoral shaft
Body packer Upper GI series or abdominal CT Ingested packets, ileus, bowel obstruction
Carbon monoxide Head CT, MRI SPECT, PET Bilateral basal ganglia lucencies, white matter demyelinization, cerebral dysfunction
Caustic ingestion Enteric contrast Esophageal perforation or stricture
Chemotherapeutics (busulfan, bleomycin) Chest Interstitial pneumonitis
Cholinergics Chest Diffuse airspace filling (bronchorrhea)
Cocaine Chest, abdominal Diffuse airspace filling, pneumomediastinum, pneumothorax, aortic dissection, perforation
Noncontrast head CT, MRI, TEE, SPECT, PET SAH, intracerebral hemorrhage, infarction, cerebral dysfunction, dopamine receptor downregulation
Corticosteroids Skeletal Avascular necrosis (femoral head)
Ethanol Chest, Head CT, MRI, SPECT, PET Dilated cardiomyopathy, aspiration pneumonitis, rib fractures, cortical atrophy, cerebellar atrophy, SDH (head trauma), cerebellar and cortical dysfunction
Fluorosis Skeletal Osteosclerosis, osteophytosis, ligament calcification
Hydrocarbons (low viscosity) Chest Aspiration pneumonitis
Inhaled allergens Chest Hypersensitivity pneumonitis
Iron Abdominal Radiopaque tablets
Irritant gases Chest Diffuse airspace filling
Lead

Skeletal

Abdominal

 Metaphyseal bands in children (proximal tibia, distal radius), bullets (dissolution near joints); ingested leaded paint chips or other leaded compounds
Manganese Brain MRI Basal ganglia and midbrain hyperintensity
Mercury (elemental) Abdominal, skeletal, or chest Ingested, injected, or embolic deposits
Metals (Pb, TI, As) Abdominal Ingested xenobiotic
Nitrofurantoin Chest Hypersensitivity pneumonitis
Opioids Chest Acute respiratory distress syndrome
Abdominal Ileus
Phenytoin Chest Hilar lymphadenopathy
Procainamide, INH, hydralazine Chest Pleural and pericardial effusions (xenobiotic-induced lupus syndrome)
Salicylates Chest Acute respiratory distress syndrome
Silica, coal dust Chest Interstitial fibrosis, hilar adenopathy (egg-shell calcification)
Thorium dioxide Abdominal Hepatic and splenic deposition

a Conventional radiography unless otherwise stated.

CT = computed tomography; INH = isoniazid; MRI = magnetic resonance imaging; PET = positron emission tomography; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; SPECT = single-photon emission tomography.

Conventional radiography is readily available in the emergency department (ED) and is the imaging modality most frequently used in acute patient management. Other imaging modalities are used in certain other toxicologic emergencies, including computed tomography (CT); enteric and intravascular contrast studies; ultrasonography; transesophageal echocardiography (TEE); magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA); and nuclear scintigraphy, including ­positron emission tomography (PET) and single-photon emission tomography (SPECT).

VISUALIZING THE XENOBIOTIC

A number of xenobiotics are radiopaque and can potentially be detected by conventional radiography. Radiography is most useful when a substance that is known to be radiopaque is ...

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