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Chapter 8: Principles of Diagnostic Imaging

David T. Schwartz

INTRODUCTION

Diagnostic imaging plays 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 8–1).219

TABLE 8–1Xenobiotics with Diagnostic Imaging Findings
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TABLE 8–1 Xenobiotics with Diagnostic Imaging Findings
Xenobiotic Imaging Studya Findings
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
Body packer

Abdominal

Enteric contrast or abdominal CT

Ultrasonography

Ingested packets, ileus, bowel obstruction

Retained packets, bowel obstruction or perforation

Ingested packets
Carbon monoxide

Head CT, MRI

SPECT, PET

Bilateral basal ganglion lucencies, white matter demyelinization

Cerebral dysfunction
Caustic ingestion

Enteric contrast

CT

 Esophageal perforation or stricture
Chemotherapeutics (busulfan, bleomycin) Chest Interstitial pneumonitis
Cholinergics Chest Diffuse airspace filling (bronchorrhea)
Cocaine

Chest, abdominal

Noncontrast, head CT, MRI, TEE

SPECT, PET

Diffuse airspace filling, pneumomediastinum, pneumothorax, aortic dissection, perforation

SAH, intracerebral hemorrhage, infarction

Cerebral dysfunction, dopamine receptor downregulation
Corticosteroids Skeletal Avascular necrosis (femoral head), osteoporosis
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
IDU injection drug use Chest, skeletal, cranial CT Septic emboli, pneumothorax, osteomyelitis (axial skeleton), AIDS-related infections
Iron Abdominal Radiopaque tablets
Irritant gases Chest Diffuse airspace filling thorax
Lead

Skeletal

Abdominal

Metaphyseal bands in children (proximal tibia, distal radius), bullets (dissolution near joints)

Ingested leaded paint chips or other leaded compounds
Manganese MRI brain Basal ganglia and midbrain hyperintensity
Mercury (elemental) Abdominal, skeletal, or chest Ingested, injected, or embolic deposits
Metals (Pb, Hg, TI, As) Abdominal Ingested xenobiotic
Nitrofurantoin Chest Hypersensitivity pneumonitis
Opioids

Chest

Abdominal

ARDS

Ileus
Phenytoin Chest, CT Hilar lymphadenopathy, pseudolymphoma
Procainamide, isoniazid, hydralazine

Chest

Echocardiogram

Pleural and pericardial effusions (xenobiotic-induced lupus syndrome)

Pericardial effusion
Salicylates Chest ARDS
Silica, coal dust Chest Interstitial fibrosis, hilar adenopathy (egg-shell calcification)
Thorium dioxide Abdominal Hepatic and splenic deposition

aConventional radiography unless otherwise stated.

AIDS = acquired immune deficiency syndrome; ARDS = acute respiratory distress syndrome; CT = computed tomography; MRI = magnetic resonance imaging; PET = positron emission tomography; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; SPECT = single-photon emission tomography; TEE = transesophageal echocardiography.

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 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

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