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Thoracic Complications of Illicit Drug Use: An Organ System Approach¹

¹ From the Departments of Radiology (M.B.G., S.R.M., S.K.D., A.D.G.) and Pathology (D.K.H.), San Francisco General Hospital, 1001 Potrero Ave, Rm 1X 55A, Box 1325, San Francisco, CA 94110; the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (J.W.T.L.); and the Department of Radiology, University of California, San Francisco (M.B.G., S.R.M., S.K.D., A.D.G., G.P.R., P.A.A., W.R.W.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 6, 2001; revision requested March 18 and received April 12; accepted April 18. Address correspondence to M.B.G. (e-mail: michael.gotway@radiology.ucsf.edu).

View larger version (137K): [in a new window]   Figure 1.  Acute myocardial infarction following cocaine use in a 53-year-old man. Frontal chest radiograph shows bilateral, symmetric areas of increased opacity that represent cardiogenic pulmonary edema. The differential diagnosis of these findings must be broad and include acute lung injury due to a variety of causes, diffuse infection, and noninfectious inflammatory conditions such as pulmonary hemorrhage and acute hypersensitivity pneumonitis. Pulmonary arterial catheter measurements confirmed elevated pulmonary capillary wedge pressure.

View larger version (125K): [in a new window]   Figure 2a.  Heroin-induced acute lung injury following heroin ingestion in a 33-year-old man. (a) Frontal chest radiograph obtained shortly after presentation to the emergency department reveals bilateral areas of increased opacity (arrows), a finding that is consistent with acute lung injury. (b) Follow-up chest radiograph obtained 2 days later reveals complete clearing of the areas of increased opacity. Such rapid clearing is common in heroin-induced lung injury.

View larger version (125K): [in a new window]   Figure 2b.  Heroin-induced acute lung injury following heroin ingestion in a 33-year-old man. (a) Frontal chest radiograph obtained shortly after presentation to the emergency department reveals bilateral areas of increased opacity (arrows), a finding that is consistent with acute lung injury. (b) Follow-up chest radiograph obtained 2 days later reveals complete clearing of the areas of increased opacity. Such rapid clearing is common in heroin-induced lung injury.

View larger version (126K): [in a new window]   Figure 3a.  Acute lung injury (crack lung) in a 37-year-old man who presented with shortness of breath and cough after crack use. (a) Frontal chest radiograph reveals ground-glass areas of increased opacity in the right lower lobe (arrow), a finding that is consistent with numerous causes, including edema, infection, hemorrhage, and aspiration. (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals ground-glass attenuation (arrows) with interlobular septal thickening (arrowheads). The differential diagnosis of these findings includes infection (especially Pneumocystis carinii pneumonia), lipoid pneumonia, and alveolar proteinosis, among numerous other causes. (c) Frontal chest radiograph obtained 2 days after CT shows resolution of the increased opacity.

View larger version (121K): [in a new window]   Figure 3b.  Acute lung injury (crack lung) in a 37-year-old man who presented with shortness of breath and cough after crack use. (a) Frontal chest radiograph reveals ground-glass areas of increased opacity in the right lower lobe (arrow), a finding that is consistent with numerous causes, including edema, infection, hemorrhage, and aspiration. (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals ground-glass attenuation (arrows) with interlobular septal thickening (arrowheads). The differential diagnosis of these findings includes infection (especially Pneumocystis carinii pneumonia), lipoid pneumonia, and alveolar proteinosis, among numerous other causes. (c) Frontal chest radiograph obtained 2 days after CT shows resolution of the increased opacity.

View larger version (128K): [in a new window]   Figure 3c.  Acute lung injury (crack lung) in a 37-year-old man who presented with shortness of breath and cough after crack use. (a) Frontal chest radiograph reveals ground-glass areas of increased opacity in the right lower lobe (arrow), a finding that is consistent with numerous causes, including edema, infection, hemorrhage, and aspiration. (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals ground-glass attenuation (arrows) with interlobular septal thickening (arrowheads). The differential diagnosis of these findings includes infection (especially Pneumocystis carinii pneumonia), lipoid pneumonia, and alveolar proteinosis, among numerous other causes. (c) Frontal chest radiograph obtained 2 days after CT shows resolution of the increased opacity.

View larger version (122K): [in a new window]   Figure 4a.  Pulmonary hemorrhage in a 29-year-old male crack smoker who presented with abrupt onset of shortness of breath and hemoptysis. (a) Frontal chest radiograph shows lower-lobe ground-glass areas of increased opacity and consolidation (arrows). (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals bilateral ground-glass attenuation (arrows), peribronchovascular thickening, and interlobular septal thickening. Bronchoscopy showed pulmonary hemorrhage. (c) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) obtained 2 months later shows resolution of the previously abnormal areas.

View larger version (99K): [in a new window]   Figure 4b.  Pulmonary hemorrhage in a 29-year-old male crack smoker who presented with abrupt onset of shortness of breath and hemoptysis. (a) Frontal chest radiograph shows lower-lobe ground-glass areas of increased opacity and consolidation (arrows). (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals bilateral ground-glass attenuation (arrows), peribronchovascular thickening, and interlobular septal thickening. Bronchoscopy showed pulmonary hemorrhage. (c) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) obtained 2 months later shows resolution of the previously abnormal areas.

View larger version (95K): [in a new window]   Figure 4c.  Pulmonary hemorrhage in a 29-year-old male crack smoker who presented with abrupt onset of shortness of breath and hemoptysis. (a) Frontal chest radiograph shows lower-lobe ground-glass areas of increased opacity and consolidation (arrows). (b) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) reveals bilateral ground-glass attenuation (arrows), peribronchovascular thickening, and interlobular septal thickening. Bronchoscopy showed pulmonary hemorrhage. (c) High-resolution CT scan (level = -700 HU, window width = 1,000 HU) obtained 2 months later shows resolution of the previously abnormal areas.

View larger version (121K): [in a new window]   Figure 5a.  Aspiration pneumonia in a 38-year-old man with obtundation following heroin overdose. (a) Frontal chest radiograph reveals bilateral areas of increased opacity, more prominent on the right side than on the left, projected over the hila (arrows). (b) Lateral chest radiograph shows that the areas of increased opacity (arrows) are somewhat masslike and are located posteriorly. (c) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows volume loss (detectable owing to the retracted position of the right major fissure) and bilateral consolidation in the superior segments of the lower lobes (arrows). Food particles were removed with bronchoscopy.

View larger version (138K): [in a new window]   Figure 5b.  Aspiration pneumonia in a 38-year-old man with obtundation following heroin overdose. (a) Frontal chest radiograph reveals bilateral areas of increased opacity, more prominent on the right side than on the left, projected over the hila (arrows). (b) Lateral chest radiograph shows that the areas of increased opacity (arrows) are somewhat masslike and are located posteriorly. (c) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows volume loss (detectable owing to the retracted position of the right major fissure) and bilateral consolidation in the superior segments of the lower lobes (arrows). Food particles were removed with bronchoscopy.

View larger version (89K): [in a new window]   Figure 5c.  Aspiration pneumonia in a 38-year-old man with obtundation following heroin overdose. (a) Frontal chest radiograph reveals bilateral areas of increased opacity, more prominent on the right side than on the left, projected over the hila (arrows). (b) Lateral chest radiograph shows that the areas of increased opacity (arrows) are somewhat masslike and are located posteriorly. (c) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows volume loss (detectable owing to the retracted position of the right major fissure) and bilateral consolidation in the superior segments of the lower lobes (arrows). Food particles were removed with bronchoscopy.

View larger version (111K): [in a new window]   Figure 6a.  Respiratory failure due to endocarditis and septic embolization in a 28-year-old man. (a) Frontal chest radiograph reveals diffuse bilateral areas of increased opacity and numerous cavities (arrows), which are consistent with septic emboli. (b) CT scan (7-mm collimation, level = -600 HU, window width = 1,500 HU) shows diffuse ground-glass attenuation, which represents diffuse alveolar damage, and multiple cavities (arrows), which are consistent with septic emboli. Left anterior pneumothorax is also present. (c) CT scan of the lower pelvis (7-mm collimation, level = 45 HU, window width = 440 HU) reveals an irregular air collection in the right side of the groin (small arrows), which indicates a recent site of self-injection by the patient, as well as a fractured needle fragment in the left side of the groin (large arrow).

View larger version (122K): [in a new window]   Figure 6b.  Respiratory failure due to endocarditis and septic embolization in a 28-year-old man. (a) Frontal chest radiograph reveals diffuse bilateral areas of increased opacity and numerous cavities (arrows), which are consistent with septic emboli. (b) CT scan (7-mm collimation, level = -600 HU, window width = 1,500 HU) shows diffuse ground-glass attenuation, which represents diffuse alveolar damage, and multiple cavities (arrows), which are consistent with septic emboli. Left anterior pneumothorax is also present. (c) CT scan of the lower pelvis (7-mm collimation, level = 45 HU, window width = 440 HU) reveals an irregular air collection in the right side of the groin (small arrows), which indicates a recent site of self-injection by the patient, as well as a fractured needle fragment in the left side of the groin (large arrow).

View larger version (115K): [in a new window]   Figure 6c.  Respiratory failure due to endocarditis and septic embolization in a 28-year-old man. (a) Frontal chest radiograph reveals diffuse bilateral areas of increased opacity and numerous cavities (arrows), which are consistent with septic emboli. (b) CT scan (7-mm collimation, level = -600 HU, window width = 1,500 HU) shows diffuse ground-glass attenuation, which represents diffuse alveolar damage, and multiple cavities (arrows), which are consistent with septic emboli. Left anterior pneumothorax is also present. (c) CT scan of the lower pelvis (7-mm collimation, level = 45 HU, window width = 440 HU) reveals an irregular air collection in the right side of the groin (small arrows), which indicates a recent site of self-injection by the patient, as well as a fractured needle fragment in the left side of the groin (large arrow).

View larger version (89K): [in a new window]   Figure 7.  Endocarditis and septic embolization in a 34-year-old man. CT scan (level = -700 HU, window width = 1,000 HU) reveals a wedge-shaped area of consolidation in the periphery of the right lung (arrow), a finding that represents pulmonary infarction.

View larger version (155K): [in a new window]   Figure 8a.  Emphysema in a 34-year-old man with a history of intravenous substance abuse and cigarette smoking. (a) Frontal chest radiograph shows enormous lung volumes with large upper lobe-predominant bullae (arrows). (b) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows the extensive mass effect of the huge bullae, which are compressing the remaining pulmonary parenchyma (large arrow). Air-fluid levels in several right-sided bullae and right medial lung consolidation (small arrows) represent superinfection.

View larger version (90K): [in a new window]   Figure 8b.  Emphysema in a 34-year-old man with a history of intravenous substance abuse and cigarette smoking. (a) Frontal chest radiograph shows enormous lung volumes with large upper lobe-predominant bullae (arrows). (b) CT scan (7-mm collimation, level = -700 HU, window width = 1,000 HU) shows the extensive mass effect of the huge bullae, which are compressing the remaining pulmonary parenchyma (large arrow). Air-fluid levels in several right-sided bullae and right medial lung consolidation (small arrows) represent superinfection.

View larger version (125K): [in a new window]   Figure 9a.  Emphysema related to methylphenidate abuse in a 45-year-old woman with a long history of such abuse. (a) Frontal chest radiograph reveals huge lung volumes with lower lobe-predominant hyperlucency. (b) CT scan (7-mm collimation, level = -1,000 HU, window width = -700 HU) shows extensive lower-lobe hyperlucency with simplification of the pulmonary architecture, a pattern that resembles panacinar emphysema due to 1-protease inhibitor deficiency. (c) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a histologic specimen obtained with polarized light reveals multiple refractile particles consistent with talc (arrows).

View larger version (114K): [in a new window]   Figure 9b.  Emphysema related to methylphenidate abuse in a 45-year-old woman with a long history of such abuse. (a) Frontal chest radiograph reveals huge lung volumes with lower lobe-predominant hyperlucency. (b) CT scan (7-mm collimation, level = -1,000 HU, window width = -700 HU) shows extensive lower-lobe hyperlucency with simplification of the pulmonary architecture, a pattern that resembles panacinar emphysema due to 1-protease inhibitor deficiency. (c) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a histologic specimen obtained with polarized light reveals multiple refractile particles consistent with talc (arrows).

View larger version (136K): [in a new window]   Figure 9c.  Emphysema related to methylphenidate abuse in a 45-year-old woman with a long history of such abuse. (a) Frontal chest radiograph reveals huge lung volumes with lower lobe-predominant hyperlucency. (b) CT scan (7-mm collimation, level = -1,000 HU, window width = -700 HU) shows extensive lower-lobe hyperlucency with simplification of the pulmonary architecture, a pattern that resembles panacinar emphysema due to 1-protease inhibitor deficiency. (c) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin stain) of a histologic specimen obtained with polarized light reveals multiple refractile particles consistent with talc (arrows).

View larger version (123K): [in a new window]   Figure 10a.  Talc-induced lung disease in a 34-year-old man with acquired immunodeficiency syndrome and a long history of intravenous drug abuse, including the use of methylphenidate. (a) Frontal chest radiograph reveals irregular nodular areas of increased opacity in the upper lobes associated with architectural distortion (arrows). (b) High-resolution CT scan (level = 40 HU, window width = 440 HU) reveals that the upper-lobe process in a has high attenuation (arrows). The location and appearance of this finding, particularly the increased attenuation, are suggestive of talc-induced lung disease.

View larger version (125K): [in a new window]   Figure 10b.  Talc-induced lung disease in a 34-year-old man with acquired immunodeficiency syndrome and a long history of intravenous drug abuse, including the use of methylphenidate. (a) Frontal chest radiograph reveals irregular nodular areas of increased opacity in the upper lobes associated with architectural distortion (arrows). (b) High-resolution CT scan (level = 40 HU, window width = 440 HU) reveals that the upper-lobe process in a has high attenuation (arrows). The location and appearance of this finding, particularly the increased attenuation, are suggestive of talc-induced lung disease.

View larger version (107K): [in a new window]   Figure 11a.  Surgically proved pulmonary amyloidosis in a 44-year-old woman with a history of intravenous drug abuse. (a) Frontal chest radiograph reveals a nodule projected over the right hilum (arrows). (b) CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows irregular calcification within the central portion of the nodule (arrows). The presence of calcification within a solitary pulmonary nodule suggests that the lesion is benign, possibly an infectious granuloma. Nevertheless, a significant portion of the mass is not calcified, which raises the possibility of malignancy; bronchogenic carcinoma and carcinoid tumor should be considered. Amyloidosis was proved at surgery. (c) Low-power photomicrograph (original magnification, x10; Congo red stain) shows multiple apple-green birefringent particles (arrows), a finding that is consistent with amyloidosis. Talc (not shown) was also present within the biopsy specimen.

View larger version (138K): [in a new window]   Figure 11b.  Surgically proved pulmonary amyloidosis in a 44-year-old woman with a history of intravenous drug abuse. (a) Frontal chest radiograph reveals a nodule projected over the right hilum (arrows). (b) CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows irregular calcification within the central portion of the nodule (arrows). The presence of calcification within a solitary pulmonary nodule suggests that the lesion is benign, possibly an infectious granuloma. Nevertheless, a significant portion of the mass is not calcified, which raises the possibility of malignancy; bronchogenic carcinoma and carcinoid tumor should be considered. Amyloidosis was proved at surgery. (c) Low-power photomicrograph (original magnification, x10; Congo red stain) shows multiple apple-green birefringent particles (arrows), a finding that is consistent with amyloidosis. Talc (not shown) was also present within the biopsy specimen.

View larger version (145K): [in a new window]   Figure 11c.  Surgically proved pulmonary amyloidosis in a 44-year-old woman with a history of intravenous drug abuse. (a) Frontal chest radiograph reveals a nodule projected over the right hilum (arrows). (b) CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows irregular calcification within the central portion of the nodule (arrows). The presence of calcification within a solitary pulmonary nodule suggests that the lesion is benign, possibly an infectious granuloma. Nevertheless, a significant portion of the mass is not calcified, which raises the possibility of malignancy; bronchogenic carcinoma and carcinoid tumor should be considered. Amyloidosis was proved at surgery. (c) Low-power photomicrograph (original magnification, x10; Congo red stain) shows multiple apple-green birefringent particles (arrows), a finding that is consistent with amyloidosis. Talc (not shown) was also present within the biopsy specimen.

View larger version (148K): [in a new window]   Figure 12a.  Cocaine-induced aortic dissection and aortic rupture in a 35-year-old man with acute onset of chest pain following the inhalation of crack. (a) Contrast material-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) through the lower portion of the chest reveals an intimal flap (arrows). The patient left the intensive care unit against medical advice. (b) Contrast-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) obtained 3 days later and after the patient had smoked cocaine again once more shows the intimal flap (small arrows). The material with soft-tissue attenuation within the mediastinum and surrounding the aorta (large arrows) represents mediastinal blood, a finding that indicates the presence of aortic rupture.

View larger version (153K): [in a new window]   Figure 12b.  Cocaine-induced aortic dissection and aortic rupture in a 35-year-old man with acute onset of chest pain following the inhalation of crack. (a) Contrast material-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) through the lower portion of the chest reveals an intimal flap (arrows). The patient left the intensive care unit against medical advice. (b) Contrast-enhanced CT scan (5-mm collimation, level = 40 HU, window width = 440 HU) obtained 3 days later and after the patient had smoked cocaine again once more shows the intimal flap (small arrows). The material with soft-tissue attenuation within the mediastinum and surrounding the aorta (large arrows) represents mediastinal blood, a finding that indicates the presence of aortic rupture.

View larger version (124K): [in a new window]   Figure 13a.  Right subclavian arterial pseudoaneurysm that resulted from a right supraclavicular pocket shot in a 28-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph reveals a rounded mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows a rounded low-attenuation mass (large arrows) surrounding an irregular collection of intravenous contrast material (small arrows). The latter finding represents a pseudoaneurysm of the right subclavian artery. (c) Right subclavian angiogram shows the pseudoaneurysm (arrow).

View larger version (109K): [in a new window]   Figure 13b.  Right subclavian arterial pseudoaneurysm that resulted from a right supraclavicular pocket shot in a 28-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph reveals a rounded mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows a rounded low-attenuation mass (large arrows) surrounding an irregular collection of intravenous contrast material (small arrows). The latter finding represents a pseudoaneurysm of the right subclavian artery. (c) Right subclavian angiogram shows the pseudoaneurysm (arrow).

View larger version (188K): [in a new window]   Figure 13c.  Right subclavian arterial pseudoaneurysm that resulted from a right supraclavicular pocket shot in a 28-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph reveals a rounded mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) shows a rounded low-attenuation mass (large arrows) surrounding an irregular collection of intravenous contrast material (small arrows). The latter finding represents a pseudoaneurysm of the right subclavian artery. (c) Right subclavian angiogram shows the pseudoaneurysm (arrow).

View larger version (120K): [in a new window]   Figure 14a.  Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).

View larger version (87K): [in a new window]   Figure 14b.  Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).

View larger version (151K): [in a new window]   Figure 14c.  Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).

View larger version (150K): [in a new window]   Figure 14d.  Right subclavian arterial mycotic pseudoaneurysm in a 27-year-old man with a long history of intravenous drug abuse. (a) Frontal chest radiograph shows an ill-defined mass projected over the right lung apex (arrows). (b) Contrast-enhanced CT scan (10-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation mass in the right supraclavicular fossa with extension into the soft tissues of the right axillary fossa (large arrows). A small focus of gas within the center of the mass (small arrow) is suggestive of superinfection. (c) Sagittal gadolinium-enhanced three-dimensional MR angiogram (repetition time msec/echo time msec = 9.8/2.4) shows a markedly enhanced extraparenchymal mass (large arrows) that is spatially separated from the right subclavian artery (small arrow). (d) Right subclavian arterial angiogram reveals extravasation of contrast material into a large mycotic pseudoaneurysm (arrows).

View larger version (119K): [in a new window]   Figure 15a.  Vertebral body osteomyelitis in a 36-year-old man with a long history of intravenous drug abuse who presented with fever and back pain. (a) Lateral radiograph of the thoracic spine shows collapse of one thoracic vertebral body (arrow) into its neighbor. (b) CT scan reveals destruction of the vertebral body (small arrow) and an associated soft-tissue mass (large arrows). (c) Sagittal contrast-enhanced T1-weighted MR image (500/40) shows collapse of one vertebral body into another (large arrow), as well as intense enhancement around the intervertebral disk space, a finding that is consistent with infection. Effacement of the ventral thecal sac by abnormal soft tissue (small arrows) represents the development of an epidural abscess.

View larger version (108K): [in a new window]   Figure 15b.  Vertebral body osteomyelitis in a 36-year-old man with a long history of intravenous drug abuse who presented with fever and back pain. (a) Lateral radiograph of the thoracic spine shows collapse of one thoracic vertebral body (arrow) into its neighbor. (b) CT scan reveals destruction of the vertebral body (small arrow) and an associated soft-tissue mass (large arrows). (c) Sagittal contrast-enhanced T1-weighted MR image (500/40) shows collapse of one vertebral body into another (large arrow), as well as intense enhancement around the intervertebral disk space, a finding that is consistent with infection. Effacement of the ventral thecal sac by abnormal soft tissue (small arrows) represents the development of an epidural abscess.

View larger version (131K): [in a new window]   Figure 15c.  Vertebral body osteomyelitis in a 36-year-old man with a long history of intravenous drug abuse who presented with fever and back pain. (a) Lateral radiograph of the thoracic spine shows collapse of one thoracic vertebral body (arrow) into its neighbor. (b) CT scan reveals destruction of the vertebral body (small arrow) and an associated soft-tissue mass (large arrows). (c) Sagittal contrast-enhanced T1-weighted MR image (500/40) shows collapse of one vertebral body into another (large arrow), as well as intense enhancement around the intervertebral disk space, a finding that is consistent with infection. Effacement of the ventral thecal sac by abnormal soft tissue (small arrows) represents the development of an epidural abscess.

View larger version (123K): [in a new window]   Figure 16a.  Necrotizing fasciitis in a 42-year-old man with a history of skin popping. (a) Axial T2-weighted MR image (2,500/80) reveals high signal intensity throughout the pectoralis major muscle (arrows) and within the musculature in the medial compartment of the upper left arm. (b) Axial contrast-enhanced T1-weighted MR image (500/40) shows extensive enhancement of the left pectoralis major muscle (large arrow) and surrounding tissues, as well as within the musculature of the medial portion of the upper left arm (small arrows).

View larger version (120K): [in a new window]   Figure 16b.  Necrotizing fasciitis in a 42-year-old man with a history of skin popping. (a) Axial T2-weighted MR image (2,500/80) reveals high signal intensity throughout the pectoralis major muscle (arrows) and within the musculature in the medial compartment of the upper left arm. (b) Axial contrast-enhanced T1-weighted MR image (500/40) shows extensive enhancement of the left pectoralis major muscle (large arrow) and surrounding tissues, as well as within the musculature of the medial portion of the upper left arm (small arrows).

View larger version (112K): [in a new window]   Figure 17.  Costochondritis in a 34-year-old man with a history of intravenous drug abuse who presented with pain in the lower left portion of the chest. Contrast-enhanced CT scan (level = 40 HU, window width = 440 HU) shows a soft-tissue mass centered around one of the lower left costochondral junctions (arrows), a finding that represents costochondritis.

View larger version (86K): [in a new window]   Figure 18.  Sternoclavicular septic arthritis complicated by an abscess in a 31-year-old man with a history of intravenous drug abuse. The patient presented with left upper chest pain, swelling, and fever. Contrast-enhanced CT scan (7-mm collimation, level = 40 HU, window width = 440 HU) reveals a low-attenuation collection deep to the left sternoclavicular joint (arrow), a finding that represents an abscess extending from infection of the joint.