Search Results (231)

Background: Legionella pneumophila is a rare but severe cause of community-acquired pneumonia and can lead to acute respiratory distress syndrome (ARDS). Awake prone positioning (APP) has been recognized as an effective adjunct for non-intubated patients with hypoxemic respiratory failure, primarily studied in coronavirus disease 2019 (COVID-19) and other ARDS etiologies. Its application in Legionella-associated ARDS remains poorly documented. Therefore, in this work, we present a case of Legionella-associated ARDS successfully managed with APP, high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), levofloxacin, and corticosteroids. Case presentation: A 62-year-old male with multiple comorbidities, including type 2 diabetes mellitus (T2DM) and a history of coronary artery bypass surgery, presented with a 3-day history of productive cough, exertional dyspnea, and general malaise. Oxygen saturation on admission was 90%, with fever and tachycardia. Inflammatory markers were markedly elevated. Chest computed tomography (CT) revealed extensive bilateral pulmonary infiltrates. Despite a negative urinary Legionella antigen test, sputum polymerase chain reaction (PCR) confirmed Legionella pneumophila on day 2. A Horowitz index of 147 mmHg on day 2 established moderate ARDS. The patient was treated with HFNC oxygen therapy, NIV, and APP for up to 12 h daily. Antibiotic therapy was initiated with amoxicillin/clavulanic acid and clarithromycin, subsequently streamlined to levofloxacin upon microbiological confirmation. Methylprednisolone 40 mg/day was administered for 8 days as adjunctive ARDS therapy. The patient demonstrated gradual clinical and respiratory improvement without requiring endotracheal intubation. Follow-up chest CT on day 7 showed regression of bilateral consolidations and ground-glass opacities (GGOs). The patient was transferred to pulmonary rehabilitation on day 11 and completed antibiotic therapy as an outpatient. Conclusions: This case illustrates the successful use of APP combined with HFNC and NIV alongside standard medical therapies, including appropriate antibiotics and corticosteroids, to avoid intubation in moderate ARDS secondary to Legionella pneumonia. Early initiation of APP may be a valuable strategy in Legionella-associated ARDS in carefully selected patients. Full article

Background and Clinical Significance: Pulmonary crystal-storing histiocytosis (CSH) without an associated haematological malignancy, lymphoproliferative disorder, plasma cell disorder, or other identifiable underlying condition is exceptionally rare. Long-term radiological data from published cases remain limited, and this case, contextualised by a narrative review of the literature, may expand the recognised imaging spectrum of localised pulmonary CSH. Case Presentation: We report the case of a 59-year-old man with incidental multiple pulmonary lesions identified on CT thorax imaging. The lesions demonstrated an unusual combination of cystic change, cavitation, and surrounding ground-glass opacities. His medical history was significant for bipolar disorder treated with lithium and a 50-pack-year smoking history. Interval imaging showed progression, prompting further investigation and ultimately right upper lobectomy. Histopathological analysis confirmed pulmonary CSH; lesional cells contained crystalloid material and showed CD68 and PAS positivity, with dual kappa and lambda expression on immunohistochemistry. Markers for other differential diagnoses, including Congo red, birefringence, Langerin, and CD1a were negative. Following diagnosis and resection, serial imaging demonstrated fluctuating yet slowly progressive pulmonary abnormalities. No lymphoproliferative or plasma cell disorder has emerged after more than seven years of post-diagnostic surveillance and more than ten years since the initial imaging abnormality. Conclusions: This case demonstrates that the radiological spectrum of localised pulmonary CSH may include cystic, cavitary and ground-glass abnormalities, with subsequent fluctuating yet slowly progressive post-resection evolution. Pulmonary CSH should be considered in the differential diagnosis of unexplained or atypical pulmonary nodules, particularly when histiocyte-rich pathology with intracytoplasmic crystalloid material is identified. Long-term multidisciplinary surveillance is warranted. Full article

Background: The Martini and Melamed criteria for diagnosing multiple primary lung cancers (MPLCs) have remained in use for half a century despite substantial changes in lung cancer epidemiology, risk factors, imaging technologies, and treatment approaches. Correspondingly, the landscape of MPLC has likely changed, necessitating revisions to their diagnostic guidelines. Research Question: What are the clinicopathologic profiles of modern-day MPLC patients, and can these features be used to identify a subset of patients classified as MPLC that may warrant additional investigation as intrapulmonary metastasis (IPM)? Study Design and Methods: We conducted a retrospective cohort study using electronic medical record data from patients who underwent multiple lung cancer resections at Mount Sinai Hospital. Patient demographics, tumor characteristics, and surgical treatments were compared with those reported in the original Martini and Melamed series. We then proposed a reclassification framework incorporating a CT-based assessment of synchronous versus metachronous tumors and contemporary clinicopathologic features documented in imaging and pathology reports. Results: Ninety-one patients underwent successive lung cancer resections. Among first nodules treated with surgical resection, 46% exhibited pathologic features suggestive of metastasis within the lung, including visceral pleural invasion (18%), vascular invasion (24%), lymphatic invasion (36%), and/or lymph node positivity (3%). In contrast, among second nodules (second temporal surgery), 45% demonstrated ground-glass opacity (GGO) supportive of a diagnosis of MPLC. Using the original criteria, 83 patients (91%) were classified as having MPLC; this proportion decreased to 53 patients (58%) under the reclassification criteria. Regardless of the criteria applied, contemporary MPLCs were more likely to occur in older patients, women, those with adenocarcinoma histology, and treated with sublobar resections compared with MPLCs described in the Martini and Melamed era. Conclusions: MPLCs are increasingly recognized, and their clinical presentation has changed substantially over time. Modern imaging and pathologic assessment may be useful tools for diagnosing MPLCs, but this requires future validation. This has important implications for staging and treatment decision-making, as patients may be undertreated by not being offered multimodal treatments or over-treated with systemic therapy when surgery alone may be sufficient. Full article

Daptomycin is widely used for serious methicillin-resistant Staphylococcus aureus (MRSA) infections, but it can cause eosinophilic pneumonia, an uncommon and potentially severe adverse drug reaction. We report probable daptomycin-induced eosinophilic pneumonia (DIEP) in a 77-year-old woman receiving intravenous daptomycin with rifampin for a postoperative MRSA foot infection with concern for orthopedic-device involvement and osteomyelitis. Daptomycin had been initiated 10 days before admission, when she developed acute hypoxemic respiratory failure with bilateral ground-glass and consolidative opacities on chest computed tomography and a negative evaluation for infection. Daptomycin was discontinued on the day of admission, yet respiratory failure progressed, requiring mechanical ventilation. Bronchoalveolar lavage performed after corticosteroid exposure demonstrated eosinophilia (9%), and she improved with systemic corticosteroids and supportive care. Although she did not meet strict FDA “most likely/definite” criteria, the temporal association, compatible imaging, exclusion of alternative etiologies, abnormal lavage eosinophilia, and clinical response following drug withdrawal support “probable” DIEP criteria. Clinicians managing complex foot infections should consider DIEP when new respiratory symptoms and infiltrates develop during daptomycin therapy, even early in the treatment course and even when peripheral eosinophilia is absent or minimal. Full article

Background/Objectives: The acute complications of COVID-19 have been well characterized and are frequently associated with increased mortality. Although substantial knowledge regarding long COVID has accumulated since the beginning of the pandemic, important uncertainties remain regarding the long-term clinical, functional, radiological, and metabolic consequences of SARS-CoV-2 infection. Identification of post-COVID-19 complications is therefore essential for appropriate recognition and management. This study aimed to evaluate the long-term complications of COVID-19 at 3 and 9 months after infection. Methods: This prospective study was conducted at Inonu University Turgut Ozal Medical Center. Patients who presented with active post-COVID-19 complaints or for routine follow-up were enrolled. Participants were evaluated at the pulmonology outpatient clinic at 3 and 9 months. At each visit, persistent or new-onset symptoms were assessed, and pulmonary function tests (PFT), the six-minute walk test (6MWT), echocardiography (ECHO), and thoracic computed tomography (CT) were performed as clinically indicated. Patients were stratified into three groups according to the severity of acute illness: outpatient, ward-hospitalized, and ICU-hospitalized. Results: A total of 205 patients (120 male, 85 female) were included. Male patients had significantly higher rates of ward and ICU hospitalization than female patients (p = 0.006). At 9 months, 85.3% of patients had at least one persistent symptom; dyspnea (69.6%), cough (35.6%), and chest pain (32.5%) were the most common. FVC showed a statistically significant increase between months 3 and 9 (p = 0.014), and the 6MWT distance improved significantly (423.56 m vs. 464.10 m; p = 0.008). Ground-glass opacity, present in 90.2% of patients at admission, persisted in 44.3% at 9 months (p < 0.001). Reticular opacities, pleuroparenchymal bands, and mosaic perfusion patterns increased over time. ICU patients had significantly lower ejection fraction values compared with ward and outpatient groups at 9 months (p = 0.046). During follow-up, 13 patients developed pulmonary embolism and 7 developed new-onset diabetes mellitus. Conclusions: Despite the well-characterized acute phase, the long-term sequelae of COVID-19 remain a significant clinical challenge. Identification of late complications is critical for reducing morbidity and understanding the long-term societal and healthcare burden of the pandemic. Multidisciplinary long-term follow-up is warranted, particularly for patients who experienced severe acute illness. Full article

Acute exacerbation of interstitial lung disease (AE-ILD) represents sudden, severe deterioration in patients with pre-existing ILD and is associated with high morbidity and mortality. Our work presents a case series of AE-ILD in patients with idiopathic pulmonary fibrosis (IPF), idiopathic non-specific interstitial pneumonia (iNSIP), and connective tissue disease-associated ILD (CTD-ILD) managed at our institution and provides a narrative review of AE-ILD. Across cases, AE-ILD manifested as rapid progression of dyspnea and extensive ground-glass opacities (GGOs) on imaging, often triggered by infections or immune-mediated processes. Despite treatment, all cases were fatal, confirming that mortality remains high in AE-ILD. In our literature review, we focus on dysregulated innate immunity, an altered microbiome, potential microaspiration, surgical procedures, and autoantibody-mediated inflammation as triggers, as well as the risk factors for and prevalence of AE-ILD. We also examine pharmacological and non-pharmacological interventions, with particular emphasis on the role of antifibrotic agents as a key protective factor. Evidence for and against corticosteroid use in AE-IPF and non-IPF AE-ILD is discussed, highlighting the radically different treatment approach for AE in melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis (DM)-associated ILD compared to AE-IPF. Our findings underscore the heterogeneous presentation and poor prognosis of AE-ILD, emphasizing the urgent need for standardized diagnostic criteria, risk stratification, and prospective studies with larger cohorts to establish evidence-based therapeutic strategies. Full article

Background: Treatment monitoring in pulmonary tuberculosis increasingly requires assessment of residual inflammatory burden and structural lung damage beyond microbiologic response alone. High-resolution computed tomography (HRCT) can provide this information, but interpretation of serial examinations is time-consuming and partly subjective. This study did not aim to evaluate AI for the diagnosis of pulmonary tuberculosis. Instead, it explored whether artificial intelligence (AI)-assisted quantitative HRCT analysis could support longitudinal assessment of treatment-related imaging changes in patients with microbiologically confirmed pulmonary tuberculosis. Methods: We conducted a retrospective, single-center, exploratory longitudinal study of patients receiving treatment for pulmonary tuberculosis. HRCT examinations acquired at diagnosis and during follow-up were anonymized, reviewed by an expert thoracic radiologist, and processed using AVIEW Lung Texture (Coreline Soft v2.0). The software quantified total lung volume and six predefined parenchymal categories: normal lung, ground-glass opacity, consolidation, reticulation, honeycombing, and emphysema. Results: Ninety-six patients contributed 256 HRCT examinations. The most frequent software-detected abnormalities were ground-glass opacity, consolidation, and emphysema-labeled low-attenuation areas. Ground-glass opacity and consolidation showed the clearest decline across serial examinations, consistent with regression of active inflammatory disease during treatment. Reticulation showed a heterogeneous course, likely reflecting both inflammatory resolution and residual structural remodeling. Honeycombing was infrequent and quantitatively limited. Lung volume changed variably and did not consistently parallel visual improvement. A key methodological limitation was the absence of a dedicated cavity class. As a result, emphysema-labeled low-attenuation areas should not be interpreted as conventional emphysema alone, because tuberculous cavities and post-destructive abnormalities were frequently included in this category. Conclusions: AI-assisted HRCT quantification may support longitudinal assessment of pulmonary tuberculosis by providing structured and reproducible measures of interval change. However, tuberculosis-specific interpretation remains dependent on expert radiologic oversight, particularly in cavitary disease. Full article

Thin-slice high-resolution computed tomography (CT) has improved the detection of small pulmonary nodules, increasing the demand for minimally invasive diagnostic and therapeutic resection. While lobectomy with lymph node dissection remains the standard surgical approach for many patients with resectable non-small cell lung cancer, accumulating evidence supports sublobar resection for selected small, peripheral, and ground-glass-dominant lesions when sufficient margins are achievable. In thoracoscopic and robotic surgery, localization of nodules ≤10 mm or lesions located >5 mm from the pleural surface can be challenging, and failure to identify the target may lead to conversion, larger resection than intended, or prolonged operative time. Several localization strategies have been developed, including CT-guided percutaneous wire/coil/dye marking, bronchoscopic dye mapping, and virtual-assisted lung mapping (VAL-MAP), robotic-assisted bronchoscopic dye or fiducial localization, radiofrequency identification microtag systems (Surgical Real-Time FInger Navigation and Detection) that provide real-time depth information, and single-stage intraoperative CT-guided marking and resection in hybrid operating rooms. This review synthesizes representative evidence and published outcome ranges, and compares workflows, marker-to-lesion precision metrics, complication profiles, operational burden, and cost structures. We emphasize the practical contrast between two-stage and single-stage workflows, the access-route differences between transthoracic and transbronchial techniques, and the need to report localization-to-incision “time at risk”. We also present an expert-consensus decision algorithm aimed at facilitating tailored selection of localization strategies for modern minimally invasive thoracic surgery. Full article

Background/Objectives: Lipoid pneumonia (LP) is a rare and frequently underdiagnosed pulmonary condition with a broad spectrum of radiological manifestations that can closely mimic infectious, inflammatory, and neoplastic lung diseases. Despite its clinical relevance, no standardized imaging-based diagnostic pathway exists. For this reason, this pictorial narrative review aims to provide a structured, imaging-centred synthesis of LP, to characterise the full spectrum of high-resolution CT (HRCT) and magnetic resonance imaging (MRI) findings, and to propose a pragmatic diagnostic workflow. Methods: A systematic literature search was performed in PubMed, MEDLINE, Embase, and the Cochrane Library from January 1950 to February 2025. Search terms combined “lipoid pneumonia” with imaging-related keywords including “HRCT,” “computed tomography,” “MRI,” and “fat attenuation.” After screening 891 deduplicated records, 60 studies were included in the narrative synthesis. Eight illustrative institutional cases with imaging–pathology correlation were additionally selected to demonstrate key imaging phenotypes. Results: HRCT is the cornerstone modality, demonstrating intralesional fat attenuation (typically −30 to −150 HU) in 40–80% of cases depending on series and disease chronicity. Additional patterns include ground-glass opacity, crazy paving, centrilobular nodules, and mass-like consolidation mimicking malignancy. Fat attenuation is absent in up to 60% of cases when inflammatory exudate or fibrosis masks lipid content. MRI, particularly chemical shift imaging, serves as a problem-solving adjunct in pseudotumoral or densitometrically equivocal presentations. A pragmatic diagnostic workflow is proposed, integrating HRCT findings, exposure history, fat-sensitive MRI in selected cases, BAL cytology, and histopathological confirmation when required. Conclusions: A pattern-based radiological approach, anchored on HRCT and integrated with clinical exposure history, BAL cytology, and selective use of fat-sensitive MRI, enables accurate diagnosis of LP in most cases and can prevent unnecessary invasive procedures including surgical resection performed under suspicion of malignancy. Full article

Background: Most predictive models for assessing the invasiveness of pure ground-glass nodules (pGGOs) have been developed in Asian populations, which may limit their applicability to Western cohorts. As the detection of pGGOs continues to increase, there is a growing need for reliable, population-specific tools to support preoperative decision-making. Methods: This multicenter retrospective study analyzed patients from the GORDON database who underwent surgical resection for pGGOs < 40 mm between January 2013 and June 2024. Radiologic features were assessed using preoperative high-resolution and contrast-enhanced CT scans. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of invasive adenocarcinoma (IAC). A radiologic nomogram was developed and internally validated using a training (80%) and validation (20%) cohort. Results: A total of 490 pGGOs were included, of which 421 (85.9%) were IAC and 69 (14.1%) noninvasive (Adenocarcinoma in Situ or Minimally Invasive Adenocarcinoma). Upon multivariable analysis, maximum radiologic diameter (adjusted odds ratio [aOR] = 1.09, p = 0.001), spiculated margins (aOR = 3.07, p = 0.006), and unenhanced CT attenuation (aOR = 1.01, p < 0.001) were independent predictors of invasiveness. These variables were incorporated into a nomogram demonstrating good discrimination, with an area under the curve (AUC) of 0.86 (95% CI, 0.81–0.90) in the training cohort and 0.80 (95% CI, 0.70–0.90) in the validation cohort. Conclusions: A radiologic nomogram based on routinely available CT features enables accurate estimation of invasive adenocarcinoma risk in pGGOs. By integrating parameters beyond lesion size, this tool supports personalized management and may improve preoperative decision-making. Full article

Background: Pneumocystis jirovecii pneumonia (PJP) increasingly affects non-HIV immunocompromised patients; however, the spectrum of computed tomography (CT) findings in this population remains poorly defined. Objectives: To describe and compare chest CT findings of PJP in patients with and without HIV infection and to evaluate the impact of respiratory coinfections on imaging patterns. Methods: This retrospective single-centre cohort study included 72 adult patients with confirmed PJP diagnosed between 2011 and 2024, 27 HIV-positive and 45 non-HIV immunocompromised patients. Chest radiography was available in 71 patients and chest CT in 62. Imaging studies were independently reviewed for predefined patterns, including ground-glass opacities, alveolo-interstitial pattern, mosaic attenuation, crazy paving, pulmonary cysts, consolidation, and pleural effusion. CT findings were compared between HIV-positive and non-HIV patients, and a subgroup analysis was performed in non-HIV patients according to the underlying type of immunosuppression. Respiratory coinfections were recorded and classified based on microbiological results. Results: Chest radiography was normal in 32.4% of patients. An interstitial pattern tended to be more frequent in HIV-positive patients, whereas consolidations were more commonly observed in non-HIV patients (p = 0.051). On CT, ground-glass opacities were the predominant finding in both groups. HIV-positive patients more frequently demostrated an alveolo-interstitial pattern, mosaic attenuation, and pulmonary cysts, while consolidations and pleural effusions were more common in non-HIV patients, particularly among solid organ transplant recipients. Respiratory coinfections were identified in 63.9% of patients; however, no statistically significant differences in CT patterns were observed between patients with and without coinfections. Conclusions: PJP demonstrates different CT presentations according to immune status. HIV-positive patients more frequently demonstrated alveolo-interstitial patterns, mosaic attenuation, and pulmonary cysts, whereas consolidations were more commonly observed in non-HIV immunocompromised patients. Respiratory coinfections do not appear to significantly influence CT patterns. Full article

Background: Strongyloides stercoralis is a soil-transmitted helminth capable of establishing chronic infection through an autoinfective cycle, with the potential to progress to life-threatening hyperinfection, particularly in immunocompromised individuals. Case Presentation: We report the case of a 70-year-old man from an endemic region in Colombia with metastatic urothelial carcinoma who developed hyperinfection syndrome following corticosteroid therapy for spinal cord compression. The patient presented with progressive respiratory failure and diffuse alveolar hemorrhage. Chest imaging showed bilateral ground glass opacities, and bronchoalveolar lavage revealed numerous larvae consistent with S. stercoralis, confirming the diagnosis. Despite supportive care and broad-spectrum antimicrobial therapy, the patient experienced rapid clinical deterioration and died. Conclusions: This case highlights the importance of considering strongyloidiasis in the differential diagnosis of diffuse alveolar hemorrhage in endemic settings, particularly in patients receiving corticosteroids. Early recognition and timely treatment are essential to reduce the high associated mortality. Preventive strategies, including targeted screening or empiric ivermectin administration prior to immunosuppression, should be considered in high-risk populations. Full article

Background: Computed tomography (CT) is routinely used to estimate tumor size before lung resection, whereas pathologic examination provides the reference tissue-based measurement after surgery. This study aimed to compare CT-derived and pathologic tumor size and to evaluate correlation, agreement, proportional bias, clinically defined accuracy, and size-based T-category concordance, with particular attention to the effect of ground-glass opacity (GGO). Methods: This retrospective single-center study included 96 patients who underwent lung resection between January 2023 and December 2025 and had complete preoperative CT and pathologic tumor measurements. Maximum tumor diameter was defined as the largest of three orthogonal measurements for each modality. Correlation was assessed using Spearman’s rank correlation coefficient, reliability using the intraclass correlation coefficient (ICC), and agreement using Bland–Altman analysis. Proportional bias was evaluated by regression of the paired difference on the paired mean. Subgroup, size category, regression and size-based T-category concordance analyses were also performed. Results: CT and pathologic maximum diameters showed strong correlation (Spearman’s ρ = 0.952, p < 0.0001) and excellent reliability (ICC = 0.959, 95% CI, 0.939–0.973). The paired comparison was not statistically significant (p = 0.175), and the mean bias was −0.76 mm. However, the 95% limits of agreement ranged from −13.66 mm to +12.13 mm. Significant proportional bias was observed, with increasing CT underestimation as tumor size increased (slope = −0.093, p = 0.0014). In tumors with GGO, CT pathology differences shifted toward overestimation (+8.91 ± 7.30 mm vs. −1.64 ± 5.80 mm without GGO; p = 0.0003). Accuracy within ±5 mm and ±10 mm was 68.8% and 88.5%, respectively, but was lower in the GGO subgroup. CT-derived and pathology-derived size-based T-categories were concordant in 60 patients (62.5%), while pathology-based upstaging occurred in 23 patients (24.0%) and pathology-based downstaging in 13 patients (13.5%). Conclusions: CT-based tumor size showed strong overall correlation with pathologic measurements, but agreement at the individual patient level was more limited than correlation metrics alone would suggest. GGO and tumor size appeared to be important modifiers of measurement performance; however, the GGO-related findings should be interpreted cautiously because of the small subgroup size. These findings support cautious interpretation of CT-derived whole-lesion diameter, particularly in subsolid tumors and larger lesions. Full article

Background/Objectives: Connective tissue disease-associated interstitial lung disease (CTD-ILD) is linked to substantial morbidity and mortality. While nintedanib (NTB) slows lung function decline in progressive pulmonary fibrosis (PPF), real-world data—particularly regarding radiographic outcomes—remain limited. We aimed to evaluate the real-world effectiveness and tolerability of antifibrotic therapy—predominantly NTB—on radiographic and functional outcomes in a Hungarian CTD-ILD cohort. Methods: We conducted a retrospective observational cohort study including 72 patients with progressive CTD-ILD who initiated antifibrotic therapy at two Hungarian tertiary centers between January 2021 and June 2025. The primary endpoint was the proportion of patients without significant radiographic progression at 6–12 months, based on blinded assessment of paired high-resolution computed tomography (HRCT) scans by two thoracic radiologists. Secondary endpoints included changes in forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) at 6 and 12 months, safety and tolerability, and correlations between lung function and disease-related factors. Results: The cohort comprised systemic sclerosis–ILD (n = 25), rheumatoid arthritis–ILD (n = 23), and other CTD-ILD (n = 24). Radiographic stability was observed in 65.8–78.9% of patients, with improvement most commonly seen in ground-glass opacities, while traction bronchiectasis remained largely unchanged. Radiographic disease extent showed the strongest inverse correlation with baseline FVC and DLCO (p < 0.05). Significant improvements in FVC and DLCO were observed at 6 and 12 months (p < 0.001). Antifibrotic therapy was well tolerated, including in combination with immunosuppressive treatment. Conclusions: These real-world data support the effectiveness and safety of NTB in PPF–CTD-ILD and highlight radiologic disease burden as a key determinant of functional impairment. Full article

The spotted seal (Phoca largha) is a flagship species and natural monument inhabiting Korean coastal waters. Due to its conservation importance and the rarity of carcass discoveries, determining the cause of death of each individual is critical. A juvenile female spotted seal carcass was discovered on the eastern coast of Korea in May 2025. External examination revealed multiple parallel lacerations consistent with propeller strike injuries. Post-mortem computed tomography (PMCT) was performed prior to necropsy to provide a comprehensive forensic analysis. CT imaging revealed the longest wound measured 10.49 cm in length and 1.58 cm in depth, suggesting a minimum propeller diameter of approximately 19 cm. Skeletal injuries included a coccygeal vertebral fracture and subluxation of the left astragalus and calcaneus. CT images of the respiratory tract showed frothy fluid in the nasal cavity and trachea, as well as ground-glass opacity and consolidation in the lung parenchyma. Necropsy findings confirmed severe pulmonary edema, congestion, and abundant frothy foam throughout the respiratory tract. Histological analysis revealed pulmonary edema with eosinophilic fluid and erythrocytes in alveolar spaces, markedly distended blood vessels, and intra-alveolar hemorrhage. This comprehensive approach demonstrated that the cause of death was drowning, secondary to propeller strike by a small vessel (<4.5 m). To the authors’ knowledge, this is the first case report providing a detailed forensic analysis of a juvenile spotted seal found on the eastern coast of Korea. This case highlights the importance of integrating PMCT with conventional necropsy to improve cause-of-death determination in marine mammal conservation. Full article