1. Chest (Pulmonary manifestations of Systemic Disease, Pleura/chest wall)

Question 1

Collagen vascular disease associated with

Answer 1

Interstitial lung diseases

Question 2

Lupus - pulmonary manifestations (2)

Answer 2

More pleural and pericardial effusions than other connective tissue diseases.
Can get “Shrinking lung”. Fibrosis is uncommon

Question 3

RA - pulmonary manifestations (3)

Answer 3

Looks like UIP and COP.
Lower lobes favoured.
Reticulations with or without honeycombing.
Solid opacities which are organising pneumonia.

Question 4

Scleroderma - pulmonary manifestations (3)

Answer 4

NSIP > UIP.
Lower lobe predominantly.
Dilated, fluid filled oesophagus.

Question 5

Sjogrens - pulmonary manifestations (2)

Answer 5

LIP,
Extensive ground glass attenuation with scattered, thin walled cysts.

Question 6

Ankylosing spondylitis - pulmonary manifestations (2)

Answer 6

Upper lobe fibrobullous disease.
Usually unilateral at first, then progresses to bilateral.

Question 7

Caplan syndrome - features (3)

Answer 7

Rheumatoid nodules & Upper lobe predominant lung nodules.
These nodules can cavitate.
May also be pleural effusions.

Question 8

Shrinking Lung - features (2)

Answer 8

Progressive loss of lung volume in lupus.
Either due to diaphragm dysfunction or pleuritic chest pain.

Question 9

Commonest manifestation of SLE in chest

Answer 9

Pleuritis with/without pleural effusion

Question 10

Hepatopulmonary syndrome - physiology (3)

Answer 10

“shortness of breath when sitting up” in liver patients (opposite to CHF).
Due to distal vascular dilation in lung bases (subpleural telangectasia), when dilated subpleural vessels don’t taper and extend to pleural surface.
When sitting up, these engorge with blood and make pt short of breath.

Question 11

Hepatopulmonary syndrome - imaging

Answer 11

Tc MAA scan shows shunting with tracer in the brain.

Question 12

Wegeners - features (4)

Answer 12

Classic triad of upper tract, lung and kidneys.
Lungs most commonly involved (95%).
Most commonly nodules with cavitation, with random distribution and about half of them cavitating.
May see ground glass changes suggesting haemorrhage.

Question 13

Goodpasture syndrome - definition/trivia (2)

Answer 13

Autoimmune pulmonary and renal syndrome.
Favours young men.

Question 14

Goodpasture syndrome - features (4)

Answer 14

Bilateral coalescent airspace opacities, look like oedema but are haemorrhage.
Resolves quickly (2 weeks).
Recurrent bleeding episodes can lead to fibrosis or haemosiderosis (iron deposits manifest as small, ill defined nodules)

Question 15

Pleural plaque - features (3)

Answer 15

Asbestos related.
20-30 year lag time after exposure,
Usually spares costophrenic angles.

Question 16

Pleural calcifications - non-asbestos causes (4)

Answer 16

Old haemothorax,
Old infection,
TB,
Extraskeletal osteosarcoma

Question 17

Mesothelioma - trivia (4)

Answer 17

Most common pleural cancer.
80% had asbestos exposure.
30-40 year lag.
Development is NOT dose dependent.

Question 18

Mesothelioma - features (3)

Answer 18

Buzzword - pleural rind.
Tendency for direct invasion.
Extension into the fissure is highly suggestive.

Question 19

Fibrous tumours of the pleura - trivia (2)

Answer 19

NOT related to asbestos, smoking or environmental pollutants.
50% found incidentally.

Question 20

Pleural mets - trivia (3)

Answer 20

Adenocarcinoma is most likely subtype to met to pleura.
Lung Ca is commonest primary (then breast, then lymphoma).
Pleural effusion is commonest manifestation of pleural mets.

Question 21

Fibrous tumours of the pleura - features (3)

Answer 21

Solitary tumours arising from visceral pleura.
Can get large and cause chest pain.
Associated with hypoglycaemia and hypertrophic osteoarthropathy

Question 22

Pleural lipoma - trivia (3)

Answer 22

Most common benign soft tissue tumour of pleura.
Don’t cause rib erosion.
Never become Sarcoma.

Question 23

Pleural lipoma - features (2)

Answer 23

Pts sometimes feel urge to cough.
Differential extra-pleural fat, usually bilateral and symmetric.

Question 24

Pleural effusion - trivia (3)

Answer 24

175ml to be seen on frontal CXR (75 for lateral).
Can be exudate or transudate (based on Lights criteria).
Elastic/compressive atelectasis of adjacent lung.

Question 25

Subpulmonic effusion - features (3)

Answer 25

Effusion between lung base & diaphragm.
More common on right, with ski-sloping or lateralisation of the diaphragmatic peak.
Lateral decub to confirm diagnosis.

Question 26

Empyema - features (3)

Answer 26

Essentially an infected pleural effusion.
More common with AIDS.
Usually more asymmetric. Also feature enhancement of the pleura, septations, or gas.

Question 27

Empyema vs pulmonary abscess

Answer 27

Empyema is lentiform, pulmonary abscess is round.
Empyema has split pleural sign (thickening & separation of visceral & parietal pleura). Abscess has claw sign (acute angle with pleura).
Empyema is treated with chest tube, abscess is not (risk of bronchopleural fistula).

Question 28

Empyema Necessitans - features (2)

Answer 28

Empyema invades chest wall and into soft tissues.
Commonly seen in TB (70%) or actinomyces.

Question 29

Diaphragmatic hernia - features (3)

Answer 29

Congenital or acquired (trauma).
Congenital are commonest in left posterior (Bochdalek), anterior right and small ones (Morgagni) less common.
Traumatic more common on left (Liver acts as a buffer).

Question 30

Diaphragm paralysis - features (4)

Answer 30

Idiopathic in 70% of cases.
Phrenic nerve compression from lung cancer is common cause in exams.
Right diaphragm is normally higher, so higher left is sus.
Fluoro used to make diagnosis (paradoxical upward movement on sniff test).