9/24- Cases: Pulmonary Vascular and Pleural

Question 1

Pleural effusion with the following properties suggests what?

• Bloody on inspection
• Protein of 3.1
• LDH of 600 with 90% lymphocytes

[(Serum protein 4.6, LDH 275 (nl. 200-300)]

Answer 1

• pleural/serum > 0.5
• pleural/serum LDH > 0.6
• pleural LDH > 2/3 upper limit of normal

He meets all 3 Light’s criteria, thus this is exudative

Question 2

What CXR characteristic to check for things outside lung?

Answer 2

Mediastinal windows on XR

• Won’t see lungs

Question 3

What does lymphocyte-predominant exudate indicate?

Answer 3

• TB
• Malignancy

Question 4

What conditions cause very low glucose?

Answer 4

Bad parapneumonic effusion

Question 5

What is shown here?

Answer 5

Small cell carcinoma

• Dark blue/purple
• Large, irregular cells

Question 6

What do these symptoms suggest?

• Progressive SOB
• Elevated JVD, prominent RV heave, loud P2, systolic murmur in tricuspid area, trace pedal edema
• No chest pain, cough, or fever

Answer 6

Pulmonary HTN

• Right sided heart failure

Question 7

What is shown here?

Answer 7

Enlarged pulmonary arteries

• Suggestive of pulmonary HTN

Question 8

What do these PFTs suggest?

Answer 8

• FEV1/FVC is within normal range (and not under 70); not obstruction
• FEV1 and FVC both > 80%
• RV is 92% (normal), no restriction
• DLCO is 51%; still very low when corrected for alveolar wall

Thus, normal spirometry and normal lung volume with isolated low DLCO

Question 9

What is the classic PFT for Idiopathic Pulmonary Arterial HTN?

Answer 9

• Normal PFTs and lung volume
• Isolated low DLCO

Question 10

What diagnostic tests should be done for the different classes of pulmonary HTN?

Answer 10

1. Idiopathic PAH: Labs, serology
2. Heart disease: ECHO
3. Pulmonary disease +/- hypoxia: PFTs, Polysomnogram (sleep apnea)
4. Chronic Thromboembolic (CTEPH): spiral CT, V/Q scan (for small/chronic)
5. Misc

Question 11

What can cause PAH?

Answer 11

• Idiopathic
• Scleroderma (connective tissue diseases)

Question 12

What structure is seen here?

Answer 12

Pulmonary artery

• Tunica media hypertrophy
• Intimal fibrosis of vascular bed
• In situ thrombosis*

*(this is in small pulmonary arteriole, not large level from thromboembolic condition)

Question 13

What do the following symptoms suggest?

• Cross country road trip
• Tachypnea, without
• Edema of one leg
• O2 saturation 82% on RA

Answer 13

DVT -> Pulmonary embolism