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Chest > B&H > Flashcards

B&H Flashcards

1
Q

How to evaluate proper CXR technique?

A

PRIM

  • penetration
  • rotation
  • inspiration
  • motion
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2
Q

Utility of lateral decubitus CXR

A
  • detect small pleural effusion on ispilateral side (5ml)
  • detect small PTX on contralateral side (15ml)
  • detect the free-flowing nature of pleural effusions
  • detect air-trapping in check valve bronchial obstruction in a patient who is unable to cooperate for inspiratory/expiratory CXR
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3
Q

Normal tracheal caliber

A
  • 25 mm in men
  • 21 mm in women
  • coronal : sagittal = 0.6 : 1.0
    • if ratio < 0.6, then saber sheath trachea
    • COPD
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4
Q

Maximal thickness of right paratracheal strip and posterior tracheoesophageal stripe?

A
  • right paratracheal stripe < 4mm
  • posterior tracheoesophageal stripe < 5mm
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5
Q

Bronchioles

A

terminal bronchioles –>

respiratory bronchioles –>

alveolar ducts and alveolar sacs

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6
Q

Pulmonary alveolar epithelial cellls

(pneumocytes)

A
  • Type 1 pnemocytes
    • 95%
    • invisible by light microscope
    • incapable of mitosis/repair
  • Type 2 pneumocytes
    • 5%
    • visible by microscpe
    • capable of mitosis, produces type 1 pneumocytes
    • produces surfactant
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7
Q

Where does the minor fissure projects on a frontal PA CXR?

A

level of the right 4th rib

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8
Q

Azygos fissure

A
  • due to incomplete migration of the azygos vein to its normal position at the right tracheobronchial angle
  • 4 layers of pleura
    • 2 visceral
    • 2 parietal
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9
Q

Bronchial artery

A
  • Right - 1 - posteriorly from aorta
  • Left - 2 - anteriorly from aorta
  • 2/3 - drains into the pulmonary venous system via the bronchial veins - small right to left shunt
  • 1/3 - drains in to the azygos and hemiazygos systems
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10
Q

Approach to CXR

A
  1. Soft tissues
  2. Bones
  3. Mediastinum
  4. Lungs
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11
Q

Convexity to the azygoesophageal recess

A
  • superior third - subcrinal lymph node or mass
  • middle third - confluence of right pulmonary veins or the right border of the left atrium
    • left atrial dilatation produces double density interface
  • inferior third - sliding hiatal hernia
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12
Q

Pectus excavatum

A
  • leftward cardiac displacement
  • loss of the interface betwen right heart border and medial right middle lobe
  • not to be confused with RML pneumonia
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13
Q

Aortic nipple

A

left superior intercostal vein

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14
Q

Heart borders on CXR

A
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15
Q

Left atrial appendage

A
  • should be concave
  • straightening or convexity is seen in patients with rheumatic mitral valve disease and left atrial enlargement
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16
Q

Good inspiration

A

10th posterior rib

6th anterior rib

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17
Q

Pericardium

A
  • thin line represents the pericardial layers between the epicardial and pericardial fat
  • nodularity or >2mm thick is abnormal
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18
Q

Diaphragmatic opening

A
  • aortic hiatus
  • esophageal hiatus
  • IVC hiatus
  • foramen of Morgagni
  • foramen of Bochdalek
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19
Q

Aortic hiatus

A
  • aorta
  • thoracic duct
  • azygos and hemiazygos veins
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20
Q

Esophageal Hiatus

A
  • esophagus
  • vagus nerve
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21
Q

Airspace communications

A
  • pores of Kohn - intralveolar channels
  • canals of Lambert - bridging terminal bronchioles with alveoli
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22
Q

Bat wing airspace opacities

A
  • pulmonary edema
  • pulmonary hemorrhage
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23
Q

Ventilated pts recieving 100% O2 can have completely collapsed lung in a few minutes

  • bronchogenic carcinoma/endobronchial lesion
  • endotracheal tube malposition
  • mucus plugging
  • foreign bodies
A

Pure O2 is absorbed fast by the lungs

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24
Q

Only direct radiographic sign of lobar atelectasis

A

Dispacement of an interlobar fissure

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25
Q

Indirect signs of lobar atelectasis

A
  • increased density of the atelectic lung
  • bronchovascular crowding
  • ipsilateral diaphgragm elevation
  • ipsilateral tracheal/mediastinal shift
  • hilar elevation in upper lobe atelectasis
  • hilar depression in lower lobe atelectasis
  • compensatory hyperinflation of other lobes
  • shifting granuloma - towards the collapsed side
  • ipsilateral small hemithorax - close proximity of the ribs - only if chronic atelectasis
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26
Q

Rounded atelectasis

A
  • pleural disease/thickening
  • curvilinear bronchovascular bundle/comet tail
  • acute angle with the pleura
  • enhances following IV contrast
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27
Q

LUL collapse/atelectasis

A
  • best seen in lateral projection
  • lateral - major fissure shifts anteriorly and marginating a long narrow band of increased opacity paralleling the anterior chest wall - the collapsed LUL
  • frontal - a veil of increased opacity over the left upper hemithorax
  • Luftsichel sign - air sickel sign - overinflated superior segment of LLL interposed b/t aortic arch and the collasped LUL
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28
Q
A
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29
Q

Lobar atelectasis

vs

Lobar pneumonia

A
  • atelectasis - volume loss; no airbronchogram - no air is the cause of the collapse
  • consolidation - volume preserved - with pus and exudate; airbronchogram - consolidation orginates from the alveolar space
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30
Q

Mucoid impaction

aka

Bronchocele

A
  • non-obstructive bronchiectasis
    • cystic fibrosis
    • ABPA
  • obstructive bronchiectasis
    • endobronchial tumor
    • bronchial atresia
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31
Q

Pneumatocele

A
  • thin-walled, gas-containing structures representing distended airspaces distal to a check-valve obstruction of a bronchus or bronchiole
  • common - Staph aureus, trauma
  • generally resolve in 4 - 6 mons
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32
Q

Focal lucent pulmonary lesions

A
  • cavity - necrosis; communicating with airway
    • > 1mm thick
    • abscess, neoplasm
  • bulla
    • < 1mm thick
    • > 1cm in diameter
  • bleb
    • < 1cm in diameter
    • in visceral pleural surface, apical
  • air cyst
    • intraparenchymal gas collection
    • > 1mm thick
  • pneumatocele
    • thin-walled cystic lesion
    • staph infection or post-traumatic
    • self-resolving
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33
Q

Non-pulmonary causes of

unilateral pulmonary hyperlucency

A
  • pt rotation - increased density over the lung rotated away from the cassette
  • Poland syndrome - congenital absence of pectoralis muscle
  • mastectomy
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34
Q
A

Poland Syndrome

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35
Q

True/pulmonary

unilateral hyperlucent lung

A
  • primary vascular abnormality
    • pulmonary artery hypoplasia
    • lobar resection
    • pulmonary arterial obstruction
  • shuting of blood away from abnormal lung
  • check-valve effect from endobronchial mass/foreign body
  • Swyer-James syndome
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36
Q
A

Swyer-James syndrome

  • Adenoviral infection during infancy
  • asymmetric bronchiolitis obliterans –> secondary decreased vascularity –> collateral air drift and airtrapping
  • Unilateral hyperlucent lung
  • Small or normal-sized hemithorax
  • Overinflation of contralateral lung
  • Diminutive pulmonary hilum
  • Decreased peripheral pulmonary arteries
  • Mediastinal shift toward the hyperlucent thorax
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37
Q

DDx of unilateral hyperlucent thorax

A
  • technical
    • rotation
  • chest wall
    • mastectomy
    • Poland syndrome
  • vasculature
    • pulmonary artery hypoplasia/stenosis
    • pulmonary embolism
  • pleural disease
    • anterior ptx
  • airways
    • emphysema
    • large bulla
    • endobronchial obstruction/FB
    • congenital lobar emphysema
    • post-infectious bronchiolitis obliterans - Swyer-James syndrome
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38
Q

Presence of calcification within an untreated mediastinal mass virtually excludes what?

A

Lymphoma

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39
Q
A

Pneumomediastinum

  • most common finding is air outlining the left heart border
  • contnous diaphgram sign
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40
Q

Upper limits of interlobar pulmonary artery

A
  • men 17mm
  • women 15mm
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41
Q

Classification of thymic tumors

A
  • benign - thymoma
    • invasive
    • non-invasive (encapsulated)
  • malignant - thymic carcinoma
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42
Q

Typical age of thymoma

A

45-50 years old

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43
Q

What is thymoma associated with

A

Myasthenia gravis

and other autoimmune dz

  • pure red cell aplasia
  • graves disease
  • sjogren’s syndrome
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44
Q

Low grade

vs

high grade

thymomas

A

High grade thymomas

  • larger
  • irregular margins
  • heterogenous enhancement
  • necrosis
  • calcification
  • mediastinal nodal metastases
  • drop metastasis to the dependent portions of the pleural space*
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45
Q

DDx of thymic masses

A
  • thymoma - invasive vs noninvasive
  • thymic carcinoma
  • thymic cyst
  • thymolipoma
  • thymic hyperplasia
  • thymic neuroendocrine tumors
  • thymic lymphoma
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46
Q

Thymic cyst

A
  • Congenital
    • unilocular
    • rare
  • Acquired
    • multilocular
    • AIDS, post-radiation/sx, Sjogren syndrome, MG, aplastic anemia
    • may mimic cystic degeneration of thymoma
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47
Q

Thymolipoma

A
  • pliable nature
  • envelopes the heart and diaphgram
  • curable if resected
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48
Q

Thymic neuroendocrine tumor

aka

Thymic carcinoid

A
  • most common histology - thymic carcinoid
  • carcinoid -> atypical caricnoid -> small cell
  • 40% - cushing syndrome due to ectopic ADTH secretion
  • can’t be distinguished from thymoma on CT
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49
Q

Thymic hyperplasia

A
  • most common in children
  • rebound effect in response to
    • an antecedent stress
    • discontinuation of chemoRx
    • treatment of hypercortisolism
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50
Q

Thymic lymphoma

A
  • most ocmmonly involved in nodular sclerosing subtype of Hodgkins dz
  • presence of other lymphadenopathy suggest the Dx
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51
Q

Hodgkin disease

vs

NHL

A
  • Hodgkin disease
    • almost always involves mediastinal/hilar nodes
    • contiguous nodal spread
    • localized - radiation
    • widespread - chemo Rx
  • NHL
    • only involves one mediastinal/nodal group
    • multifocal disorder; unpredictable
  • Calcification in untreated lymphoma is extremely uncommon
  • Lung parenchymal involvement is due to direct extranodal extension from hilar nodes along the bronchovascular lymphatics
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52
Q

Solid teratoma

vs

cystic teratoma

A

solid teratoma

  • usually malignant
  • exclusively in male
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53
Q

What does mediastinal lymphadenopathy look like

for patients with lymphoma?

A

bilateral LAD

but asymmetric

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54
Q

Isolated posterior mediastinal LAD

A

Usually only seen in patients with NHL

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55
Q

Sarcoidosis

vs

Lymphoma and metastases

A
  • sarcoidosis - bilateral and symmetric;
    • enlarged lymph nodes do NOT coalesce
  • lymphoma/mets - bilateral but asymmetric
    • intranodal tumor extends through the nodal capsule to form conglomerate enlarged nodal masses
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56
Q

Castleman disease

A

Angiofollicular lymph node hyperplasia

aka

Castleman disease

  • intense enhancement
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57
Q

Foregut cysts

A
  • bronchogenic cyst
  • enteric cyst
  • complications
    • secondary infection
    • rapid enlargement due to hemorrhage
  • CT appearance
    • well-defined, thin-walled mass
    • fluid density 0-10 HU
    • does not enhance
    • > 40 HU due to mucoid material, milk of calcium, blood
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58
Q

Pericardial cyst

A
  • right anterior cardiophrenic angle
  • CT - smooth, sharply marginated, low-attenuation mass
  • MR or US - subxyphoid approach - simple cyst
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59
Q

Lymph nodes with central calcification

A
  • TB
  • Fungal
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60
Q

Lymph nodes with peripheral calcification

aka

eggshell calcification

A
  • sarcoidosis
  • silicosis/CWP
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61
Q

Lymph nodes that are hypervascular

intensely enhancing

A
  • carconoid tumor/small cell carcinoma
  • Kaposi sarcoma
  • metastases
    • RCC
    • thyroid
  • Castlman disease
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62
Q

Lymph nodes that are centrally necrotic

A
  • mycobacteria/TB
  • fungus
  • metastases
    • squamous cell carcinoma
    • seminoma
    • lymphoma
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63
Q

DDx for anterior mediastinal mass

A
  • thymic masses
  • thyroid masses
  • germ cell neoplasms
  • lymphoma/lymph nodes
  • ectopic parathyroid mass
  • mesenchymal tumor
    • lipoma
    • hemangioma
    • leiomyoma
    • liposarcoma
    • angiosarcoma
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64
Q

DDx of middle medistinal mass

A
  • lymph node masses
    • malignancy
    • infection
    • idiopathic - sarcoidosis/Castleman
  • foregut or mesothelial cysts
    • bronchogenic cyst
    • pericardial cyst
    • foregut duplication cyst
  • tracheal and central bronchial lesions
  • diaphragmatic hernias
    • Morgagni hernia
    • traumatic diaphragmatic hernia
  • vascular lesions
    • arterial
    • venous
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65
Q

DDx of posterior mediastinal mass

A
  • neurogenic tumors
  • esophageal lesions
  • foregut cysts
  • vertebral lesions
  • lateral thoracic meningocele
  • pancreatic pseudocyst
66
Q

Neurogenic tumors in the posterior mediastinum

A
  • peripheral (intercostal) nerves
    • neurofibroma
    • schwannoma
  • sympathetic ganglia
    • ganglioneuroma - benign
    • ganglioneuroblastoma
    • neuroblastoma - highly malignant, < 5yo
  • paraganglion cells
    • chemodectoma
    • pheochromocytoma
67
Q

Multiple lesions in the mediastinum, particularly bilateral apicoposterior mass

A

neurofibromatosis

68
Q
A

Dumbbell neurofibroma

  • tumor extension from paravertebral space into the spinal canal via an enlarged intervertebral foramen
  • high T2, high post gad
69
Q

Esophageal pulsion diverticulum

A
  • proximal
    • at cervicothoracic junction
    • Zenker’s diverticulum
  • distal
    • juxtadiaphgramatic mss with an air-fluid level
70
Q

Hiatal hernia

2 types

A
  • sliding hernia - gastric cardia
  • paraesophageal hernia - gastric fundas
71
Q

Lateral thoracic meningocele

is associated with which syndrome?

A

Neurofibromatosis

72
Q

Most common posterior mediastinal mass

in patients with neurofibromatosis

A

lateral thoracic meningocele

73
Q

Location of tear in

Boerhaave syndrome

A
  • vertical tear
  • left posterolateral wall
  • esophagogastric junction
74
Q
A
75
Q

Causes of chronic sclerosing/fibrosing mediastinitis

A
  • histoplasmosis
  • TB
  • radiation
  • drugs - methysergide
76
Q

Most commonly affect structure in

chronic sclerosing/fibrosing mediastinitis

A
  • SVC
77
Q

Most common CXR finding of

chronic sclerosing/fibrosing mediastinitis

A

asymmetric, lobulated widening

of the upper mediastinum

78
Q

Most common cause of pneumomediastinum

A

air from the lungs

  • sudden rise in intrathoracic and intraalveolar pressure
  • air dissecting along the bronchovascular interstitium
  • dissects centrally - pneumomediastinum
    • Macklin effect
  • dissects peripherally - pneumothorax
79
Q

Causes of pneumomediastinum

A
  • alveolar rupture
  • tracheal/bronchial
  • esophageal
  • fistula formation
  • recent sx - sternotomy, thoracotomy
  • pneumoperitoneum
    • along the internal mammary vascular sheaths
  • pneumoretroperitoneum
    • along the aortic hiatus
  • subc emphysema in the neck, stab wound, laryngeal fracture
    • dissect along the retrophayngeal space, prevertebral space, or along the great vessel sheaths
80
Q
A

pneumomediastinum

81
Q

Ludwig angina

A
  • infection of the floor of the mouth extending inferiorly to involve the mediastinum
  • retrosternal chest pain
82
Q

Hilar mass is often obscured by

A

adjacent lung collapse

obstructive pneumonits

83
Q

Posterior mediastinal involvement in

extrathoracic malignancy

A
  • RCC, testicular cancer
  • retroperitoneal nodes –> thoracic duct –> posterior mediastinal nodes
  • if valve incompetency –> anterior, hilar lymph nodes
84
Q

Primary vs Secondary

pulmonary lymphoma

A
  • Primary - parenchymal and pleural involvement
  • Secondary - intrathoracic lymph node involvement
85
Q

Post-primary TB does NOT have?

A

Hilar or mediastinal lymphadenopathy

86
Q

Classic findings of pneumonic plague

A

Hyperdense mediastinal and hilar LAD on unenhanced CT due ot intronodal hemorrhage

87
Q

What viral infections give medistinal and hilar LAD

A

Mononucleosis

Measles

88
Q

Most common cause of BILATERAL hilar adenopathy?

A

small cell carcinoma

melanoma

lymphoma (Hodgkin dz)

89
Q

DDx for small hilum (hila)

A
  • Unilateral
    • absence or hypoplasia of PA
    • hypoplastic or hypogenetic lung - Scimitar syndrome
    • Swyer-James syndrome
    • lobar atelectasis
    • lobar resection
    • compression or invasion of PA
  • Bilateral
    • emphyema/COPD
    • obstruction of the main PA flow
      • sclerosing mediastinitis
      • valvular pulmonary stenosis
      • embstein anomaly
90
Q

Pulmonary edema

A

interstitial edema

–>

alveolar (airspace) edema

–>

impaired oxygen and CO2 exchange

91
Q

Kerley lines

A
  • Kerley A - central connective tissue septal thickening
  • Kerley B - peripheral interlobular septal thickening
  • Kerley C - network of thickened interlobular septa
92
Q

Causes of unilateral pulmonary edema

A
  • positional - pt is decubitus; may shift with pt positioning
  • protective effect - one pulmonary arterial flow is diminished by pulmonary embolus or extrinsic compression
  • re-expansion pulmonary edema from ipsilateral pleurocentesis
93
Q

Cause of alveolar pulmonary edema localized to RUL

A

Severe mitral valve regurgitation

94
Q

Causes of pulmonary edema

A
  • hydrostatic pulmonary edema
  • increased capillary permeability edema (ARDS)
  • neurogenic pulmonary edema
  • high-altitude pulmonary edema
  • re-expansion pulmonary edema
  • acute upper airway obstruction edema
  • amniotic fluid embolism
  • fat embolism
95
Q

Neurogenic pulmonary edema

A
  • following head trauma, seizure, increased ICP
  • massive sympathetic discharge from the brain
    *
96
Q

High-altitude pulmonary edema

A
  • response to hypoxia
  • scattered areas of pulmonary arterial spasm - pulmonary arterial hypertension
  • over flow of lood at thigh pressure to uninvolved areas
  • daage of capillary endothelium and increased permeability edema
  • PATCHY in distribution
97
Q

Re-expansion pulmonary edema

A
  • negative intrapleural pressure
  • free-radical injury upon reperfusion after prolonged collapse and ischemia
98
Q

Causes of pulmonary hemorrhage

A
  • spontaneous
    • thrombocytopenia
    • hemophilia
    • anticoagulant therapy
  • trauma
    • pulmonary contusion
  • embolic
    • pulmonary embolism/infarction
    • fat embolism
  • vasculitis
    • autoimmune
      • Goodpasture syndrome
      • Wegener’s granulomatosis
      • idiopathic pulmonary hemorrhage
      • SLE/RA
    • infectious
      • gram-ve bacteria
      • influenza
      • aspergillosis
      • mucormycosis
  • drugs
    • penicillamine*
99
Q

Goodpasture syndrome

A
  • cytotoxic Ab directed at the renal glomerular basement membranes and cross reacts with alveolar basement membrane
  • young adult male
  • recurrent hemorrhage leads to pulmonary fibrosis
  • Dx - immunofluorescent studies of renal or lung tissue - smooth wavy line of fluorescent staining along the basement membrane
100
Q

Goodpasture syndrome

vs

Idiopathic pulmonary hemorrhage

A
  • Goodpasture syndrome
    • young male
    • anti-GBM Ab
    • renal and pulmonary involvment
  • Idiopathic pulmonary hemorrhage
    • children, equal sex distribution
    • no anti-GMB Ab
    • no renal involvement
101
Q

Pulmonary hemorrhage can lead to

A

Elevated CO diffusion capacity

102
Q

Most common finding on CXR

in patients with PE

A
  • Majority - abnormal
    • most common finding - atelectasis - Type 2 pneumocytes ischemic -> surfactant deficiency
    • Westermark sign
    • Hampton hump
  • 40% - normal
  • Utility of performing CXR
    • rule out pneumonia, PTX
    • aid VQ scan
103
Q

How to distinguish regular pulmonary arterial hypertension from the presence of a left-to-right shunt?

A
  • PAH - pruning - enlarged main and hilar pulmonary arteries that taper rapidly toward the lung periphery
  • Left-to-right shunt - pulm vascular resitance drops initially - enlargement of both central and periphal pulmonary arteries producing “shunt vascularity”
    • later on, medial hyperplasia and intimal fibrosis –> regular PAH pruning
104
Q

Shunt vascualrity

A

Initially if there is a left to right shunt, pulm vascular resistance drops to accomodate - shunt vascularity

later, as medial hyperplasia and intimal fibrosis -> increased pulm vascular resistance –> pruning

105
Q

Pulmonary capillary hemangiomatosis

PCH

A

proliferation of capillaries throughout the pulmonary interstitium –> venular obstruction > increased pressure to pulmonary arterial side with medial hypertrophy and obliteration of vesel lumina

CXR - pulmonary artery hypertension but NO pulmonary venous hypertension

106
Q

What kind of margin is strongly suggestive of malignancy

A
  • notched/lobulated margin
  • spiculated margin
107
Q

Benign calcifications of

pulmonary nodule

A
  • complete calcification
  • central calcification - bull’s eye - histo/TB
  • concentric/laminated calcification - granuloma
  • periphralcalcification
  • popcorn calcification - hamartoma (calcified cartilaginous componenet)
108
Q

Pulmonary nodule that contains fat?

A

Dx of hamartoma

109
Q

Solitary pulmonary nodules

A
  • neoplasm
    • bronchogenic carcinoma
    • hamartoma, bronchial adenoma, granular cell myoblastoma, mesenchymal neoplasm
    • lymphoma
    • carcinoid
    • solitary metastasis
  • infection
    • septic embolus
    • round pneumonia
    • lung abscess
    • infectious granuloma
    • parasitic - echinococcal cyst
  • inflammation
    • Wegener’s granulomatosis
    • necrobiotic nodule (rheumatoid lung)
  • vascular
    • AVM
    • PA aneurysm
    • hematoma
  • airways
    • bronchogenic cyst
    • foregut duplication cyst
    • sequestration
    • mucocele
  • miscellaneous
    • round atelectasis
    • amyloidoma
110
Q

Typical findings of a pulmonary hamartoma

A
  • < 2.5 cm
  • smooth or lobulated borders
  • contain focal fat
  • popcorn calcification - multiple clumps of calcifium dispersed throughout the lesion
  • rule - hamartomas that contain calcium also contain fat!
111
Q

Bronchogenic carcinoma types

A
  • adenocarcinoma - most common
    • BAC - lepidic growth*
    • grow along pre-existing bronchiolar and alveolar without invasion or distortion of these structures
    • solitary pulmonary nodule
    • ground glass opacity
  • squamous cell carcinoma
    • hilar mass with obstructive pneumonitis
  • small cell carcinoma
  • large cell
    • large peripheral mass
112
Q

In order for a mass (squamous cell carcinoma)

to cavitate, what mus thapen?

A

Communication of the mass with the bronchial lumen

113
Q

Bronchial neuroendocrine tumors

spectrum

A
  • Kulchitsky cells (KCC)
  • KCC-1 - typical carcinoid tumor
  • KCC-2 - atypical carcinoid tumor
  • KCC-3 - small cell carcinoma (most malignant)
114
Q

Where do bronchogenic carcinomas arise from?

A
  • small cell carcinoma and squamous cell carcinoma
    • central bronchal epitheium
  • adenocarcinoma and large cell carcinoma
    • bronchial and alveolar epithelium
115
Q

Manifestation of an endobronchial obstructing lesion

A
  • lobar atelectasis, OR
  • post-obstructive pneumonitis
    • preserved volume or even increased volume
    • bulging conexity/interlobar fissure
    • “drowned lung”
    • chronic inflammatory infiltrate - alveolar filling with lipid-laden macrophages - endogeneous lipoid pneumonia
  • obstructed lung often obscures the underlying mass
    • collapsed lung - enhancing
    • mass - hypodense!
  • distal to the endonbronchial obstructing lesion - mucus plugging - mucus bronchogram
116
Q

How to differentiate a cavitating malignant lesion

from

a cavitating inflammatory lesion

A

Cavitating neoplasms tend to be thicker and more nodular than cavitating inflammatory lesions

117
Q

What findings are suggestive of a BAC

A

air bronchograms

bubbly lucencies

mixed solid/GGO

118
Q

CT angiogram sign

A
  • Diffuse form of BAC
  • low-density airspace opacification due to mucoid material produced by the malignant cells
  • surrounding enhancement pulmonary vessels
  • Other DDx for CT angiogram sign
    • BAC
    • lymphoma
    • lipoid pneumonia
119
Q

Isolated adrenal masses in patients with NSCLC

A

Twice likely to be benign adrenal adenomas than metastases

  • CT
    • unenhanced CT < 10 HU
    • enhanced delayed CT > 60% washout
  • MR
    • chemical shift
  • PET
    • high sensitivity - if negative, r/o adrenal mets
    • but low specificity - if positive, may still be adenoma
120
Q

Pulmonary carcinoid tumor

A
  • right upper and middle lobes
  • hemoptysis due to hypervascularity
  • main have
    • atelectasis or post-obstructive pneumonitis
    • hyperlucent lung due to collateral air flow and reflex hypoxic vasocontriction
  • iceberg tumor - small intraluminal and large extraluminal soft tissue component
  • marked contrast enhancement
  • may have punctate calcification
121
Q

Morphology of pulmonary metastsis

vs

bronchogenic carcinoma

A
  • pulmonary metastasis - smooth in contour
  • bronchogenic carcinoma - lobulated and spiculated
122
Q

The likelihood that a solitary pulmonary nodule

SPN

represents a mets or bronchogenic carcinoma

A
  • if synchronous extrathoracic malignancy - 50%
  • if prior malignancy - almost always a primary bronchogenic carcinoma
123
Q

How to confirm the Dx of lymphangitic carcinomatosis?

A

transbronchial bx

124
Q

Nodular lymphoid hyperplasia

A

Not quite lymphoma yet

non-neoplastic reaction proliferation of lymphocytes in the lung

125
Q

Lymphocytic interstitial pneumonitis

A
  • infiltration of the pulmonary interstitium by lymphocytes
  • associated with
    • Sjogren syndrome
    • hypogammaglobulinemia
    • Castleman syndrome
    • AIDS
  • lower lobe predominance
  • diffuse GGO with poorly defined centrilobular nodules, and thin walled cysts
126
Q
A

Lymphocytic interstitial pneumonitis

LIP

127
Q

Posttranslant lymphoproliferative disorder

PTLD

A
  • solitary or multiple sharply marginated nodules or masses
  • Rx: reduction in immunosuppression
128
Q

Pulmonary kaposi sarcoma

A
  • AIDS patients
  • pulmonary involvement always follow skin, oropharyngeal, and/or visceral involvement
  • small to medium, poorly marginated nodular and coarse linear opacities
  • extending from hilum to mid and lowe rlung
  • slow progression, relatively asymptomatic
129
Q

How to differentite

Kaposi sarcoma

vs

pneumonia

vs

lymphoma

A
  • pneumonia - both gallium and thallium avid
  • lymphoma - gallium avid only
  • KS - thallium avid only
130
Q
A

Pulmonary blastoma

  • young adults
  • extremely large at presentation
131
Q

3 potential routes of pulmonary infection

A
  • tracheobronchial tree
    • lobar pneumonia
    • bronchopneumonia
    • interstitial pneumonia
  • pulmonary vasculature
  • direct extension from the mediastinum, chest wall, and upper abdomen
132
Q

Lobar pneumonia

A
  • pneumococcal infection
  • exudate begins within distal airspaces
  • spread through pore of Kohn and canals of Lambert
  • airways are usually spared
    • air bronchograms
    • volume loss unusual
133
Q

Bronchopneumonia

A
  • most common pattern of pneumonia
  • staphylococcal pneumonia
  • centered in and around lobular bronchi
  • multifocal opacities that are roughly lobular in configuration - patchwork quilt
  • exudate within the bronchi –> no air bronchograms
  • when affected areas coalesce, may look like lobar pneumonia
134
Q
A

Bronchopneumonia

135
Q

Interstitial pneumonia

A
  • viral or mycoplasma infection
  • inflammatory thickening of bronchial and bronchiolar walls and the pulmonary interstitium –> CXR airway thickening and reticulonodular opacities
  • alveolar spaces remain aerated –> no air bronchograms
  • semental and subsegmental atelecatsis
136
Q

Bacillus anthracis infection

A
  • hemorrhagic lymphadenitis and mediastinitis - hyperdense lymph nodes
  • hemorrhagic pleurla effusions - hyperdense
  • peribronchial opacities
137
Q
A

Anthrax

138
Q

Legionella pneumophila

A
  • gram negative bacteria
  • air conditioning and humidifier system
  • may present as ROUND PNEUMONIA
  • may progress to lobar or multilobar pneumonia despite the intiation of abx rx
  • radiographic resolution of pneumonia is often prolonged and lag behind symptomatic improvemen
139
Q

Actinomycosis

A
  • normal anaerobic organism in the human oropharynx
  • causes disease when gaining access to devitalized or infected tissue
  • dental - extension from mandibular osteomyelitis
  • thoraic actinomycosis - spread contiguous tissue - pleura, chest wall, ribs
140
Q

Mycoplasma

A
  • most common atypical pneumonia
  • CXR - fine reticular pattern –> segmental airspace –> lobar consolidatoin
  • CT - tree-in-bud appearance - bronchiolitis
141
Q

Primary TB

A
  • most often affect children
  • incidence in adults increases b/c AIDS
  • most pts with primary TB are asymptomatic
  • in some patients
    • Ranke complex - calcified parenchymal focus (Ghon lesion) + nodal calcification
    • parenchymal consolidation
    • unilateral pleural effusion
    • tuberculous empyema - may break thr the parietal pleura to form an extrapleural collection - empyema necessitatis
  • hematogenous spread of infection during primary TB infection
    • lung apices
    • renal medulla
    • bone marrow
142
Q

Post-primary TB

A
  • cough & constitutional sx
    • vs. 1 TB asymtpomatic
  • apical and posterior segments of upper lobes; superior segments of lower lobes
  • cavitation
    • transbronchial spread
  • Rasmussen aneurysm - cavitary focus erodes into a branch of the pulmonary artery –> hemoptysis
  • granulomatous response - parenchymal healing
    • fibrosis
    • bronchiectasis
    • volume loss - cicatrizing atelectasis
    • PAH
    • mycetoma in TB cavity
  • broncholith - erosion of calcified peribronchial lymph node into the bronchus
  • bronchostenosis
143
Q

Milliary TB

A
  • can affect both primary or post-primary TB
  • 2-3 mm nodules - randome distribution
  • high mortality
144
Q

Atypical mycobacterial infection

A
  • most common - mycobacterium avium intracellulare (MAI)
  • typical presentation
    • like post-primary TB
  • atypical presentation
    • middle or elderly women
    • middle lobe and lingula
    • peribronchial nodules
    • tree-in-bud
145
Q

Viral pneumonia

A
  • bronchopneumonia or interstitial pneumonia
  • usually complete resolution
  • but may have
    • bronchiectasis
    • bronchiolitis obliterans - Swyer James Syndrome
    • interstitial fibrosis
146
Q
A

Healed varicella pneumonia

147
Q

Varicella-zoster pneumonia

A
  • severe pneumonia in adults
  • diffuse bilateral ill-defined nodular opacities 5-10 mm
  • usually resolve completely
  • in some patients my involute and calcified - innumerable small 2-3mm calcified nodules
148
Q

Spectrum of aspergillus caused pulmonary disease

A

aspergilloma

semi-invasive aspergillosis

invasive aspergillosis

ABPA

149
Q
A

Waterlily sign

Hydatid disease - echinococcal cyst

150
Q

Rim-enhancing lymph nodes with central necrosis on CT are characteristic finding for what?

A

TB in an AIDS patient

151
Q
A

Halo sign

  • angioinvasive aspergillosis
  • surrounding edema and hemorrhage
152
Q

What is the most common cause of fungal infection in the AIDS patients?

A

Cryptococcosis

  • AIDS-defining opportunistic infection
  • can affect any immunocompromised hosts
  • RARELY affect immunocompetent pts
  • 2 subtypes
    • cryptococcus neoformans
    • cryptococcus gattii
153
Q

PJP

PCP

A
  • fine reticular or gg pattern
  • pregressive dz - confluent symmetric a/s opacification
  • thin0walled cysts
  • pleural effusion and LAD UNCOMMON
154
Q

Pulmnoary complications post-BMT

A
  • neutropenic phase (0-1mo)
    • pulmonary edema
    • alveolar hemorrhage
    • fungal infection
    • drug reaction
  • early phase (1-3mo)
    • fungal infection
    • drug reaction
    • CMV infection
    • upper resp virus infection
    • idiopathic pneumonia
    • acute GVHD
  • late phase (>3mo)
    • bronchiolitis obliterans
    • BOOP
    • chronic GVHD
    • upper resp virus infection
    • idiopathic pneumonia
155
Q
A

Subpleural band

  • parallel the chest wall
  • asbestosis >> IPF
156
Q
A

Parenchymal band

  • asbestosis
  • sarcoidosis
  • UIP
157
Q

Honeycombing

A
  • lined by bronchiolar epithelium - bronchiectasis
  • IPF
  • chronic HSP
  • occasionally - sarcoidosis
158
Q

Gound glass opacity

A
  • pulmonary alveolar proteinosis
  • pulmonary hemorrhage
  • pulmonary edema
  • infection - PCP, CMV
  • interstitial lung dz
    • UIP
    • NSIP
    • DIP
    • HSP
    • RB-ILD
159
Q

Interstitial lung dz presents as

conglomerate masses

A
  • sarcoidosis
  • silicosis/CWP - PMF
  • post-radiation fibrosis
  • IVDU - talcosis, starch
160
Q

Manifestations of RA lung diseases

A
  • serositis
    • pericardial effusion
    • pleural effusion
  • interstitial pneumonitis
    • UIP
  • necrobiotic nodules
    • peripheral cavitating nodules, rheumatoid nodules
  • Caplan syndrome
  • bronchiolitis obliterans
  • COP
  • pulmonary arteritis
    • pulmonary arterial hypertension, right heart enlargement
    • pulm hemorrhage
  • chest wall
    • tapered distal clavicles
    • GH joint arthropathy
    • rotator tendon atrophy - high riding humeral head
    • superior rib notching/erosion

Chest (13 decks)

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