Chest Flashcards
UIP Pattern
- subpleural, basal
- heterogeneous dist’n
- reticulation
- honeycombing
- traction bronchiectasis
- costophrenic angles
- absence of features of other dx
Inconsistent with UIP pattern
- upper-mid lungs
- peri-bronchovascular
- GGO > reticular
- consolidation
- micronodules
- multiple cysts
- diffuse mosaic/air-trapping
NSIP
- peripheral, basal
- spares subpleural
- consolidation
acute HP
- soft GGO nodules
- loose granulomas
- centrilobular
subacute HP
- mosaic attenuation
- GGO & air trapping
- no emphysema or fibrosis
- no bronchiectasis
- centrilobular
subacute to chronic HP
- bronchocentric
- upper lungs
- bronchiectasis
- honeycomb
- GGO in bases
- centrilobular
respiratory bronchiolitis ILD
- upper lungs
- GGO
- emphysema
eosinophilic pneumonia
- dense, peripheral consolidation
stages of sarcoidosis
- lymphadenopathy
- LN & lung disease
- lung involvement only
- fibrosis (upper lungs)
which involves mediastinum more? hodgkins or nonhodgkins lymphoma
hodgkins - 75% involve mediastinum
spherical vs oblong morphology of paravertebral mass
- spherical = peripheral nerve
- oblong = sympathetic ganglion
pulmonary hypertension
mean pulm arterial pressure >25 mmHg (mPAP)
pulmonary hypertension groups
- pulmonary arterial hypertension (structural narrowing)
- left sided heart disease
- lung disease or hypoxia
- chronic thromboembolic PH/PA obstruction
- multifactorial
lymphangioleiomyomatosis associated with what?
tuberous sclerosis
most common autoimmune disorder w/ LIP
adult: sjogren
peds: HIV
interstitial lung disease most commonly associated with rheumatoid arthritis
UIP
Rasmussen aneurysm
complication of pulmonary TB
pulmonary artery aneurysm adjacent or within a tuberculous cavity
scimitar syndrome
aka hypogenetic lung syndrome
- pulmonary hypoplasia + PAPVR
- acyanotic L to R shunt
- hypoplastic right lung drained by an anomalous pulm v into systemic venous system (IVC, R atrium, portal v)
tracheobronchopathia osteochondroplastica
affects cartilage of lower 2/3 of trachea & proximal bronchi
nodular thickening +/- calc’n
anterior & lateral walls of trachea
- spares posterior (membranous) wall (like relapsing polychondritis, but more nodular)
relapsing polychondritis
recurrent multisystemic inflam’n of cartilaginous structures: tracheobronchial tree, ear, nose, larynx, peripheral jts
smooth thickening of anterior & lateral walls of trachea + luminal narrowing
- spares posterior (membranous) wall (like TO, but more smooth)
tracheobronchial amyloidosis
focal or diffuse submucosal deposition of amyloid in tracheobronchial tree
irregular nodular soft tissue thickening
- circumferential (involves posterior wall of trachea, like sarcoidosis)
obstructive effects: atelectasis, hyperinflation
tracheobronchial granulomatosis with polyangiitis
subglottic stenosis with soft tissue thickening of tracheal wall
+/- peripheral involvement, long segment stenosis
consider if airway wall thickening/stenosis with lung nodules & glomerulonephritis
galaxy sign
coalescent granuloma, classically pulmonary sarcoid (also TB)
satellite micronodules along margins of larger nodular opacities (consolidation or GGO)
organizing pneumonia histology
- Masson bodies: polypoid plugs of loosely organized granulation tissue within alveoli and alveolar ducts
- foamy macrophages
- fibroblast proliferation
organizing pneumonia causes
- infection
- connective tissue disorder
- toxic inhalational
- drug toxicity
- transplant: heart, lung, bone marrow
- cryptogenic (dx of exclusion)
same list as bronchiolitis obliterans
organizing pneumonia distribution
peripheral
peribronchovascular
perilobular arcade (surrounding the secondary pulmonary lobule)
organizing pneumonia morphology
consolidation (+/- migratory)
ground glass (immunocompromised)
reverse halo/atoll sign: central GGO w rim of consolidation
streaky/bandlike, oblong, irregular margins
Churg-Strauss syndrome
aka eosinophilic granulomatosis w polyangiitis (EGPA)
dx criteria (4/6 + bx vasculitis):
- asthma: almost all pts
- blood eosinophilia (>10% of total WBC)
- transient peripheral consolidation/GGO
- neuropathy (mono/poly)
- paranasal sinus abN: pain or radiographic
- extravascular eosinophils on bx
“asbestosis” term
specific term: presence of lung FIBROSIS secondary to asbestos exposure
- i.e. not synonymous w asbestos-related pleural dz
- consider asbestosis if ILD & pleural plaques
- fibrosis w/o pleural plaques does not exclude asbestosis
simple/classic silicosis
centrilobular nodules <1cm
- upper and posterior lung
- spares bronchovascular and septal regions (cf. sarcoid)
hilar/mediastinal LN w peripheral/egg shell calc’n
asymptomatic
10-50 year latency (w low level exposure)
if remove exposure, dz likely won’t progress
complicated silicosis
conglomerate nodules/masses >1cm - central migration to hilum with time progressive massive fibrosis - with calc'n (more than sarcoidosis) - paracicatricial emphysema, risk for PTX
symptomatic
even if exposure removed, dz will likely progress
coal workers pneumoconiosis
exposure to coal dust free of silica (washed coal)
appearance similar to silicosis
- simple: centrilobular nodules <1cm
- complicated: conglomerate nodules/masses >1cm with PMF
Caplan syndrome
seropositive rheumatoid arthritis + upper lobe predominant nodules/pneumaconiosis (classically CWP)
accelerated silicosis
high concentration exposure
5 years or less
quicker progression from simple to complicated form of silicosis
acute silicosis/silicoproteinosis
- crazy paving pattern, resembles alveolar proteinosis
- central “butterfly” alveolar opacities w air bronchograms
- hilar/mediastinal lymphadenopathy
- rapid progression over months
- evolution to fibrosis w severe architectural distortion, bullae, PTX
asbestosis
UIP pattern (histologically similar) + hx asbestos exposure
+/- calcified pleural plaques, round atelectasis
parenchymal bands, radial bands
pleural plaques
- localized (not diffuse) pleural thickening; generally w shoulders
- favour 4th-8th intercostal spaces, mediastinal & diaphragmatic pleura
- spare apices and costophrenic angles
- can be calcified or non calcified
asbestosis vs IPF
both cause UIP pattern
IPF: more advanced, progresses more rapidly, digital clubbing
asbestosis: slower progression, asbestos related pleural disease
malignant pleural thickening in mesothelioma
> 1cm thick
nodular
circumferential
affect mediastinal pleura more often
beryllium disease
looks like sarcoidosis:
- starts as bilat mediastinal/hilar LN
- +/- lungs: upper, initially nodular dz, eventually scars
- extrathoracic manifestations rare (cf. sarcoid)
dx with beryllium sensitization test (BES) test
lung cyst def’n
parenchymal lucency/low attenuation w well-defined interface with N lung
- uniform thin wall, 1-2mm (some sources: up to 3-4 mm)
- ovoid in shape (NOT multilobulated or dumbbell shaped)
- usu <1cm in diameter
- should not increase in size over time
- solitary or multifocal
pulmonary LCH - clinical
cigarette smoke exposure >95% (rxn to antigen)
M>F 20-40 yrs
peribronchiolar infiltration by Langerhans cells
often asymptomatic, cough, dyspnea
secondary spontaneous PTX
unpredictable course: spontaneous resolution vs PH, lung transplantation
pulmonary LCH - imaging
progression: nodules -> cavitating nodules -> irregular cysts w bizarre shapes
emphysema, fibrobullous dz
upper lobe, spare costophrenic sulci
*consider PLCH in adult smokers w upper lung dominant small nodular &/or cystic lung disease
centrilobular emphysema
- MC form of emphysema
- cigarette smoking
- upper lobes & superior seg lower lobes
- centrilobular low attenuation, no discernible wall +/- visualize central lobular artery
paraseptal emphysema
- alveolar ducts & sacs in periphery & peribronchovascular
- upper lung
- single tier of cystic spaces, separated by intact interlobular septa
- tall/thin young adults, Marfan/Ehler Danlos, smokers, IVDU, HIV
- gravity + incr neg pressure at apices, spont PTX
panlobular emphysema
- all components of acinus (entire 2/2 lobule)
- basal predominant
- alpha-1 antitrypsin deficiency
- other: smokers, elderly, IVDU (methylphenidate/Ritalin)
- diffuse regions of low attenuation w paucity of vascular structures
lung ossification
metaplastic bone formation in lung parenchyma
2 patterns:
- nodular: longstanding mitral valve stenosis
- dendriform pattern: chronic inflammation, interstitial fibrosis
metastatic calcification (pulmonary)
Ca2+ deposition in otherwise N tissue:
- diffuse, stippled, or circumferential
- clustered into rosettes, resemble mulberries
- poorly defined centrilobular nodules
- upper lobes: higher pH, calcium is less soluble in alkaline environment
- bone scan positive
hypercalcemic states (CKD, hemodialysis dependence)
bronchiectasis - types
cylindrical: nontapering uniform diameter, “tram-tracking”
varicose bronchiectasis: alternating dilation/narrowing, “string of pearls”
cystic bronchiectasis: marked rounded dilation, “cluster of grapes”
Williams-Campbell syndrome
rare congenital central cystic bronchiectasis
defective cartilage in 4th–6th order (central) bronchi
- preservation of trachea and main bronchi
distal regions of abN lucency (air trapping vs. bronchiolitis)
central bronchi balloon on inspiration, collapse on expiration
- helps diff from other causes of cystic bronchiectasis
allergic bronchopulmonary aspergillosis
severe central bronchiectasis with mucous plugging
occurs in cystic fibrosis and asthma
- if new consolidations or mucoid impactions in CF or asthma, consider ABPA
ABPA diagnostic criteria
"ASPER" Asthma Specific Serum antibodies (IgE, IgG) to Aspergillus Proximal (central) bronchiectasis Elevated IgE (> 1000 ng/mL) Reactive skin test (wheal)
if proximal bronchiectasis absent, dx = “seropositive ABPA”
mosaic attenuation
geographic areas of differential attenuation
- if hyperattenuating areas are abN -> ground-glass ddx
- if hypoattenuating areas are abN (too few or too small vessels) -> “mosaic perfusion”
associations with LAM
- chylothorax
- pneumothorax
typical airway feature of granulomatosis polyangiitis
subglottic stenosis
circumferential thickening trachea
classic Kaposi sarcoma features
“flame-shaped” nodules/opacities in peribronchovascular distribution
most common location bronchogenic cyst
subcarinal
secondary pulmonary lobule
bronchiole and pulmonary artery
organisms causing empyema necessitans
BATMAN breaks through barriers
Blastomyces Actinomyces Tuberculosis (75% of cases) Mucor Aspergillus Nocardia
causes DIP
- smoking
- nitrofurantoin
- busulphan
- sulfasalazine
- connective tissue disease
- dust inhalation
sparing costophrenic angles
- LCH
- HP
benign calcification patterns in pulmonary nodule
diffuse, central, laminated, popcorn if <3cm
exceptions: if >3cm (can be malignant), if known primary tumor
e. g. diffuse pattern in osteosarcoma or chondrosarcoma; central & popcorn pattern in GI-tumors, also hx of chemotherapy
round atelectasis - 4 components
round/oval pleural mass
swirl of vessels
pleural thickening or effusion
volume loss
asbestos fibres w/ higher mesothelioma association
- crocidolite
- amosite
longer, thinner
causes pulmonary artery aneurysm
- iatrogenic (swan ganz)
- infectious/mycotic (rasmussen 2/2 Tb)
- takayasu
- behcets
- hughes stovin syndrome
- trauma
- chronic PE
causes pulmonary artery stenosis
- post sx repair (TOF)
- vasculitis (behcet, takaysu)
- connective tissue disease (ehlers danlos)
- fibrosing mediastinitis
- extrinsic compression (mediastinal mass)
- congenital rubella
- william’s syndrome
is PAPVR a shunt?
yes - left to right shunt
fibrous tumor pleura is associated with?
hypoglycemia
hypertrophic osteoarthropathy
Serum markers in sarcoidosis
Elevated ACE
Hypercalcemia
1-2-3 sign
Lambda sign
Galaxy sign
All sarcoid signs
123: bilateral hila and right paratracheal
Lambda: 123 on gallium
Galaxy: mass with satellite modules
Cancer versus progressive massive fibrosis on MRI
Cancer - T2 bright
PMF - T2 dark
Kaposi sarcoma, lymphoma, PCP
Thallium and gallium findings
Kaposi:
- thallium positive
- gallium negative
Lymphoma
- thallium positive
- gallium positive
PCP
- thallium negative
- gallium positive
Note: thallium Na/K/ATP pump - “alive” positive
Gallium - iron analogue - inflammatory marker
Most common recurrent disease post lung transplant (%)
Sarcoidosis - 35%
Causes of pan lobular emphysema
- alpha one anti trypsin
- IV ritalin (methylphenidate)
Pulmonary arterial hypertension + normal wedge pressure
pulmonary veno-occlusive disease
Probable UIP pattern
- absent honeycombing *
- basal, subpleural
- heterogeneous distribution
- reticular pattern w/ peripheral traction bronchiectasis
Indeterminate for UIP pattern
- variable/diffuse
- evidence of fibrosis w/ some features suggestive of non-UIP pattern
GPA airway findings
- subglottic stenosis
- focal involvement
- tracheal involvement 15%
- bronchial involvement 50-60%
major findings LIP (lymphocytic interstitial pneumonia)
- basal predom
- bilat ground glass
- ill defined centrilobular nodules
- small subpleural nodules
- bronchovascular bundle thickening
- interlob septal thickening
- thin walled cysts (perivascular & subpleural distribution)
less common: 1-2 cm nodules, consolidation, bronchiectasis, honeycombing
Coarctation aorta
Associated with turners & bicuspid valve
Have berry aneurysms
Figure3 sign
Rib notching (4th to 8th) - rib 1/2 = Costocervical trunk
associations with thymoma
- myasthenia gravis
- pure red cell aplasia
- hypogammaglobulinemia
nerve sheath tumors vs sympathetic ganglia tumors
nerve sheath: neurofibroma, schwannoma, neurolemma
sympathetic: ganglioneuroma, neuroblastoma, ganglioneuroblastoma
length nerve sheath & sympathetic ganglia tumors
Nerve sheath tumors tend to be one or two rib interspaces in z-axis
Sympathetic ganglia tumors are longer.
what structure corresponds to the aortic nipple on CXR
left superior intercostal vein
