Chest Flashcards
Ddx for solitary pulmonary nodule
tumor: carcinoma, hamartoma, metastasis
Inflammation: Histo, TB coccidioidomycosis
Vascular: MAV, varix
Congenital:
Other: round pneumonia, loculated effusion, mucus plugM
Ddx for multiple pulmonary nodules
mets
Abces: staph, klebsiella, strp, (nocardia and legionella in immunocompromised)
granulomatous dz: TB or fungal (aspergillius, histo)
septic emboli
Sarcoid, RA nodules, Wegener granulomatosis
What is Wegener’s granulomatosis?
a multi-system systemic necrotizing non-caeseating granulomatous vasculitis affecting small to medium sized arteries, capillaries and veins 1, and the lungs are the most frequently involved organ, seen in 95% of cases
Appearance of pulmonary Wegener’s?
Highly varied, most commonly nodules +/- cavitation (irregular, thick-walled), hemorrhage, less commonly reticulonodular or peripheral wedge-shaped opacities
Ddx cavitary lung mass
Infxn: TB (reactivation), fungal disease, pulmonary abscess (if widespread, possibly septic emboli) squamous cell ca, wegener’s, RA,
Ddx miliary lung nodules
miliary TB, fungal dz, mets (thyroid), pneumoconiosis (silicosis - upper lobe fibrosis/nodules), old varicella, sarcoid
Ddx centrilobular nodules
Infectious bronchiolitis (MAI, TB), hypersensitivity pneumonitis (esp. if gg), endobronchial spread of tumor, RB-ILD (smokers), LCH (early), pneumoconiosis (silicosis or coal-workers’ - look for eggshell LN calcs)
Ddx cystic lung disease
emphysema, LAM (women of reproductive age), pulmonary LCH (smokers: cavitating nodules, irregular, varying sizes), PCP, LIP (peribronchovascular) post-infectious blebs Child: hydrocarbons
Ddx lower-lobe predominant ILD
UIP, collagen vascular dz (scleroderma, RA, SLE), asbestos-related lung dz, drug toxicity (eg chemo)
Ddx upper-lobe predominant ILD
postprimary TB, sarcoidosis, CF, pneumoconiosis (silicosis or coal workers’), LCH (smokers)
Ddx hyperlucent lung
chest wall abnl (on x-ray), Swyer-James, acute asthma, airway obstruction, PE (oligemia), bronchial atresia (central mass or nodule, may see mucoid impaction)
What is Swyer-James syndrome?
post-infectious obliterative bronchiolitis, generally characterized on radiographs by a unilateral small lung with hyperlucency and air trapping, CT shows the affected lung as being hyperlucenct with diminished vascularity
Ddx anterior mediastinal mass
Lymphoma, Thymic lesion (thymoma, thymic carcinoma), germ cell neoplasm, (goiter, but usually you can tell it’s from the neck)
Ddx middle mediastinal mass
LAN, vascular abnormality, foregut duplication cyst, pericardial cyst, HH
Ddx posterior mediastinal mass
Neurogenic tumor (neuroblastoma in kids, ganglioneuroma in older), lymphoma, cyst (neurenteric, foregut duplication cyst, extramedullary hematopoiesis
Differences between intralobular and extralobular sequestration
Intralobular has pulmonary venous drainage and tends to get infected. Extralobar has systemic drainage and rarely gets infected
What’s Lemierre syndrome?
Lemierre syndrome refers to rare thrombophlebitis of the jugular veins with distant metastatic sepsis seen in the setting of initial oropharyngeal infection (pharyngitis / tonsillitis +/- peri tonsillar abscess)
reverse batwing sign is likely:
Chronic eosinophilic pna (COP, vasculitis, aspiration, contusion, infarction)
Halo sign around lung nodule: most likely? Other possibilities?
Halo is hemorrhage. Classically angioinvasive aspergillosis. Others: TB, other fungal (mucor, coccidio, crypto), Wegener’s, mets
finger in glove =
allergic bronchopulmonary aspergillosis (ABPA) - overreaction to aspergillus also bronchial atresia, CF with mucus impaction
crazy paving ddx:
Alveolar proteinosis Sarcoid NSIP Organizing pneumonia (COP) Infection (PCP, viral, Mycoplasma, bacterial) Neoplasm (adeno) Pulmonary hemorrhage Edema (heart failure, ARDS, AIP)
Pulmonary LCH: who? Appearance?
Young (20-40), Hx of SMOKING Early: small peribronchiolar nodules Late: multiple irregularly-shaped cysts mid and upper lung predilection
Bilateral paraspinal masses
extramedullary hematopoeisis, NF, lymphadenopathy
perilymphatic nodules
Sarcoidosis lymphangitic carcinomatosis from lung ca, met non-lung ca (breast) silicosis
Atoll sign: aka? ddx?
reverse halo COP also regular pna, TB, fungal, Wegener’s, sarcoid
fibrosing mediastinitis: appearance? Caused by? causes what?
Fibrosis/soft tissue in mediastinum. Can compress vessels (SVC, pulmonary), central airways, or esophagus Causes - mostly idiopathic, also infection (histoplasmosis!), sarcoid, radiation, drugs (methylsergide)
centrilobular ground-glass nodules
Hypersensitivity pneumonitis, atypical infection (PCP, mycoplasma) Smokers: RB-ILD
mosaic attenuation ddx:
Black is abnl: obstructive small airways disease (asthma, obliterative bronchiolitis in lung transplant rejection, CF) PE White is abnl: ground glass (hypersensitivity pna, PCP, eosinophilic PNA, hemorrhage)
appearance of NSIP on CT
patchy, reticulonodular, ground glass, mostly subpleural. Can get some fibrosis in fibrotic subtype
Ddx airspace dz
AIR SPACED Aspiration, Inhalation, Renal failure (edema), Sarcoid, PNA, Pulmonary hemorrhage, alveolar proteinosis, Collagen Vascular dz, Eosinophilic pna, Drugs
DIseases associated with thymoma:
30% have myasthenia gravis (15% of myasthenia pts have thymoma) also aplastic anemia, cushing’s disease, hypogammaglobulinemia
Ddx of enlarged pulmonary arteries:
idiopathic/primary Increased pressures: precap (chronic PE), cap: lung fibrosis/emphysema, postcap: heart stuff (LV failure, mitral stenosis) or Pulmonary veno-occlusive disease (PVOD) Increased volume: ASD, VSD, AVM, thyrotoxicosis High flow AND pressure can lead to Eisenmenger’s with reversal of shunt (ASD, VSD, PDA) Wall prob - vasculitis (Takayasu)
Pulmonary amyloid looks like:
Two subtypes: nodular (diffuse nodules, 50% calcify, 0.5-15cm) diffuse (interlobular septal thickening, alveolar infiltrates) poor prognosis
ping-pong balls in the chest are called:
Plombage, old way to fill space treating TB
PCP appearance:
ground glass, crazy paving, pneumatoceles in 30%, rarely pleural effusion
Ddx for “tree-in-bud” and what is that
infection (incl TB and atypicals, ABPA), aspiration, diffuse panbronchiolitis, CF, tumor (eg met breast)
Ddx subpleural/peripheral opacities
*Eosinophilic pna (reverse batwing), COP, lymphoma, alveolar sarcoidosis, drugs, NSIP, pulmonary infarct, multifocal pna
Ground glass / ill-defined opacities (not centrilobular nodules)
hypersensitivity pneumonitis, PCP, eosinophilic pna, hemorrhage, DIP (smoker), inhalation injury, adenocarcinoma (Bx if it doesn’t go away on follow-up)
Ddx lower lobe lung fibrosis
UIP, NSIP, asbestosis, CVD (collagen vascular disease)
What’s the name for a cardiac mri sequence when the blood is white and it’s moving?
SSFP cine (steady state free-procession)
Myocardial delayed enhancement - subendocardial:
focal or vascular territory: ischemia
if whole inner surface: amyloid
Myocardial delayed enhancement - transmural
ischemia (and if greater than 50% no use in revascularization). Check vascular territory
Myocardial delayed enhancement - at anterior and posterior aspect of septum
Hypertrophic Cardiomyopathy
Myocardial delayed enhancement - midwall, patchy
myocarditis, amyloidosis, sarcoidosis
Myocardial delayed enhancement - subepicardial
myocarditis, sarcoid
Ddx consolidation
Pus: infectious pna, including TB
Blood: hemorrhage
Cells: tumor
Fluid: edema
Ddx for perihilar opacity, sparing subpleural/periphary
Lymphoma, radiation pneumonitis, fibrosis (eg progressive massive fibrosis in pneumoconiosis), hemorrhage, drug rxn, pneumonia
Enlarged/dilated trachea ddx
Tracheobronchomalacia,
Mounier-Kuhn syndrome (aka tracheobronchomegaly)
Ddx for pericardial calcification: What does it cause?
pericarditis
surgery
radiation
uremia
Causes contstrictive pericarditis (Calcium is Constrictive, look for septal bounce)
AV groove Ca
Ddx tracheal thickening - what do you need to check for?
Two types- spares posterior membrane: relapsing polychondritis TPO (tracheobroncopathia osteochondroplastica) -submucosal chondral or calcified nodules Diffuse: Wegener’s granulomatosis sarcoidosis amyloidosis post-intubation stenosis (focal) TB (some other infections)
Nodule with surrounding ground glass
Wegener’s, hemorrhagic mets, angioinvasive aspergillosis
Causes for lobar atelectasis
Mucus plug, intrabronchial lesion, extrabronchial lesion, foreign body
cardiac wall mass ddx
mets, lymphoma, rhabdomyoma (children), angiosarcoma
smooth pleural thickening with calcification is called? causes?
Fibrothorax Causes: tuberculosis thoracic empyema asbestos related pleural disease rheumatoid arthritis haemothorax
Causes of pericardial thickening
Viral, rheumatologic, mets (esp if nodular)
What is Eisenmenger syndrome?
Reversal of a left to right shunt such that there is right to left shunting - VSD, ASD, PDA
What problem is associated with aortic coarctation?
Bicuspid aortic valve in 50% Interestingly, pseudocoarct also has 50% bicupid valve
Ddx for right cardiophrenic mass
Pericardial cyst, fat, Morgagni hernia, LAN, thymoma, pleural tumors
Heart valve mass ddx:
vegetation, thrombus, papillary fibroelastoma (most common but usually very small), mets, myxoma (rare)
Atrial mass ddx:
Myxoma (75% LA) - often prolapses -if so, call the clinician (concern for embolization), thrombus, lipoma, mets
Hypertrophied septum
HCM - likely HOCM. Check for SAM Rx: EtOH ablation or surgery.
When do you image for delayed enhancement cardiac MRI images?
10-15 minutes
Ddx pneumopericardium
Trauma/surgery, infection, tumor with fistula
Right-sided aortic arch: types? assocated with anomalies?
Mirror image branching: associated with other congenital cardiac anomalies 98% of the time Aberrant left subclavian artery - associated with other cardiac defects 5-10% of the time
dilated aberrant subclavian origin is called:
Diverticulum of Kommerell
Ddx bronchiectasis:
post-infectious or aspiration CF (upper) ciliary dyskinesia/Kartagener’s (lower) ABPA fibrosis Mounier-Kuhn
What infectious agent is characteristic of CF?
pseudomonas
How does radiation dose compare for prospective vs retrospective gating of cardiac CT?
Prospective is 80% less radiation, requires regular rhythm on EKG Retrospective is less technically demanding
What does carcinoid of the heart involve?
fibrous plaques of the tricuspid and pulmonary valve leading to right heart failure
What’s a pseudocoarctation?
One that is not hemodynamically significant
fatty right ventricle wall = What’s the concern?
ARVD - arrythmogenic right ventricular dysplasia (fatty and fibrofatty variants) Causes sudden death
Ddx bronchiectasis
CAPT K has Mournier Kuhn C - cystic fibrosis / congenital cystic bronchiectasis A - allergic bronchopulmonary aspergillosis (ABPA) P - postinfectious (most common) T - TB (granulomatous disease) K - Kartagener’s syndrome M - Mounier Kuhn syndrome (tracheobronchomegaly)
What’s the snowman sign? What does it mean?
Widened superior mediastinum for TAPVR (pt must have a shunt, usually patent foramen ovale)
What’s LAM associated with?
TS - tuberous sclerosis
What’s the difference between a true and false left ventricular aneurysm?
True: all layers, not that dangerous. Wide neck, tends to have clot. False: contained rupture, very dangerous, usually after MI. Narrow neck.
Cardiac: the LA is enlarged. What’s the differential, how do you choose?
Mitral valve problem: Normal sized LV: mitral stenosis (or prolapsing myxoma) 2/2 rheumatic heart dz. Look for domed mitral valves. Larve LV: mitral regurgitation
Ddx cardiac mass:
Thrombus mets, incl. lymphoma vegitation (valves) myxoma (most common benign) angiosarcoma (most common malignant)
What’s a significant coronary artery stenosis?
For most: 70% For L main: 50%
What cardiac anomalies are most commonly associated with a R aortic arch?
TOF, Truncus
What’s esophageal rupture called? What if the mucosa’s just torn? What are they caused by?
Boorhaave’s syndrome - vomiting, endoscopy, surgery Torn mucosa = Mallory-Weiss (usually vomiting or coughing)
How much enhancement can a pulmonary nodule have to be considered probably (95%) benign?
less than 15-20 HU
endobronchial mass:
carcinoid, adenoid cystic, sq. cell, mucoepidermoid (of course, r/o foreign body or mucus)
What’s it called when a thoracic infection extends into the chest wall?
Empyema necessitans (TB, actinomycosis, nocardia)
peribronchovascular ill-defined/flame-shaped opacities
Kaposi sarcoma
causes of unilateral right pulmonary edema
MI with rupture of mitral papillary muscle positional (pt lying on that side) PE on less affected side s/p lung transplant w/ reperfusion edema
Tracheal mass ddx:
Squamous cell ca, adenoid cystic, esophageal cancer eroding, mets (H&N, lung, melanoma, breast, renal)
Head cheese sign in lungs
Mixed gg and air trapping: HP (DIP, mycoplasma/atypical pna)
continuous diaphragm sign means:
Pneumoperitoneum, pneumopericardium, or pneumomediastinum
Causes of pneumomediastinum
retroperitoneal air tracking superiorly, asthma, ruptured esophagus (Boorhaave)
Scimitar syndrome - describe: associations?
Partial anomalous pulmonary venous return, on R, often hypoplastic R lung. Associated with pulmonary sequestration
what’s the appearance of the ascending aorta in Marfan’s?
Annuloaortic ectasia - does not spare the sinotubular ridge
what’s the normal thickness of the pericardium?
2mm above 4 is clearly pathologic
how do you measure velocity in cardiac MRI?
phase contrast
Complications of a myocardial bridge?
(coronary coursing through myocardium) vasospasm, angina
What’s the middle artery called in trifurcation of the left coronary?
Ramus intermedius
Dilated, tortuous coronary arteries - what from?
ALCAPA - anomalous left coronary artery from the pulmonary artery causes collateral formation, steal (left coronary to pulmonary), and ischemia
LV noncompation - complications?
thrombus, failure, arhythmia
Name for spade-shaped heart, apical ballooning
Takotsubo - stress, not ischemic (Don’t Take it So Bad)
pulmonary artery aneurysm adjacent or within a tuberculous cavity is called
Rasmussen aneurysm
What is the galaxy sign in the lung?
Sarcoid nodule with multiple, maybe gg satelites (can also be TB)
What is stunned myocardium? What is hybernating myocardium? Should they be revascularized?
Stunned has normal or near normal perfusion, but decreased or absent motion temporarily. This does not need revascularization, as it will recover on its own. It is due to ischemia that was relieved (spontaneously or by TPA/cath) before significant injury occurred. Hibernating is chronically ischemic myocardium which has reduced perfusion and contraction. It will help to revascularize it, it will not recover on its own
Ddx for acute airspace disease
pneumonia, hemorrhage, pulmonary edema
Causes of pulmonary edema:
Cardiogenic - usually big heart: L heart failure, mitral regurg, pericardial (effusion, contriction) Non cardiogenic - usually normal size heart: renal failure, sepsis, near-drowning, neurogenic, inhalational injury, trauma or contusion, radiation, anaphylaxis, drugs, high altitude
unilateral interstitial lung disease is most likely
lymhangitic carcinomatosis
