CHEST IMAGING 2 Flashcards
3 MEDISTINOSCOPY COMPLICATIONS
Complicaiton Rate
- <2% complication rate
- Mediastinal bleeding
- PTX
- Vocal Cord Paralysis
- recurrent laryngeal nerve injury
what is this?
Pathophysiology?
Rad Features?
Similar to?
- CWP
- Complicated CWP in a 57-year-old man. (a) Chest radiograph shows a conglomeration of small nodules with sparing of the bibasilar area and egg-shell calcifications in both hila. (b) High-resolution CT scan shows conglomerate masses (progressive massive fibrosis) and adjacent small nodules. A thoracostomy tube (arrowhead) was placed in the left hemithorax for a pneumothorax.
- https://www.researchgate.net/figure/Complicated-CWP-in-a-57-year-old-man-a-Chest-radiograph-shows-a-conglomeration-of_fig1_296716540
- Development depends on type of inhaled Coal
- antracite 50%
- bitumunous
- lignite 10%
- Pathology
- coal macule around resp bronchioli with ass. focal dust
- Centrilobular emphysema
- Rad
- indistinguishable from silicosis
- Simple RN penocmonociosis
- upper and middle lobe 1-5mm with surrouned emphysema
- Complicated
- with progressive massive fibrosis
- ususally eveloves from simple CWP.
- mass lesion >1cm
- Simple RN penocmonociosis
- indistinguishable from silicosis
Causes of Pneumothorax
5 categorgies
- Iatrogenic
- Trauma
- Cystic Lung Disease
- Parenchyma necrosis
- Catamenial
- Iatrogenic
- Percutaneous bx
- barotrauma
- Trauma
- Lung lac
- Tracheo-osophageal rupture
- Cystic Lung Disease
- bullae/bleb
- emphysema
- asthma
- PCP
- honey combing
- LAM
- EG
- Parenchyma necrosis
- Lung abscess
- nerotic pneumonia
- Septic emboli
- Fungal disease
- TB
- Radiation
- Cancer
- Catamenial
- recurrent spontaneous PTx during mensturation. A/W endometriosis
Assymetric Pulmonary oedema
7 causes
- PE causing unilateral obstruction of a PA
- Gravity
- Lung disease/underlying COPD
- Unilateral obstruction of a pulmonary vein (tumour)
- Severe Mitral Regurgitation (case 1)
- Re-expansion post lung collapse
- congenital or surgical right-to-left shunt (e.g. Blalock-Taussig shunt) Case2
Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 49315
Unilateral pulmonary oedema represents only 2% of cardiogenic pulmonary oedema with predilection for the right upper lobe and is strongly associated with severe mitral regurgitation 1, 2. It is hypothesised that the regurgitation jet is directed towards the right superior pulmonary vein thus preferentially increasing the hydrostatic pressure in the right upper lobe 3.
5 DDx of CALCIFIED PLEURAL PLAQUES
- FATT
- TB - usually diffuse
- Asbestos - usually focal
- FLUID
- haematoma
- infection
- TALC
Germ Cell Tumours of the thorax
5
- MNEMONIC SECTE
- Seminoma
- Embroyonal cell tumour
- Choriocarcinoma
- Teratoma
- Endodermal Sinus Tumour
A heterogeneous mass is filling most of the left thoracic cavum and displacing the mediastinum to the right. It contains a single focal calcification and a few spots of fat densities. It invades the pericardium, the thoracic wall and the diaphragm.
Case Discussion
CT-guided biopsy was performed.
Histopathology report: Non-seminomatous mixed germ cell tumour composed of mature and immature teratoma, AFP-positive yolk sac tumour, and embryonal carcinoma. Growth fraction > 50%.
The patient received neoadjuvant chemotherapy before surgical resection.
Causes of Drug induced interstitial pneumonitis/fibrosis
7
- CHEMO
- Bleomycin (case)
- Cyclophosphamide
- MTX
- Nitrofurantoin
- Gold
- Carbemazepine
- Amiodarone
https://www.patientcareonline.com/view/drug-induced-lung-diseases-state-art-review
Lower lobe predominant conditions
MNEMONIC
BADAS
- CVD
- Idiopathic Pulmonary Fibrosis
- Asbestosis
- Bronchiectasis
- Aspiration
- Drugs, DIP
- Asbestosis
- Scleorderma (and other CTDs)
Radiographic features of contusion
What 5 conditions should you think of if it doesn’t resolve after 10 days?
- Pulmonary opacities are due to Hx and oedema
- Air bronchograms are commonly seen on CT but may not be present if there is bronchial obstruction.
- Appear 6-24 hrs after injury and resolve by 7-10 days.
- If doesnt resolve after 10 days think:
- post lac h’toma
- aspiration
- HAP
- atelectasis
- ARDS
There are patchy airspace opacities seen in the right upper lobe, reflecting either pulmonary contusion or haemorrhage.
Lucency is seen adjacent to the left heart border suggestive of a pneumothorax.
1 case question available
Case Discussion
Chest injury is a common occurrence in the trauma setting, with up to one third of admitted trauma patients sustaining serious chest injuries1.
Pulmonary contusions are a common thoracic trauma injury and occurs in 30-75% of patients sustaining major chest injuries. Common mechanisms of injury include falls and motor vehicle accidents5.
Pathologically, pulmonary contusions are the result of haemorrhage from a pulmonary laceration into the surrounding alveolar spaces2.
While radiograph and CT are both used for initial assessment and evaluation, both have their limitations. Radiograph has a poor sensitivity and will miss many diagnoses of pulmonary contusion. This is often because the pathological change doesn’t occur until 6 hours later. The radiograph will often be the first imaging performed on admission, and these changes haven’t occurred yet. On the other hand, CT may be overly sensitive, picking up subtle parenchymal changes which have no or minimal clinical impact.
Chest radiograph may show singular or multiple patchy alveolar infiltrates consistent with intra-alveolar haemorrhage.
Case courtesy of Dr Dayu Gai, Radiopaedia.org, rID: 32005
What 6 mediastinal lesions can be high density on non-con CT?
- Calcified lymphnodes
- Calcified mass
- Tumor
- Goiter
- Vascular
- Chondrosarcoma (picture)
- Haemorrage
The authors report a clinical case of a primary sternal chondrosarcoma, presented as a mass in the anterior mediastinum. The patient was treated with subtotal sternectomy and sternal transplantation followed by radiotherapy. Twelve months after surgery, the patient is in good clinical condition, without any sign of tumor relapse an
Re: THORACIC TERATOMA
What % are malignant?
What tissue components?
What cell type do they arise from?
- 20% malignant
- therefore all mediastinal teratomas should be removed
- Typically present as large mass lesions
- Variable tissue contents
- Calc 30%
- fat/fat fluid levels
- Cystic Areas
- Soft tissue
Pathology
- Mediastinal teratomas are germ cell tumours arising from ectopic pluripotent stem cells that failed to migrate from yolk endoderm to the gonad.
- By definition, they should contain elements from all three embryological layers: endoderm, mesoderm and ectoderm.
- Frequently, however, elements from only two layers are evident 7 (see teratoma article).
- A mediastinal dermoid cyst can be considered a variant of mature teratoma, predominantly formed by squamous epithelium and skin appendages (ectoderm and mesoderm respectively) 9.
Teratomas may either be:
- mature: well differentiated
- immature: poorly differentiated
- with malignant transformation
- mature teratoma with non-germ cell malignancy arising from one of the components 2
Because they originate from primitive cells, they have variable neoplastic potential. Generally, cystic lesions tend to be benign whereas solid lesions tend to be malignant; however the final diagnosis is made histologically.
Mature teratomas and most immature teratomas are benign tumours, but still, carry a risk of malignancy despite being indolent initially and require close clinical, serological, and radiological follow-up, or surgical excision 4,5,9.
There is also a low incidence of malignant transformation of somatic cells (i.e. non-germ cell components) within these tumours, e.g. carcinoma, sarcoma, leukaemia 6.
Case courtesy of Dr Gagandeep Singh, Radiopaedia.org, rID: 8593
6 PULMONARY RENAL SYNDROMES
- Characterised by pulmonary haemorrhage and nephritis
- Pulmonary findings usually present as consolidation on CXR
- DDX
- GoodPasture syndrome
- Anti-GBM
- Wegners (GPA)
- ANCA +VE
- SLE
- Henoch-schonlein purpura
- Poly arteritisis nodosa
- Penicillamine hypersensitivity
- GoodPasture syndrome
What is a 7 step Approach to assessing ILD?
- Type of pattern
- Distribution
- Lung volumes
- Evolution over time
- Pleural disease
- Lymph nodes
- Oesophagus
Tracheobronchial Tear
What are the two presentations?
What is the mortality?
- High mortality 30%
- requries early bronchoscopy
- Two presentations
- Tear of Right mainstem and distal left bronchus
- PTX not relived by chest tube
- Tear of trachea and left mainstem bronchus
- air leak are usually confined to the mediastinum and subcutaneous tissues.
- Tear of Right mainstem and distal left bronchus
Diaphragmatic Tear
Where do they occur?
RAD FEATURES
4
- 90% on the left
- 90% initially overlooked
- 90% of strangulated diaphragmatic hernias are of traumatic origin
RAD FEATURES
- AFL or air collection above diaphragm
- abnormal elevation of left hemidiaphragam
- +/- herniated gastric fundus or colon
- Abnormal location of NGT
- Confirm with Coronal MRI
DDx of Ground Glass opacity HRCT
- All the ‘acute’ interstitial disease
- Allergic Hypersensitivity
- DIP
- Active IPF
- Viral
- PCP
- BOOP/COP
- EP/LCH
- Pulmonary oedema
- NSIP
Rad features of Hypersensitivity pneumonitis
acute and chronic
- ACUTE
- Reversable
- Diffuse GGO
- PN interstitial pattern
- Rare _> patchy areas of consolidation
- CHRONIC
- progressive interstitial fibrosis
- UL > LL with honey combing
- Pulmonary hypertension
- progressive interstitial fibrosis
- INTRO
- Granulomatous inflammation of bronchioles and alveoli caused by immunological response to inhaled organic material
- Type III
- antigen/antibody complex
- Type IV
- cell mediated
- Antigens are often fungal spones or avian antigens.
Case:
image1 cxr
Subtle perihilar alveolar infiltrate.
CT:
Perihilar ground glass changes
Poor expiratory effort reveals peripheral gas trapping
Case Discussion
Further history reveals the patient slept near her pet parrot.
Learning point: hypersensitivity pneumonitis can mimic asthma (clinically, not radiologically) and the patient improves with steroid therapy.
Case courtesy of Dr Yi-Jin Kuok, Radiopaedia.org, rID: 17192
What is this condition?
GOODPASTURE SYNDROME
- TRIAD OF FEATURES
- Pulm hemorrhage
- iron-deficiency anemia
- Glomerulonephritis
- Binding of Antibodies to the glomerular and alvelolar basement membranes
- Symptoms
- haemoptysis and renal failure
- Dx
- renal bx.
6 CAUSES of bronchoplural fistula
- Fistual between the bronchus and pleural space
- 2-4% of pneumonectomy patients with large fistulas
- the fluid in the pneumonetomy cavity may drown the opposite healthy lung
- Predisposing factors
- active inflammation
- necrotising infection
- tumour in the bronchial margin
- devascularised bronchial stump
- poor vascular supply
- Preop radiotherapy
- contamination
What is this?
Epidemiology
2 Associations
Rad features
- A DDX for Multiple Pulmonary Nodules
- “histiocytosis” ie LCH
- Pulmonary Langerhans cell histiocytosis (PLCH) may be seen as part of widespread involvement in patients with disseminated Langerhans cell histiocytosis or more frequently as a distinct entity in young adult smokers.
- Epidemiology
- Pulmonary Langerhans cell histiocytosis is usually identified in young adults (20-40 years of age).
- A history of current or previous cigarette smoking is identified in up to 95% of cases 1,4.
- It is a rare disorder with no well-established gender predilection, which appears to be more common in Caucasian populations 4.
- Associations
- Haematopoietic neoplasms
- acute lymphoblastic leukaemia (ALL) 11
- acute myeloid leukaemia (AML) 10
- Clinical presentation
- Presentation is usually with dyspnoea or a non-productive cough.
- Other symptoms include constitutional symptoms (fatigue and weight loss), pleuritic chest pain, or spontaneous pneumothorax 1,4. Up to a quarter of patients are asymptomatic.
- Pathology
- Langerhans cells proliferate in the bronchiolar and bronchial epithelium, forming granulomas.
- It is postulated that as these cellular granulomas evolve, peripheral fibrosis forms resulting in traction on the central bronchiole which becomes cyst-like 3. This explains the presumed evolution from a nodule, through cavitating nodule and thick-walled cysts, to the ‘stable’ thin-walled cysts 3,4. An immune-mediated mechanism has been postulated, although an inciting agent has not been isolated 4. This proliferation is accompanied by inflammation and granuloma formation. Electron microscopy may reveal characteristic Birbeck granules 1,2.
- More recent evidence suggests that pulmonary Langerhans cell histiocytosis represents a myeloid neoplasm with inflammatory properties 9.
- Radiographic features
- Pulmonary Langerhans cell histiocytosis has variable appearance depending on the stage of the disease, ranging from small peribronchiolar nodular opacities to multiple irregularly-shaped cysts. There is a mid and upper zone predilection 1,3,4.
- Plain radiograph
- The earliest change is a diffuse bilateral symmetrical reticulonodular pattern with a predilection for the mid and upper zones.
- The ill-defined nodules range from 1-10 mm in size.
- Later, cyst formation may be seen or may mimic a honeycomb appearance due to a summation of air-filled cysts. Cysts can be identified in only 1-15% of cases 1, and range from 1-3 cm in diameter. There is a preservation of lung volumes or even hyperinflation 1,3,4. Reduced lung volumes are uncommon and only seen in end-stage fibrotic cases 4. Lymph node enlargement visible on chest x-rays is rare 4.
- CT
- As is usually the case, CT and especially HRCT is superior to plain chest radiography in identifying both the reticulonodular opacities and cysts 1,3,4. Distribution is the key in differentiating pulmonary Langerhans cell histiocytosis from other cystic lung diseases with a predilection for the mid and upper zones and regional sparing of the costophrenic recesses, anterior right middle lobe and lingula left upper lobe 1,3,4.
- nodules
- more pronounced early in the disease
- may range in number from a few to innumerable
- 1-10 mm in diameter (typically 1-5 mm 4)
- centrilobular distribution - may also be peribronchial or peribronchiolar
- usually have irregular margins
- may be cavitary nodules with thick walls, later becoming cysts
- surrounding lung parenchyma appears normal
- cysts
- more pronounced later in the disease
- usually less than 10 mm in diameter
- may measure up to 2-3 centimetres in size
- the extreme bases may be preserved
- usually thin-walled, but on occasion may be up to a few millimetres thick
- confluence of 2 or more cysts results in bizarre shapes
- bilobed
- cloverleaf
- branching
- internal septations
- Other common findings include 1,3:
- ground-glass and/or reticular opacities
- DIP-like change 1
- mosaic attenuation
- septal line thickening
- emphysema
- In late disease, other findings include:
- coalescent cysts
- fibrosis
- honeycombing
- The appearance of new nodules later in the disease (when cystic change is established) indicates disease progression but is a rare finding 3.
- Treatment and prognosis
- Overall prognosis is generally good with over 50% of patients demonstrating spontaneous resolution or stabilisation even without treatment 3. This is especially the case in patients who stop smoking.
- In a minority of patients (~20%) and more frequently in those who continue to smoke, the disease is progressive with deterioration in respiratory function and eventual end-stage pulmonary fibrosis 3.
- Treatment may not be required once smoking has ceased. Corticosteroids are frequently used and appear beneficial. In patients with rapidly progressive disease, no proven therapy has been found. In some selected patients lung transplantation may be an option, provided smoking has ceased. Recurrence in the transplanted lung has been described 4.
ACUTE INTERSTITIAL CONDITIONS
I need ACUTE HELP
- Hypersensitivity
- Edema
- LPD
- Pneumonitis/Viral
8 ddx of RETROCRURAL ADENOPATHY
- INFLAMMATION
- Sarcoid
- LAM
- Amyloid
- INFECTION
- AIDS
- TB
- MAI
- NEOPLASM
- lymphoma
- mets
https://pubs.rsna.org/doi/pdf/10.1148/rg.285075187
What is this condition?
What sign/appearance is seen here?
Histoplasmoma
DDX for SPN
Histoplasmoma is the name for a specific kind of nodule secondary to granulomatous reaction to histoplasmosis infection often described as having a pathognomic target lesion appearance.
Histoplasmomas can appear in the lungs or central nervous system.
Although classically conceived as a solitary lesion, there are reports of multiple histoplasmomas in a single patient 1.
Histoplasmomas vary in size and may grow over time, and can even exceed the technical definition of a pulmonary nodule’s size (i.e. >3 cm) 3.
The initial working diagnosis was a neoplastic lesion because of the prior thyroid disease. The patient was submitted to a thoracotomy, and a wedge pulmonary resection was performed. The specimen was analyzed by frozen sections, which ruled out malignancy. The post-operative recovery was uneventful and she was discharged on day 5 after surgery, and was kept off medications.
Grossly, the lesion was round, measured 2.5 cm, and was surrounded by a dense and thick fibrous capsule with a softened and pearly-colored core, which contained concentric whitish layers resembling an onion (the latter was most evident after the formalin fixation) with few interspersed calcifications (Figure 3A and 3B). Histopathology showed a sharp single nodule limited by a fibrous capsule. The center showed coagulative necrosis with concentric lines of mild calcification. The periphery showed palisaded histiocytes and moderate inflammatory infiltrate composed of lymphocytes, plasma cells, and some multinucleated giant cells. The Gomori-Grocott with silver methenamine (GMS) stain showed numerous rounded to oval clustered 2-4 µm yeast-like forms, consistent with Histoplasma capsulatum. The Ziehl–Neelsen staining failed to demonstrate acid fast bacilli. No malignancy was evidenced (Figure 3C and 3D).
de Matos, Paulo Marcelo Pontes Gomes et al. “Pulmonary histoplasmoma: a disguised malady.” Autopsy & Case Reports 8 (2018): n. pag.
Asbestos:
4 pleural and 3 pulmonary findings
What sign is seen here?
- pleura
- pleural plaques
- diffuse thickening
- benign pleaural effusion
- pleural calc
- Lung
- intersitial fibrosis
- rounded atelectasis with commet tail sign
- Fibrous mass
The comet tail sign is a finding that can be seen on CT scans of the chest. It consists of a curvilinear opacity that extends from a subpleural “mass” toward the ipsilateral hilum. The comet tail sign is produced by the distortion of vessels and bronchi that lead to an adjacent area of round atelectasis, which is the mass 2. The bronchovascular bundles appear to be pulled into the mass and resemble a comet tail.
Adjacent pleural thickening is almost always seen and well demonstrated at CT. On administration of IV contrast, homogeneous enhancement is seen. This, however may also be seen in carcinomas and hence cannot be used as a differentiating feature.
Rounded Atelectasis. Axial enhanced CT scan of the chest shows a nodular-area of increased density (blue arrow), associated with pleural thickening and pleural plaques (yellow arrows) consistent with asbestos- related pleural disease. Red arrow point to “comet tail” density that surrounds rounded atelectasis
Case courtesy of The Radswiki, Radiopaedia.org, rID: 11894
http://learningradiology.com/notes/chestnotes/roundatelectasispage.htm
What are the differentials for Multiple pulmonary MASSES?
What is the pathophysiology of this condition
Main rad features
Rx?
Complication
- TENSION PTX
- Valve effect during insp/exp leads to progressive air accumulation in Thoracic Cavity.
- increased pressure causes mediastinal shift
- Complicaiton
- +/- vascular compromise
- Rx with chest tube
- Heimlich valve
- RAD FEATURES
- over expanded lung
- depressed diaphragm
- medistinal shift.
What is this?
Who does it tend to happen to?
Pathological origin
Tumour markers
best diagnostic clue
- Mediastinal seminomas or mediastinal germinomas are primary malignant germ cell tumoursof the mediastinum.
- Epidemiology
- Mediastinal seminomas are rare mediastinal tumours
- Account for up to one-third of primary malignant mediastinal germ cell tumours 1.
- They are almost only found in males ≥10 years
- median age being in the fourth decade
- Diagnosis
- The final diagnosis is based on pathology, gender and the absence of a testicular lesion on imaging 1.
- Pathology
- Mediastinal seminomas are germ cell tumours that originate from the thymus
- Clinical presentation
- Systemic symptoms and signs include
- weight loss
- nausea
- fever and
- gynaecomastia
- superior vena cava syndrome
- Systemic symptoms and signs include
- Markers
- β-hCG and/or LDH might be elevated
- AFP is usually normal
Case courtesy of Dr Sherif Mohsen, Radiopaedia.org, rID: 77360
- Case Discussion
- The case was pathologically proven as extragonadal seminoma.
- 90% of seminomas occur in men aged 20-40 years.
- symptoms/signs:
- chest pain, dyspnoea, cough
- fever, weakness, weight loss
- prognosis:
- 90% 5-year survival without metastases
- top differential diagnoses:
- thymoma (invasive)
- lymphoma
- teratoma
- best diagnostic clue:
- large prevascular mediastinal mass with calcifications in a young man
5 RADIOGRAPHIC FEATURES/Signs OF PE on XRAY
- Fleishner sign
- the increased diameter of the PA (16mm)
- seen in acute PE.
- Disappears in a few days
- Hampton hump
- triangular peripheral cone of infarct.
- Which is blood in the 2ndary pulmonary lobule
- should reduce in size on subsequent films
- Westermark Sign
- localized oligaemia
- wedge-shaped opacity
- pulmonary edema
- atelectasis
- pleural effusion
- Increased RA or RV
- cor pulmonale
Oesophageal tear
What are some xray findings of oesophageal tear?
where do blunt injury tears usually occur?
- Can occur at the thoracic inlet or GOJ
- blunt injuries are usually seen at the phrenic ampullar and cervical oesophagus
- where as penetrating injuries can occur any where
- XR is Non-specific.
- usually shows wide medistinum
- left pleural effusion or
- hydropnumo tx
- pneumomediastinum is common but is a non-spec finding
- Pleural fluid has low pH and High amylase
- Case courtesy of Dr Chris O’Donnell, Radiopaedia.org, rID: 35525
What are the 3 types of Kerly lines?
- Kerly A
- 2-6 cm long
- central
- no relationship to bronchoarterial bundles
- Kerly B
- <2 cm peripheral
- interlobular septal
- perpendicular to pleura
- Kerly C
- Fine network caused by superimposed kerly B lines
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 15434
Kerley A lines (orange arrows),
Kerley B lines (blue arrows) and
Kerley C lines (green arrows) are all seen, and all represent essentially the same thing; expansion of the interstitial space by fluid.
Causes of Pulmonary oedema
3 categories
16 ddx
- CARDIOGENIC
- ADULTS
- LVF from CAD
- mitral regurgitation
- Ruptured chordae
- endocarditis
- NEONATES
- TAPVC below diaphragm
- Hypoplastic Left heart
- Cor tratriatum
- ADULTS
- RENAL
- renal failure
- Volume overload
- LUNG
- lung injury causing capillary leak
- septic shock
- neurogenic shock
- Fat embolism
- inhalation
- aspiration
- drowing
- Suboptimal image as left costophrenic angle is not included in the film.
- Pacemaker device noted in the left hemithorax with one electrode in place.
- Both lungs are congested with upper lobe pulmonary venous diversion, prominent interstitial lung markings and multiple kerley B lines.
- Increased cardiothoracic ratio.
- Right costophrenic angle is clear.
- No pneumothorax.
- Findings are suggestive of cardiogenic interstitial pulmonary oedema.
Case courtesy of Dr Abeer Ahmed Alhelali, Radiopaedia.org, rID: 51448
Pulmonary oedema is graded depending on chest x-ray and pulmonary capillary wedge pressure (PCWP) is as follows:
grade 0: normal chest radiograph, PCWP 8-12 mmHg
grade 1: upper lobe diversionon a chest radiograph, PCWP 13-18 mmHg
grade 2: interstitial oedema on a chest radiograph, PCWP 19-25 mmHg
grade 3: alveolar oedema on a chest radiograph, PCWP >25 mmHg
Our case is representing grade 2 pulmonary oedema.
Ddx of Cystic/FLUID
MEDIASTINAL / THORACIC
MASSES
9
- Thymic cyst (1st picture)
- Thymoma
- Teratoma
- Pericardial cyst
- Foregut duplication
- Meningocele
- Neurenteric cyst
- Lymphangioma (2nd case)
- Cystic lymphadenopathy
FIGURE 6-13. Thymic cyst. CT scan of a 60-year-old man shows a circumscribed, rim-calcified oval mass of homogeneous fluid attenuation (C) in the expected location of the thymus gland.
https://pubs.rsna.org/doi/pdf/10.1148/radiographics.22.suppl_1.g02oc09s79
Rad features of this condition
Chronic complicaitons of this condition
GOODPASTURE SYNDROME
- Pulmonary Haemorrage
- consolidation with air bronchograms
- Clearing of haemorrage in 1-2 weeks
- Complications
- Rpt hx leads to hemosidderosis and pulmonary fibrosis
- interstitial reticular pattern
- Rpt hx leads to hemosidderosis and pulmonary fibrosis
- Renal findings clinically
17 DDX Solitary nodule
- Neoplastic
- primary malignancy
- solitary met
- hamartoma
- lymphoma
- Infection
- TB
- Histoplasmoma
- coccidiodomycosis
- Congenital
- Bronchogenic cyst
- sequestration
- vascular
- PE
- AV fistula
- infarct
- Varix
- Misc
- mucoid impaction
- round pneumonia
- LN
- loculated effusion
CF
Spectrum of disease:
GIT, Pulmonary, sinus and GU symptoms
- PULMONARY
- 100% have a chronic cough
- recurrent infections (Pseudomonas and staph)
- Progressive respiratory failure
- Clubbing
- GI
- Pancreatic insufficiency 85%
- Steatorrhea
- malabsorption
- liver cirrhosis
- rectal prolapse
- neonates
- meconium ileus
- meconium peritonitis
- Other
- sinusitis:
- hypoplastic frontal sinus
- opacification of other sinuses
- infertility in males
- sinusitis:
5 RADIOGRAPHIC FEATURES OF ASTHMA
5 complications of asthma
- Normal Xray in most patients
- air trapping, hyperinflation,
- flattened diaphragm
- increased retrosternal airspace
- Limited diaphragmatic excursion
Complications
- infection
- ABPA
- tracheal or bronchial obstruction
- PTX
- Pneumomediastinum.
ASBESTOSIS
Intro/definition
Rad findings
Increased risk of 3 things
- refers specifically to asbestos related lung disease and pulmonary fibrosis
- Reticular linear patterns
- initial subpleural location
- Progression from bases to apex
- honeycombing late in the disease
- no hilar adenopathy
- 7000 fold increase in mesothelioma
- 10% risk in lifetime
- 30-year latency
- 7 times increase in bronchogenic Ca
- 3 fold increase in GI malig.
What are 8 differentials for a densely enhancing mediastinal mass?
3 groups
- VASCULAR
- Aneurysm
- Esophageal varicies
- Vascular anomaly
- TUMOUR
- Paraganglioma
- Thyroid met
- RCC
- Castlemans
- GOITER
Cardiac Herniation
what is the radiology sign?
Mortality rate?
when does it tend to occur?
- SNOW CONE appearance of the heart border.
- Presence of a cardiac notch
- Rare
- mortality 50-100%
- most often occurs after a Right pnuemonectomy
- Requires interrapicradial resection
- heart rotated to the right
- Cardiac herniation thru pericaridial sac.
- Results in intrapericardial air
- Cardiac catheter might be kinked
http://jaccr.com/wp-content/uploads/2017/01/4.-Patrick-Figure-1.jpg
6 Infections that can cause chest wall invasion:
- Actinomycosis
- Norcardia
- TB
- Blastomyces
- Aspergillus
- Mucour
Diagnosis: Actinomycosis with empyema necessitans
https://journal.chestnet.org/article/S0012-3692(15)34611-0/fulltext
Asbestos and Malignancy
4 types of ca.
- Malignant mesothelioma
- Bronchogenic ca
- Ca of the larynx
- GI malignancies
Asbestos-Related Pleural Disease. There are innumerable pleural plaques, seen mostly en face. They have a typical appearance called a “rolled-edge” (red arrows. They have been likened to the appearance of a “holly leaf.” There is also plaque-like, pleural calcification present (yellow arrows).
http://learningradiology.com/archives06/COW%20199-Asbestos-related%20Pleural%20Disease/asbestosrelatedcorrect.htm
RAD FEATURES of BRONCHIECTASIS
3 on xray
4 on HRCT
What sign is this?
- CXR
- tramline horizontal, parallel lines
- bronchial wlal thickening
- atelectasis
- HRCT
- Conspicuous bronchi seen in out 1/3 of lung
- bronchi appear larger than accompanying vessels
- Bronchial walls thickened
-
Signet ring sign
- Focally thickened bronchial wall adjacent to PA branch
Case courtesy of The Radswiki, Radiopaedia.org, rID: 11258
The signet ring sign is seen in bronchiectasis when the dilated bronchus and accompanying pulmonary artery branch are seen in cross-section. The bronchus and artery should be the same size, whereas in bronchiectasis, the bronchus is markedly dilated.
Lung Torsion
what is a prerequisite
which lobe is most common
what are the complications?
- Prerequisite is the prescence of complete fissues
- Mass, pleural effusion, ptx, penumonia, resection of the inferior pulmonary ligament
- most commonly of the RML which can rotate on its bronchovascular pedicle
- obstruction of venous flow, ischaemia and necrosis
- Pain radiograph: mobile opacity at different locations on different views.
Rad features of this condition.
What sign is this?
How to estimate percentage?
- White line of the visceral pleura
- volume loss of the underlying lung.
- Deep sulcus sign
- lateral decubitus:
- suspected side up
- where as it should be down for fluid
- Upright expiration xray
Collins method 19
% = 4.2 + 4.7 (A + B + C)
- A is the maximum apical interpleural distance
- B is the interpleural distance at midpoint of upper half of lung
- C is the interpleural distance at midpoint of lower half of lung
- Case courtesy of Dr M Sanal Kumar, Radiopaedia.org, rID: 36707
What is Chronic Beryllium Disease?
What is it similar to?
What are two major CT/xray fidnings?
What distinguishes it from the other condition?
- Similar to Sarcoid
- Reticulonodular pattern which leads to fibrosis
- Bilateral Hilar LAD
- Distinction from sarcoid
- exposure to berylium
- neg Kviem test
- Positive berylium transformation test
- Increased beryllium in lungs/LNs
- INTRO
- Chronic beryllium lung disease (CBD) or sometimes just simply known as berylliosis refers to lung changes that can be seen with prolonged exposure to beryllium which is an alkaline earth metal that is used in many different industrial applications.
- Epidemiology
- It is reported to occur in 2-5% of beryllium-exposed individuals.
- Pathology
- It is characterised by the development of granulomatous inflammation secondary to a cell-mediated immune response to beryllium.
- While it is a multisystem granulomatous disease, it predominantly involves the lungs.
- It is sometimes classified as a form of fibrotic pneumoconiosis as well as a type of pulmonary granulomatous disease. Although some authors describe this to represent a hypersensitivity disorder rather than a true pneumoconiosis 7.
- DIAGNOSIS
- The following criteria need to be present for a definitive diagnosis:
- history of beryllium exposure
- positive blood or bronchoalveolar lavage (BAL) beryllium lymphocyte proliferation test (BeLPT)
- non-caseating granulomas on lung biopsy
- The following criteria need to be present for a definitive diagnosis:
- https://www.pennmedicine.org/-/media/documents%20and%20audio/articles/clinical%20briefings/2018/beryllium%20clinical.ashx
DDX HRCT NODULAR OPACITIES
- 1-2 mm interstitial nodules often a/w reticular opacities
-
haematogenous
- infection
- Tumour
-
Inflammatory
- sarcoid
- LCH
-
pneumoconiosis
- Silicosis
- CPW
-
haematogenous
GRADING of Cardiogenic Pulmonary Oedema
3 grades
- Fluid accumilation in the lung due to cardiogenic causes such as
- CHF
- Pulmonary venous hypertension
- follows a defined pattern
- GRADE 1: “VASCULAR REDISTRIBUTION”
- Upper lobe venous congestion
- diameter of UP vessels equal to or over diamter of LL vessels at a comparable distance from the hilum.
- Pulmnary veins in 1st IC space >3mm
- GRADE 2 “INTERSTITIAL OEDEMA”
- peribronchovasulcar cuffing
- perihilar hazee
- Kerly lines
- Unsharp central pulmonary vessels (perivascular oedema).
- Pleural effusions
- GRADE 3: ALVEOLAR OEDEMA
- Airspace density.
- Patchy consolidation
- air bronchograms
- GRADE 1: “VASCULAR REDISTRIBUTION”
Annotated alveolar oedema (white arrows) and interstitial oedema (black arrowheads).
Case Discussion
This patient presented with acute onset of dyspnoea. The frontal chest radiograph is the key to diagnosis of acute pulmonary oedema.
It shows evidence of both interstitial and alveolar oedema. Alveolar oedema manifests as ill-defined nodular opacities tending to confluence (see image with arrows). Interstitial oedema can be seen as peripheral septal lines - Kerley B lines (arrowheads).
Peripheral septal lines are due to thickening of the interlobular septa. They are 1-3 cm long and extend to the pleural surface. They may be due to pulmonary venous hypertension, as in this case. Other causes are: lymphangitis carcinomatosis; pneumoconioses; sarcoidosis; and pulmonary lymphoma.
Image contributed by: Dr Laughlin Dawes
https://radiopaedia.org/cases/apo-arrowsjpg
What is the Pathophysiology of HYPERSENSITIVITY PNEUMONITIS
- Granulomatous inflammation of bronchioles and alveoli casued by immunological response to inhaled organic material
-
TYPE III
- antigen/antibody complex
- TYPE IV
- Cell mediated/delayed
- Antigens are often fungal spores or avian related antigens
Pathophysiology[edit]
Hypersensitivity pneumonitis involves inhalation of an antigen. This leads to an exaggerated immune response (hypersensitivity). Type III hypersensitivity and type IV hypersensitivity can both occur depending on the cause.[7]
Case courtesy of Dr Mark Holland, Radiopaedia.org, rID: 19551
Causes of Bronchiolitis in ADULTS
Two major categories
- OBLITERATIVE
- Toxic fumes
- sulphur dioxide
- ammonia
- NitrousDioxide
- Lung transplant rejection
- Grave Vs Host
- Infection
- DRUGS
- Gold
- pneicillanine
- Connective tissue Disease
- Rheumatoid
- Toxic fumes
- PROLIFERATIVE
- acute infections
- Respiratory bronchioltiis
- COP
- COPD
- asthma
- Chornic bronchitis
- Footnote: High-Resolution Computed Tomographic (HRCT) images of the lung from a patient with Graft-versus-Host Disease and Advanced Obliterative Bronchiolitis. In Panel A, an image obtained during inspiration reveals dilated airways and the tree-in-bud appearance of obstructed bronchioles. In Panel B, an image obtained during an expiratory breathhold shows patchy, hyperlucent areas between areas of normal lung tissue, which is characteristic of air trapping and is referred to as mosaic attenuation.
DDX cystic Spaces HRCT
- Congenital
- CPAM
- Bronchogenic Cyst
- Sequestration
- Infectious
- TB
- Coccidiodomycosis
- PJP
- Echinococcus
- DIP (Desquamative Intersitial Pneumonia)
- LIP (Lymphoid Intersitial Pneumonia)
- Diffuse cystic lung disease
- LCH
- LAM (Lymphangioleiomyomatosis)
- Sporadic
- Tuberous Sclerosis
- Honey comb Cystic Lung disease
- Asbestosis
- IPF
- HSP
- CVD
- Sarcoid
- Misc
- Birt Hogg Dube Syndrome
- Cystic lung disease in T21
- Amyloidosis
- NF 1 associated cystic lung disease
- Light Chain deposition disease
Fat embolism syndrome (FES)
The classical clinical triad consists of:
Symptoms usually develop x days after the event.
CT findings;
- Lipid emboli from bone marrow enter pulmonary and systemic circulation when complicated by ARDS, has a high mortality rate
- Can also affect the CNS
- PResent initially with clear lungs, sudden onset of dyspnea and multiple fractures
- interstitial and alveolar hemorrhagic edema produces a varied radiographic appearance
- Opacities have a delayed onset
- clear in 3-7 days
- INTRO
- Fat embolism syndrome (FES) is a rare clinical condition caused by circulating fat emboli leading to a multisystemic dysfunction. The classical clinical triad consists of:
- respiratory distress
- cerebral abnormalities
- petechial haemorrhages
- Fat embolism syndrome (FES) is a rare clinical condition caused by circulating fat emboli leading to a multisystemic dysfunction. The classical clinical triad consists of:
- Epidemiology
- It occurs in ~2.5% (range 0.5-4%) of those with fat embolism, a phenomenon that subclinically occurs in a vast majority of patients (>90%) with bone fractures and during orthopaedic prosthetic procedures.
- Clinical presentation
- Symptoms usually develop 1-2 days after the event. Although fat emboli can virtually reach any organ in the body, the results of the embolic shower are most often evident in the lungs, brain, and skin.
- Pulmonary dysfunction is present in 75% of patients and is the earliest to be manifested 6. The presence of numerous fat globules in the small pulmonary vessels results in dyspnoea and further hypoxaemia.
- Neurological symptoms are seen in 86% of patients 6: ranging from acute confusion to drowsiness, rigidity, convulsions, or coma.
- The skin manifestation is characterised by a petechial rash in the chest, axilla, conjunctiva, and neck that appears within 24–36 hours and disappears within a week 6.
- Diagnosis
- Gurd’s and Wilson’s criteria requires the presence of at least one major and at least four minor criteria:
- Major criteria
- petechial rash
- respiratory insufficiency
- cerebral involvement
- Minor criteria
- tachycardia
- fever
- retinal changes
- jaundice
- renal signs
- thrombocytopenia
- anaemia
- high ESR
- fat macroglobulinaemia
- Pathology
- Fat particles, from bone marrow after lower extremity fracture, or from vessels and heart after cardiac surgery, are released in blood circulation then embolise to, and occlude, the pulmonary capillaries. Some of the fat globules can pass through the pulmonary capillaries and reach intracranial capillaries. Pathophysiology is thought to be most likely due to both mechanical obstruction as well as a secondary inflammatory response to the released free fatty acids from trapped fat particles within the small vessels. Consumptive thrombocytopenia and anaemia are common complications of fat embolism.
- Radiographic features
- Fat embolism syndrome remains a clinical diagnosis. Imaging may aid to exclude competing differential diagnosis or be suggestive of fat embolism.
- Chest
- CT
-
three predominate patterns are observed 1
- ground-glass change with geographic distribution
- ground glass opacities with interlobular septal thickening
- nodular opacities: no zone predominance or gravity dependence in the nodular pattern
- filling defects in pulmonary arteries are rarely described in non-fulminant syndromes
CLASSIFICATION OF PAH
What are the different causes of Pulmonary hypertension?
- PRECAPILARY HTN
- VASCULAR
- Increased flow (left to right shunt)
- PE/Chronic PE
- Vasculitis
- drugs
- Idiopathic
- LUNG
- emphysema
- interstitial fibrosis
- fibrothorax
- chest wall deformity
- reduced alveolar ventilation
- VASCULAR
- POST CAPILARY HTN
- CARDIAC
- LV failure
- Mitral stenosis
- Atrial tumour
- PULM VENOUS
- Thombosis
- Idiopathic Veno occlusive disease.
- CARDIAC
- Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rID: 12644
What is actinomycosis?
What are the thoracic manifestations?
- Uncommon indolent infection caused principally by Prokaryotic bacteria actinomyces
- CLINICAL
- Non-productive cough and low grade fever
- spread to pleura and chest wall may result in chest wall pain
- Haemoptysis
- RAD FEATURES
- lung parenchymal
- usually non segmental pneumonia in the lower zones and peripherally crossing fissures or like a mass lesion
- may involve chest wall
- empyema
- pleural thickening
- adenopathy
- bronchiectatic
- lung parenchymal
A 39-year-old man with a history of alcohol and tobacco abuse was admitted after experiencing 1 month of productive cough, night sweats, mild dyspnoea and weight loss. Physical examination revealed alteration of general state (45 kg, loss of 15 kg), mild fever (38°C) and low oxygen saturation (88%). HIV serology testing was negative. Chest X-ray and CT scan showed right upper lobe cavitation (figure 1A, B). Bronchoalveolar lavage (BAL) was performed and piperacillin/tazobactam was started. Direct examination and culture of respiratory samples were both negative for tuberculosis. Actinomyces spp was found in BAL and sputum samples. Treatment was changed to high doses of intravenous amoxicillin. Stomatological examination revealed apical lesion of teeth 16 and 28, which were removed. Six weeks after first admission to hospital, the patient had a favorable outcome with weight gain, fever clearance, regression of inflammatory syndrome and radiological improvement (figure 1C). Treatment was changed to oral therapy with amoxicillin for 4 months. The outcome was favourable.
- Sénéchal A, Valour F, Chidiac C, et al*
- Pulmonary actinomycosis with large cavitation in an alcoholic 39-year-old man*
- Case Reports 2014;2014:bcr2014206556.*
What is this condition?
What is the pathophysiology?
5 Rad findings
Silicosis
- INTRO
- silica in quartz
- severity of diease is related go the toal amount inhaled
- < 5 microns in diameter
- Rx is to stop expoure
- different to CWP as silicosis may be progressive despite removal from exposure
- Silicosis has a progressive nature despite cessation of dust exposure
- EPID
- only 5% of pts with >20 years exposure will develop a complicated form of pneumoconiosis
- mining
- quarryuing
- sandblasting
- only 5% of pts with >20 years exposure will develop a complicated form of pneumoconiosis
- PATHOLOGY
- silica is phagocytosed by pulmonary macrophages
- Breakdown of macrophage releases enzymes which produce fibrogenic response
- cytoxic reaction causes formation of non-caseating granuloma
- Granulomas develop into silicotic nodules 2-3mm diamter
- pulm fibrosis develops as nodules coalesce.
- RAD FEATURES
- NODULAR PATTERN
- common nodules 1-10mm
- Calcific nodules 20%
- Upper >lower lones
- Coalescent nodes cause areas of conglomerate opacities
- RETICULAR PATTERN
- may proceed or be with Nodular pattern
- Hilar adenopathy
- common
- egg shell calc.
-
progressive massive fibrosis
- Masses >1cm formed by coalescent nodules
- Posterior segment of Upper lobes
- Vertical orrientation
- +/- cavitation
- NODULAR PATTERN
Image 1:
Silicosis with Progressive Massive Fibrosis. There are large conglomerate upper lobe “masses” (black arrows). Multiple enlarged and calcified hilar lymph nodes are seen, many with rim-like or “egg-shell” calcification (white arrows). There is scarring in both lower lobes (green arrows).
http://learningradiology.com/notes/chestnotes/silicosis.htm
Two months postpartum with a persistent cough.
Where is the mass?
What sign is this?
Based on the location, what are the differentials?
Case Discussion
- Well defined soft tissue density projecting over the right hilum. Hilar vessels can be still appreciated. Lateral projection confirms that the mass is located in the anterior mediastinum.
- An excellent example of the hilum overlay sign.
- Differential diagnoses of an anterior mediastinal mass include:
- thymic lesions
- germ cell tumours
- thyroid and parathyroid lesions
- mediastinal lymphoma
- thoracic aortic aneurysm
- Histology confirmed nodular sclerosing subtype of Hodgkin’s lymphoma.
Case courtesy of Dr Arkadi Tadevosyan, Radiopaedia.org, rID: 53664
What is the Pathophysiology of
BRONCHIOLITIS OBLITERANS?
What is this CT of?
- submucosal and peribronchial inflammation of the mucous membranes and respiratory bronchioles with resultant concentric fibrosis and luminal narrowing
- Hyperinflation with increased parenchymal lucency.
- reduced vascular markings and central bronchiectasis
CASE
The transplanted lung has a diffuse mosaic pattern of attenuation that is accentuated on the expiratory acquisition, where sharply defined areas of decreased lung attenuation are consistent with air-trapping. A component of oligemia is also present with the areas of low attenuation (mosaic perfusion appearance). No relevant bronchiectasis or bronchial wall thickening. The left lung shows features of advanced fibrosis.
Case Discussion
This patient has had a drop of lung function in the last months, particularly with a sustained drop of the FEV1 in more than 20%. The HRCT has corroborative findings that support bronchiolitis obliterans: diffuse air-trapping and mosaic perfusion appearances.
The left lung shows diffuse architectural distortion and volume loss consistent with the known pulmonary fibrosis.
Bronchiolitis obliterans is the most common form of chronic lung allograft dysfunction (CLAD), accounting for about three quarters. Also, studies have shown that about 50% of post-lung transplant patients develop BOS within 5 years 1.
TYPES of Pulmonary infarct
Fig. 1Proximal arterial occlusion (arrow) and distal lung parenchymal opacification consistent with a peripheral consolidation mixed with ground-glass opacity (arrowheads) on soft tissue (left) and lung (right) views.
- Incomplete-infarct
- Hemorrhagic Pulmonary edema without tissue necrosis
- resolution within days
- Complete infarct
- Tissue necrosis
- Healing by scar formation
https://www.resmedjournal.com/article/S0954-6111(18)30116-1/fulltext
8 DDx CARDIOPHRENIC MASS
- Fat pad
- Diaphragmatic hernia
- anterior and right is MORGAGNI
- posterior and Left is BOCHDALEK
- pericardial cyst (pic 1)
- aneurysm
- dilated RA
- Anterior mediastinal mass
- primarily lung/pleaural mass
- Cardiophrenc angle nodes (usually lymphoma post radiation)
http://www.learningradiology.com/notes/chestnotes/pericardialcystcorrect.htm
Pericardial Cyst. Frontal and lateral views of the chest demonstrate a mass at the right cardiophrenic angle with rim-like calcification that indicates the calcification has formed in the wall of a hollow viscus. This is a characteristic location for a pericardial cyst, which is calcified in this case.
ddx of MILLARY NODULES
- INFECTION
- TB
- Histoplasmosis (Immunocomprimised) CASE
- Neoplastic
- Mets
- Breast
- Thyroid
- Chorio
- Melanoma
- Primary
- LCH/EG
- BAC
- Mets
- Silicosis
- Sarcoid
ddx of SMALL CYSTIC DISEASE
- True cyst wall
- LIP
- LAM
- LCH
- Cystic PCP
- Honey combing
- No cyst wall
- Emphysema
65 year old lady with Sjogrens disease and cystic pulmonary change from LIP
10 years follow up shows stable thin walled pulmonary cysts scattered through both lungs
https://radiopaedia.org/cases/lymphocytic-interstitial-pneumonia
8 Complications of Cystic Fibrosis
- Lobar atelectasis (especially RUL)
- Pneumonia
- Respiratory insufficiency
- Hypertrophic osteoarthropathy (clubbing)
- Recurrent PTX (2ndary to rupture of bullae or blebs)
- Cor pulmonale and PAH
- Haemoptysis
- Aspergillis superinfection
https://www.semanticscholar.org/paper/Imaging-of-Cystic-Fibrosis-and-Pediatric-Murphy-Maher/f6febcb2a0901b6228a5bade45176646e788bd2b
Fig. 2—24-year-old man with cystic fibrosis who was undergoing annual surveillance contrast-enhanced CT. Midthoracic axial CT image on lung window setting shows typical findings of advanced bronchiectasis: advanced cylindric bronchiectasis (arrows), which is most marked in right upper lobe, with associated volume loss and bronchial wall thickening (arrowheads). Chest port is shown in right anterior chest wall. Collapse
CF
8 Rad features
- Bronchiectasis
- BAR: Severe lumen > 3x larger to blood vessles
- Infection
- Peribronchial wall thickening:
- wall thickness greater than or equal to the. diamter of adjacent blood vessles
- Mucous plugging
- air trapping
- collapse
- consolidation
- Predominangtly in UL and superior segments of lower lobes.
Case Discussion
Bronchiectasis is visible in the upper zones of both lungs.
In a young patient upper zone bronchiectasis has a narrow differential with cystic fibrosis the most likely diagnosis. This is a patient with known CF.
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 6311
DDx Calcified lung nodules
- LARGE
- TUMOUR
- medullary thyroid Ca met
- Osteogenic and mucinous tumour mets
- INFECTION
- treated varricella
- Histoplasmosis
- Coccidodomycosis
- TB
- Schitosomiasis
- INHALED
- Silicosis
- CWP
- TUMOUR
- SMALL
- Alveolar microlithiasis
- Chronic venous congestion
- Metastatic calcification from renal disease (Picture)
ANTERIOR MEDIASTINAL MASSES
mnemonic
TTTT
- Thymus
- thymoma
- cystic
- benign
- invasive
- Thymic Cyst
- Thymic Ca
- Thymic carcinoid
- Thymic Lymphoma
- Thymolipoma
- thymoma
- Thyroid lesions
- TB
- Teratoma
- and other germinal cell lymphomas
- Seminoma
- embroyonal cell ca
- chorioca
- and other germinal cell lymphomas
- Terible Lymphoma
- T-CELL LYMPHOMAS
- NHL
- HL
- T-CELL LYMPHOMAS
OTHERS:
- LAD
- lymphoma
- Sarcoid
- TB
- Aneurysm
5 ddx of EGG shell calcs in hilar nodes
- Silicosis
- Sarcoid (rare and late in disease) Case in picture
- Treated lymphoma
- CWP
- Granulomatous disease such as histoplasmosis (more often causes diffuse calc).
Case courtesy of Dr Yair Glick, Radiopaedia.org, rID: 52381
POST PNEUMONECTOMY SYNDROME
- Airway obstruction that occus after pulm resection and is due to an extreme shift of the mediastinum or rotation of the hilar structures
- Occures most often after a RIGHT pneumonectomy
- or after a left pneumonectomy if a right sided arch is present.
RAD FEATURES
- Air trapping
- hyper expansion
- recurrent pneumonia
- bronchiectasis
- narrowing of bronchi or trachea
- bronchomalacia
- hyperinflation of the contralateral lung
- mediastinal shift.
What is this condition?
What is the AKA of this condition?
What patients tend to get this?
What are the complications?
what is the sign?
- Klebsiella pneumonia, also known as Friedländer pneumonia, refers to pneumonia resulting from an infection from the organism Klebsiella pneumoniae.
- Epidemiology
- There tends to be a higher prevalence in older patients with alcoholism and debilitated hospitalised patients 3.
- Pathology
- Klebsiella pneumoniae is among the most common Gram-negative bacteria encountered by physicians worldwide and accounts for 0.5-5.0% of all cases of pneumonia 2.
- Complications
- This organism can cause
- extensive pulmonary necrosis and
- frequent cavitation
- This organism can cause
- Radiographic features
- Plain radiograph
It is one of the causes that could be suspected when there is cavitatory pneumonia +/- a bulging fissure sign.
- Often there can be extensive lobar opacification with air bronchograms.
A helpful feature which may help to distinguish from pneumococcal pneumonia is that Klebsiella pneumonia develops cavitation in 30-50% of cases (in comparison, cavitation is rare in pneumococcal pneumonia). This occurs early and progresses quickly. Massive necrosis (pulmonary gangrene) is a recognised complication.
Extensive right upper lobe consolidation, with bulging of the horizontal fissure.
Sputum analysis grew Klebsiella pneumoniae.
Case Discussion
Klebsiella pneumoniae is a gram negative organism that usually affects people with alcoholism or chronic debilitating diseases (similar to other gram -ve pneumonias). On CXR, consolidation is lobar and resembles streptococcus pneumonia. Lobar expansion (e.g. bulging of the horizontal fissure in this case) is less common nowadays with modern antibiotic treatment. Also, lobar expansion is not specific for Klebsiella infection.
A helpful feature which may help to distinguish from pneumococcal pneumonia is that Klebsiella pneumonia develops cavitation in 30-50% of cases. This occurs early and progresses quickly. Massive necrosis (pulmonary gangrene) is a recognised complication. In comparison, cavitation is rare in pneumococcal pneumonia.
Lung Laceration
3 Causes
5 Complications
4 Types
- Produced by
- sharp trauma (rib fractures)
- deceleration
- implosion
- Pathogenticlaly there is a linear tear that becomes round or ovoid (pneumatocele)
- Complications
- Pneumatocele
- hemoptysis
- pleural/parenchymal hemorrhage
- BPF
- infection
- TYPES
- 1 midline +/- PTX. Shear between parenchyma and Tracheobronchial tree
- 2 paraspinal. shear due to sudden herniation of lower lobe parenchyma in front of vertebrae
- 3 subpleural: + PTX 2ndary to rib fractures
- 4 Subpleural + PTX shear site at the site of transpleural adhesion
10 DDX of Reticulonodular Opacities
on HRCT
- A reticulonodular interstitial pattern is an imaging descriptive term that can be used in thoracic radiographs or CT scans when are there is an overlap of reticular shadows with nodular shadows. This may be used to describe a regional pattern or a diffuse pattern throughout the lungs. It is a non specific imaging descriptor but can be seen in varied conditions such as:
- silicosis
- pulmonary sarcoidosis 2
- berylliosis 2
- lymphangitic carcinomatosis 2
- hepatopulmonary syndrome - basal 4
- pneumocystis pneumonia - can sometimes give a fine reticulonodular pattern 3
- bronchocentric granulomatosis 5
- pulmonary Langerhans cell histiocystosis (case)
- lymphocytic interstitial pneumonitis 6
- Erdheim-Chester disease 1
Case courtesy of Dr Hazem M Almasarei, Radiopaedia.org, rID: 57154
7 PULMONARY GRANULOMA DDX
- Diagnostic algorithm of granulomatous lung diseases.
- OP: organising pneumonia;
- EGPA: eosinophilic granulomatosis with polyangiitis;
- NSG: necrotising sarcoid granulomatosis;
- GPA: granulomatosis with polyangiitis;
- GLILD: granulomatous–lymphocytic interstitial lung disease;
- HP: hypersensitivity pneumonitis;
- PLCH: pulmonary Langerhans cell histiocytosis.
PAH
Normal values and definition
- Systolic pulmonary artery pression > x mmg or
- Mean pulmonary arterial pressure greater than x mmHg
- Normal values
- Psys: x mmhg
- Pdias: x mmHg
- Pmean: x mmHg
- Capillary wedge pressure x mmhg
- Systolic pulmonary artery pression >30mmg or
- Mean pulmonary arterial pressure greater than 25mmHg
- Normal values
- Psys: 20mmhg
- Pdias: 10mmHg
- Pmean: 14mmHg
- Capillary wedge pressure 5mmhg
- https://www.radiologic.theclinics.com/article/S0033-8389(16)30064-1/fulltext
15 Ddx of POSTERIOR MEDIASTINAL MASSES
3 major categories
1 NEUROGENIC
- PERIPHERAL NERVES
- Schwannoma
- NF1
- Neurofibroma
- SYMPATHETIC GANGLION
- ganglioneuroma
- Neuroblastoma
- Sympatheticoblastoma
- PARASYMPATHETIC GANGLION
- paraganglioma
- phaeochromocytoma
- Lateral myelomeningocele
- Tx SPINE
- Neoplasm
- hematoma
- Extramedullary hematopoiesis
- Discitis
- VASCULAR
- Aneurysm
- Azygous Continuation
Embryonal Cell Carcinoma
- Rad features
- Prognosis
- Markers
- Epidemiology
- Associations
- Diagnostic clues
- Rad features
- Mediastinal invasion
- On chest CT mediastinal embryonal carcinomas have been described as lobulated, poorly marginated and heterogeneous masses, areas of necrosis and haemorrhage are common 3-4. Pleural or pericardial effusions might be present.
- prognosis
- mean survival time <10months
- Markers
- Increased a-fetoprotein and hCG
- Epidemiology
- young men
- 8% of primary mediastinal germ cell tumours 1.
- Associations
- Kleinfelters
- Diagnostic clues
- A large heterogeneous mediastinal mass with lung metastases in young men in the setting of rapid symptom onset and an elevated LDH and serum AFP might point to a malignant non-seminomatous germ cell tumour.
https: //www.nejm.org/doi/full/10.1056/NEJM199712253372608
- A large heterogeneous mediastinal mass with lung metastases in young men in the setting of rapid symptom onset and an elevated LDH and serum AFP might point to a malignant non-seminomatous germ cell tumour.
CT Features of Adult type Bronchiolitis
- Nodules with branching opacities
- GGO + Consolidation
- Mosaic pattern (obliterative type)
- due to hypoxic vasoconstriction in areas of bronchiolar obstruction with redistribution to normal areas.
- Reduced size and number of vessels in the affected lung with air trapping on Insp/exp CT.
- therefore the apparent GG appearing lung is normal
- Bronchiectasis/bronchial wall thickening.
CT - HRCT
The presence of bronchiolitis is best assessed with HRCT. CT features include one of a combination of
- centrilobular micronodules (often seen as tree-in-bud opacities),
- bronchial wall thickening
- bronchiolar dilatation (often referred to as bronchiolectasis)
- mosaic attenuation (and/or air trapping if expiratory imaging is used)
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 24616
Prominent Hilum
ddx
3 categories
10 ddx
- TUMOUR
- central bronchogenic ca
- lymphoma
- ADENOPATHY
- INFECTION
- TB
- Fungal
- Histoplasma
- INFLAMMATION
- Sarcoid
- Silicosis
- TUMOUR
- Oat Cell (ie small cell lung cancer)
- Met
- INFECTION
- Vascular
- PA enlarged (PAH)
Left – calcified bilateral hilar lymphadenopathy in sarcoidosis
Right: Pulmonary artery hypertension
https://epomedicine.com/medical-students/chest-xray-approach-to-hilum/
Causes of Pulmonary infiltrates with Eosinophilia
4+3
- Group of disease characterised by tranisent pulmonary opacities and eosinophilia
- Loffler syndrome
- simple pulm eosinophila
- Acute eosinophilic pneumonia
- Chronic eosinophilic pneumonia
- Pneumonias of unknown origin
- Allergic broncopulmonary mycoses
- ie ABPA
- Helmithic
- Drugs
- penicilin
- tetracycline
- sulfonamides.
- Allergic broncopulmonary mycoses
- Loffler syndrome
What kind of lung markings are these?
What are the Dx/Differentials?
- Reticular pattern
- Lymphangitic carcinomatosis: irregular septal thickening, usually focal or unilateral 50% adenopathy’, known carcinoma.
- Cardiogenic pulmonary edema: incidental finding in HRCT, smooth septal thickening with basal predominance (Kerley B lines), ground-glass opacity with a gravitational and perihilar distribution, thickening of the peribronchovascular interstitium (peribronchial cuffing)
- Lymphangitic carcinomatosis.
- Lymphangitic carcinomatosis with hilar adenopathy.
- Alveolar proteinosis: ground glass attenuation with septal thickening (crazy paving).
- Cardiogenic pulmonary edema.
https://radiologyassistant.nl/chest/hrct/basic-interpretation
