CR Chest Challenge Flashcards
Case 107
Photographic negative of pulmonary edema
Chronic Eosinophilic Pneumonia
RRx - Steroids
Asthma Correlation - 50%
Case 107
Three entities that typically present with a peripheral distribution of consolidation
Chronic Eosinophilic Pneumonia Cryptogenic Organizing Pneumonia (COP) Loffler's Syndrome Pulmonary Infarcts Vasculitides
Case 108
Most common location for a paratracheal air cyst
Right posterolateral wall at the level of the thoracic inlet
Tracheal Diverticulum
Case 110 Mediastinitis Retrosternal fluid --> highly sensitive? --> specific in early post operative period?
- Yes
- No
- Specificity of retrosternal fluid for mediastinitis increases after POD 14
Case 111
What type of organism is most commonly responsible for nosocomial pneumonia?
Gram Negative
Case 111
Term used to describe cavitary pneumonia associated with intravacitary sloughed lung
Pulmonary Gangrene
Case 111
Organism most closely associated with pulmonary gangrene?
Klebsiella - not specific.. also Strep, TB, Mucormycetes
Case 112
Four types of emphysema
Centrilobular (upper lobes) Paraseptal
Panlobular (lower lobes) Paracicatrical
Case 112
Two causes of panlobular emphysema
Alpha1-antitrypsin (AAT) deficiency
IV injection of methylphenidate (Ritalin)
Case 113
Three CT findings of Obliterative Bronchiolitis
Mosaic Perfusion
Bronchial Dilitation
Air Trapping
Case 113
Four diseases or conditions that may be associated with OB
Bone Marrow Transplant RA
Viral Infections Lung Transplant
Toxic Fume Inhalation IBD
Case 113
Hallmark features of Obliterative Bronchiolitis
Mosaic pattern of attenuation
Air Trapping
Case 113
What distinguishes small airways dz from pulmonary vascular dz?
Air Trapping –> small airways dz
Case 114
Multiple pulmonary masses s/p hysterectomy
Metastatic Leiomyoma
Case 114
Slow growing pulmonary metastasis
Metastatic Leiomyoma
Thyroid CA
Salivary Gland Tumors
Case 114
Fast growing pulmonary metastasis
Sarcoma
Melanoma
Germ Cell Neoplasms
Case 115
Linear opacity coursing parallel to the pleural surface
Subpleural curvilinear line
Case 115
Linear opacity coursing perpendicular to the pleural surface?
Parenchymal bands
Case 115
Subpleural curvilinear lines and parenchymal bands are associated with what chronic infiltrative lung dz?
Asbestosis
Case 115
Findings in Asbestosis
**Thickened Septal Lines Subpleural curvilinear lines Parenchymal Bands Subpleural Dependant Density Honeycombing
Case 116 What is post-pneumonectomy Syndrome? Why do patients get dyspnea? Is this most common after left or right pneumonectomy? Treatment?
Herniation of the contralateral lung in to the resected lung cavity
Compression of the lower lobe bronchus by vascular structures
Most commonly on the right
Surgical repositioning - saline prosthesis in cavity
* RARE*
Case 117
What is Mounier-Kuhn Syndrome?
Congenital tracheobronchomegaly w/ recurrent infections
- Atrophy or absence of elastic fibers and thin muscular mucosa
- Tracheal Diverticula
- Ineffective coughing mechanism
- Pooling of secretions
Case 117
Radiologic definition of tracheomegaly?
Coronal tracheal diameter of
- > 25 mm in men
- > 21 mm in women
- measured 2 cm above the aortic arch
- on standard PA radiograph
Case 118
Most common cause of central bronchiectasis?
ABPA - Aspergillosis
Case 118
Findings associated with ABPA
Mucoid impaction
Recurrent Atelectasis
Patchy Consolidation
- Asthmatics are predisposed
Case 119
Crazy-paving
Ground-glass opacity with superimposed smooth septal thickening in a patchy or geographic distribution
- Aleveolar Proteinosis
Case 119
Three pulmonary infections that may complicate PAP
Nocardia
Aspergillus
Mucormycetes
Case 119 How is PAP Diagnosed? Treated? Cause? Typically Patient?
PAS-positive proteinaceous material
Brochoalveolar lavage (BAL)
Unknown
Men - 4th and 5th decade
Case 120
Define Tracheomalacia
Excessive pliability and collapsibility of the trachea secondary to weakness of the tracheal walls and supporting cartilages
Case 120
Primary (congenital) tracheomalasia patients primarily lack?
Which phase of respiration collapses the trachea?
Cartilage
Expiration - lunate trachea
Case 120
Tracheomalacia
Congenital Causes?
Acquired Causes?
Congenital deficiency of cartilage
Prior intubation / COPD / Trauma / Infection / Goiter
Case 121
Two most common cell types of primary malignant tracheal neoplasms
How much tracheal stenosis before patients are symptomatic
Adenoid Cystic Carcinoma - better prognosis
Squamous Cell Carcinoma - smokers, male, poor prognosis
75% narrowing
Case 122
Two most common causes of tubular opacities in the lung
Mucoid Impaction
AVM
Case 122
Two entities commonly associated with mucoid impaction
Most common cell type of NSCLC to present as an endobronchial lesion
ABPA and Cystic Fibrosis
Squamous Cell CA
Case 122
In bronchial obstruction, how does the adjacent lung remain aerated?
Collateral air drift
- Pores of Kohn
- Canals of Lambertt
Case 123 Localized Fibrous Tumors of the Pleura Benign? Asbestos? What skeletal abnormality is associated? T1 and T2 signal intensity of fibrous tumors?
No
No - 60% benign / 40% malignant - most curable by surgical resection
Hypertrophic Osteoarthropathy - Episodic Hypoglycemia
Low T1 and Low T2
Case 124
Heart Transplant
Pulmonary nodule - infection or neoplasm?
Two organisms causing majority of infectious nodules in these pts
Non-infectious etiology
Infection
Aspergillus (2 months) and Nocardia (5 months)
Post-transpland lymphoproliferative disorder (2-6% occurence)
Case 125
Causes of PAH
Left to Right Shunt
Chronic PE
Mitral Valve Dz
Case 126
Neoplastic causes of endobronchial lesion
Carcinoid Lung CA
Hamartoma Lipoma
Mucoepidermoid Tumor Lymphoma
Endobronchial Mets
Case 126
Endobronchial Lesion and gastric wall thickening
Lymphoma
Breast Cancer
Case 126
Causes of complete lung atelectasis
Main stem intubation
Obstructing mucous plug
Obstructing Neoplasm
Foreign Body
Case 127
Neoplasms that result in a fine nodular pattern of metastasis
Thyroid
Melanoma
Renal Cell
Breast and Pancreas (Adenocarcinomas)
Case 127
Neoplasms that may result in calcified mets
Thyroid Colon
Breast Sarcoma
Ovary Treated Mets
Case 127
Non-neoplastic causes of fine nodular pattern
Healed VZ Pneumonia
Healed Histoplasmosis
Silicosis
Case 128
Enhancing mediastinal LN
Castleman’s Dz
- Angiofollicular LN Hyperplasia
- Hyaline Vascular is more common subtype
- Plasma Cell most commonly associated with clinical manifestations
- May develop Lymphoma
Hypervascular Mets
Case 128
Hypervascular mets
Renal Cell
Thyroid
Melanoma
Carcinoid
Case 129
Spin Echo / Gradient Echo
- Anatomy - Black Blood
- Luminal Flow - White Blood
Spin Echo - Black Blood / excellent for anatomy
Gradient Echo - White Blood / evaluate luminal flow
Case 130
Relapsing Polychondritis
Rare inflammatory disease that affects cartilages
Auricular 90%
Respiratory 50%
Case 130
Entities with diffuse tracheobronchial narrowing
Wegner’s Relapsing Polychondritis
Sarcoidosis Tracheopathia (spares post wall)
Amyloidosis Osteochondroplastica (spares post wall)
Infection Saber sheath trachea
Case 131 Swyer-James Syndrome Cause CxR Findings HRCT Findings
- Acute viral infection in early childhood prevents development of lung
- Unilateral hyperlucent lung / Reduced vascularity
- Dec lung attenuation / Bronchiectasis / Air Trapping
- Variant of postinfectious OB
Case 132 Nontuberculous mycobacterial infection (NTMB) Causes Demographics Imaging characteristics
Mycobacterium avium Complex (MAC) and Myco Kansasii
Older men - COPD, hemoptysis
Older women - no COPD or hemoptysis, RML and Lingula
Cylindrical bronchiectasis / multiple tiny nodules / tree in bud
Case 133 Cardiac Bronchus Where does it arise? Symptoms? Treatment?
Bronchus Intermedius
Recurrent infections / hemoptysis / cough / dyspnea
Surgical Resection in symptomatic patients
Case 134 Aberrant Right Subclavian Arthery (ARSA) Prevalence? Swallowing difficulty? Associated acquired aortic abnormality?
Last branch from arch coursing L->R behind esophagus & trachea
1%
Dysphagia lusoria
Aortic Dissection - Stanford A surgical / Stanford B medical
Case 135 Interlobar Sequestration Describe Most common type Most common side Diagnosis
Aberrant lung tissue w/o normal connection to bronchial tree
Supplied by systemic artery
Intralobar most common - contained within the substance of the lung
Extralobar - contained within its own pleural envelope - syst ven drain
Left side most common / Posterior basal segment
Identification of systemic arterial supply confirms the diagnosis
Case 136
Three early postoperative complications of lung transplantation
Reperfusion Edema
Acute Rejection
Infection- most common / cytomegalovirus (CMV)
Case 138
Three disease entities that manifest as diffuse ground glass on CT
Hypersensitivity Pneumonitis
Atypical Infection (PCP, CMV)
Pulmonary Edema
Pulmonary Hemorrhage
Case 138
Difference between ground glass and consolidation on CT
GG does not obscure underlying lung structures
Case 138
Name seven Idiopathic Interstitial Pneumonias recognized by the American Thoracic Society (ATS) and the European Respiratory Society (ERS)
IPF - Idiopathic Pulmonary Fibrosis NSIP - Nonspecific IP COP - Cryptogenic Organizing Pneumonia AIP - Acute IP RB-ILD - Respiratory Bronchiolitis-ILD DIP - Desquamative IP LIP - Lymphocytic IP
Case 139
Cardiogenic causes of pulmonary edema associated with pregnancy
Preeclampsia
Peripartum Cardiomyopathy
- Last month of pregnancy
- or first 6 months following delivery
Case 139
Non-cardiogenic causes of pulmonary edema in pregancy
Tocolytic Therapy
Amniotic Fluid Embolism
Case 139
Is pregnancy associated with increased incidence of PE?
Why are pregnant patients at increased risk for community-acquired pneumonias?
Yes
Depression in cell mediated immunity
Case 139
Preeclampsia -
Eclampsia -
Hypertention / Edema / Proteinuria
Seizures
Case 140
Fat attenuation mass in the interatrial septum
Lipomatous Hypertrophy of the Interatrial Septum (LHIS)
- 50% association with mediastinal lipomatosis
- Brown / Fetal fat (PET +)
- May rarely cause arrhythmias but mainly benign
Case 141
Oligemia distal to an obstructing embolus
Westermark’s Sign
Case 142
Disorder most closely associated with a basilar distribution of panlobular emphysema?
Alpha1-antitrypsin Deficiency (AAT)
- Bronchiectasis
- Autosomal Recessive
- Cirrhosis
Case 143
Cryptogenic Organizing Pneuonia
Peripheral patchy foci of consolidation
Peribronchovascular foci of consolidation
- Reverse halo sign
Case 145
Anterior mediastinal cyst
Anterior mediastinal mass ddx that contains solid and cystic elements
Thymic Cyst
Thymoma / Hodgkin’s / Germ Cell Tumors
Case 145
Most common cause of thymic mass
Thymoma
Case 145
Thymic mass with solid and cystic components
Thymoma
Hodgkin’s
Germ Cell Tumors
Case 147
Hyperdense liver and pulmonary nodules
Amiodarone toxicity
- used to treat arrhythmias
- incidence is 5 - 20%
Case 148
Multiple small nodules with peribronchovascular distribution
Sarcoidosis - ++ symmetrical hilar lymph node involvement
Lymphangitic Carcinomatosis
Lymphoma
Kaposi’s Sarcoma
Case 149
Saphenous Vein Graft Aneurysm Following CABG
Most serious complication is dehiscence
Case 150
Most common type of pulmonary infection to occur in HIV patients. Pneumocystis, bacterial, or mycobacterial?
Bacterial
Case 151
Renal transplant patient presents with low grade fever and nonproductive cough
CMV
Case 151
Is PCP a common opportunistic infection in transplant recipients?
No
Case 151
What are the microscopic features of CMV?
Cellular enlargement
Intra-nuclear inclusion bodies
Case 152
Pulmonary Venoocclusive Disease Triad
Severe PAH
Pulmonary Edema
Normal pulmonary venous wedge pressure
Case 152
Pulmonary Venoocclusive Disease (PVOD)
Describe
Disorder characterized by obstruction of the pulmonary veins and venules by intimal fibrosis
Etiology unknown
Diagnosis requires biopsy
Case 153
Multiple tracheal masses
Papillomatosis - HPV
Amyloid
- Nodules low signal on T1 and T2
Case 154
Five causes of tracheal stenosis
Trauma Amyloidosis
Infection COPD
Sarcoid Relapsing Polychondritis
Wegner’s Tracheobronchopathia
Case 154
Tracheal stenosis vs Tracheomalasia
Focal Narrowing
Excessive Collapsability during expiration
Case 154
Idiopathic Tracheal Stenosis - more common in men or women?
Middle aged women
Treatment - surgery
Case 156
Mosaic Pattern of Lung Attenuation
Secondary to Small Airways Disease
How can you differentiate pulm vasc dz from small airways dz?
Geographically marginated areas of low attenuation
Compare number and size of vessels
- Similar –> increased attenuation areas are abnormal
- Reduced –> low attenuation areas are abnormal
Obtain expiratory CT images –> small airways will show air trapping
Case 157
Cyst within a cyst
Echinococcus
Case 157
What is the significance of a Meniscus or crescent sign
Impending cyst ruprture
Case 159
Entities associated with conglomerate masses in the upper lung zones
Sarcoid Coal Workers Pneumoconiosis
Silicosis Berylliosis
TB
Case 161
Inhalational Anthrax Infection
Imaging Findings
CxR - mediastinal widening, hilar enlargement, pleural effusions
- Hilar LNs and pleural effusions rapidly enlarge
Case 162
Two diseases that manifest as ground-glass opacity and cysts
PCP
LIP - Lymphocytic Interstitial Pneumonia
Case 163
Three smoking related interstitial lung diseases
PLCH
DIP
RB-ILD
Case 163
What is DIP?
DDx?
Desquamative Interstitial Pneumonia
- rare interstitial pneumonia that occurs almost exclusively in cigarette smokers
- no honeycombing
DDx - PLCH, RB-ILD
Case 164
Indications for pleurodesis?
Intractable pleural effusions
Recurrent pneumothorax
Case 164
What agent is used to perform PET imaging?
F18-Fluorodeoxyglucose
Case 164
What is more common mets or mesothelioma?
Mets
Case 164
What is latency period btwn asbestos and mesothelioma?
30 to 40 yrs
