Moduel 1: Thoracics Flashcards
opacification of the Raider triangle
aberrant right subclavian artery
metallic valves
how to tell mitral from aortia
mitral is bigger
pacemaker wire going through a valve means it is the
tricupsid
most superior valve is the
pulmonary valve
what is luftsichel sign
collapse of the left upper lobe
compensatory expansion of the lower lobe, the superior part of which forms and air sickle shape around the left mediasitnum
the lingula is a part of which lobe
the left upper lobe
list the right teritiary bronchi
Apical
Posterior
anterior
medal and lateral
superior
posterior
lateral
anterior
medial
list the left tertiary bronchi
Anterior
apicoposteiror
superior
inferior
superior
posterior
lateral
anteromedialbasal
chest radiograph
hilum overlay sign is what
hilum mass obliterates the silhouette of the pulmonary vessels
mass differentiatebetween being pulmonary or from mediasitnum
loko at the shouldering angle.
acute is from the lung
mediastinal ill be obtuse
how many layers of pleura does an azygoes lobe have?
4
why does azygoes lobe have 4 layers of pleura
folded in on itself
what is a trcheal bonrhcus
when to call it a pig bronchus
bronchus off the trachea. can get infections.
if whole if right upper lobe is from this then pig bronchus
what is proximal interruption of the pulmonary artery
congenital absence of one pulmonary artery
but more distal vasculature is present
proximal interruption of pulmonary artery
exists on what side
ax to
exists opposite to aortic arch side
ax to PDA, TOF and trunchus
strep pneumo favours where
lower lobes.
most common form of pnumonia in AIDS patient sis
strep pneumoniae
Endocarditis patients, bacteria can travel to lungs an make an abscess
Classic Bug
Staph A
anthrax pneumonia apperance
mediastinal widerning, pleural effusion
haemorrhagic lymphadenitis
mediastinitis
BULGING fissure pneumonia
Klebsiella
Which patient stypically get a klebsiella infeciton
alcoholics and nuring home patients.
klebiella sputum is
current jelly
H. Influenza seen in
COPDers
aplenia
H Flu will appear as
bronchitis
bilateral lower lobe bronchopneumoinia(sometimes)
Pseudomonas affects who?
ICU
CF
Primary cilicary dyskinesia.
pleural effusions common
Pseudomonas get what in the lung
abscess formation and patchy opacitites
appearance of legionella on radiograph
peripheral and sublobar arispace opacity
who gets legionella
COPD
Polutes air conditioners.
immunocompromised will caviate
actinomycosis is what appearance to the lungs?
peripheral airspace changes
can be aggresveia and invade ribs
mycoplasma chest radiograph appearance
fine reticular pattern
tree in bud
patchy opacities
story for an actinomycosis
dental procedure gone wrong with mandible osteomyelitis and aspiration
what is the time split for post bone marrow
graft vs host
Acute 20 - 100
chronic 100+
acute graft vs host manifests in which organs
extra pulmonary]]so skin, liver, GI tract
chronic graft vs host disease presents in which organs
lungs
lymphocytic infiltration of the airways and obliterative bronchiolitis
post bone marrow transplant
patients are susceptible to diseases based on time frame.
what are the timeframes?
Early neutropenic (0 - 30 days)
early (30 - 90)
late (>90)
Early neutropenic (0 - 30 days)
early (30 - 90)
late (>90)
post bone marrow tranplant pulmonary findings by differnetials
Early neutropenic (0 - 30 days)
- oedema
- haemorrhage
- drug induced lung injury
-fungal pneumonia
early (30 - 90)
- PCP, CMV
late (>90)
- Bronchiolitis obliterans, COP
infections in AIDS by CD4 count
what are they
> 200 - bacterial and TB
<200 - PCP, atypical mycobacterial
<100 - CMV, disseminated fungal, mycobacterial
CT patterns in AIDS
focal airspace opacity
ddx
Bacterial (strep pneumonia)
TB if low CD4
chronic opacity - lymphoma/Kaposi
CT patterns in AIDS
muti focal air space opacity
ddx
bacterial or fungal
CT patterns in AIDS
GGO
ddx
PCP (or CMV if CD4 <100)
PCP aids infection will appear as
GGO.
bilatearlly in perihilar region
SPARES the peripheries
HIV
flame shaped perihilar region
Kaposi sarcoma
HIV persisten opacities think
lymphoma
Lung cysts in HIV
LIP
HIV
Hypervascular lymph nodes
Castlemans or Kaposi
giant lymph node hyperplasia, is an uncommon benign B-cell lymphoproliferative condition is castylemans
what are the diferent types of TB based on timiing
Primary
Primary progressive
Latent
Post primary
Primary TB - what happens
inhale a bug
form a granuloma(Ghon focus) (can get nodal expansion)
if node calcifies called a Rnke Complex.
if node bursts then get endobronchial spread or miliary.
primary progressive TB
what happens
local progression WITH CAVITATION
what is latent TB
Positive PPD, negative CXR, no symptoms
post primary TB
what happens to cause
endogenous reactivation of latent TB
evidence of progression, ie cavity. Adjacent vessels can get aneurysms
how to treate immune reconstituition inflamatory syndrome
give steroids
when do people get pleural effusions with TB
3-6 months after primary infection.
need to biopsy as often culture negative
two non TB mycobateriums to know about are
MAC
Kansasii
types of lung pattern for non TB mycobacterium
Cavitatory
- MAC
Bronchiectatic
-lady windemere(also MAC)
HIV patients
- low immune system, lots of infections
Hypersensitivity pneumonitis
- hot tub lung. GGO centrilobular nodules
lady windemere lung will look like
Middle lobe and lingula
bronchiectasis and tree in bud
who gets invasive aspergillus
immunosupressed
what is a halo sign
consolidative mass with a halo of GGO around it
what does the air crescent sign mean ?
healing as the ball has gotten smaller
allergic bronchopulmonary aspergilloma affects which patients
asthmatics
get finger in glove
if there is fungal invasion of the mediastinum pleura chest wall
Mucomycosis
bone marrow transplant patient can get CMV between 30 - 90 days
how will it appear on chest xr
multiple nodules
ground glass
consolidative
measles chest radiograph
multifocal ground glass opacities with small nodular opacities
influenza appearance
coalsecent lower lobe opacity
SARS appearance on radiograph
GGO
lower lobe
ebstein barr causes
big spleen
large lymph nodes
complictions of septic emboli
wedge shaped infarctions
cavitations
empyema
pneumothroax
Mnemonic for causes of CAVITY
CANCER (SCC)
Auto Immune (Caplan, wegners)
Vascular - Septic emboli / bland emboli
I - infection (TB)
T - Truama - pneumatoceles
Y - young - conenital CCAMS, sequestrations
what is lemierre syndrome ?
jugular vein thrombosis with septic emboli
bacteria responsible for lemierre syndrome
Fusobacterium necrophorum
nodule vs mass based on size
<3cm
benign nodule calcifications patterns
Solid
laminated
central
popcorn
benign nodule doubling times
super fast (1 month)
super slow (16 months)
dodgy nodule
features
GGO
air bronchogram through it
spiculated margins
PET nodule
hot / cold for GGO/nodule
GGO - cold likely cancer, hot infection
Solid - hot can be cnacner, infection, grnaulomatous
four types of lung cancer are
SCC
Small cell
large cell
Adenocarcinoma
SCC lung cancer
centrally located
smoking risk
cavitate
can get ectopic PTH production
Small cell lung cancer
central.
some lymphadenopathy.
Paraneoplastic syndromes can occur like Lambert Eaton (Acth)
Large cell lung cancer appears as
large and peripheral (4cm + )
adeno lung cancer
location and
ax
peripheral and upper lobes
ax with lung fibrosis
what are the subtypes of adenocarcinoma
atypical adenomatous hyperplasia of lung (AAH)
- precursor
Adenocarcinoma in situ (ACIS)
- <3cm
Minimally invasive adenocarcinoma (MIA)
- <3cm but <5mm stromal invasion
what stage of lung cancer is unresectable ?
3B
what makes something 3B
Supraclavicular, contralateral mediastinum, sclaene hilar adenopathy
Tumour invading different lobes
Malignant pleural efffusion
lobe malignnacy for T3 T4 and M1
T3 is two in same lobe
T4 is two in same lung
M1 is different lungs
bronchopleural fistula sing
intially increase pleural fluid but then decreases
types of mets to the lungs by behaviour
Direct invations
haematogenous mets
lymphangetic carcinomatosis
why do mets favour the lower lobes
greater blood supply
cannonball mets from
rcc
choriocarcinoma (testicle)
carcinoids can be calssfied based on
location
- bronchial and peripheral
histroloy
- typical, atypical
Lymphangetic carcinomatosis will have what appearance on imaging
nodular thickening of the interlobular septa and subpleural interstitium
does NOT distort the pulmonary lobule (as per IPF)
classically bronchogenic cancer, cervical and others
what cancer is this
occurs in bronchus, mre common in trachea than carcinoid
adenoid cystic
Second most common after squamous cell carinoma
types of pulmonary lymphoma
Primary
secondary
HIV
PTLD
Primary lymphoma in lung is what type?
usually non hodkin
low grade MALToma
primary lymphoma of lung defined as
lack of extrathoracic involvement for 3 months.
Secondary lymphoma in lung
much more common.
NHL more likely, but HL if involving the lung.
Secondary NHL vs secondary HL
NHL more common.
HL more likely to have intrathoracic disease at presenetaiton
NHL - no mediastinal disease
PTLD lymphoma
Post-transplant lymphoproliferative disorders
when does it affect
within a year of tranpslace.
B cell lymphoma related to EB virus.
AIDS related pulmonary lymphoma
is what type
high grade NHL
realtes to EBV.
often in low CD4<100.
AIDS patient with lungnodules, pleural effusion, lymphadenopathy
lymphoma
a bloody pleural effusion is common in
kapsoi sarcoma
Kaposi sarcoma vs lymphoma on Nuclear medicine
Kaposi
Gallium NEGATIVE
Lymphoma
gallium positive
Kaposi hiots when CD4 is less than
200
flame shaped hilar opacities is
Kaposi sarcoma
microscopic fat and popcorn calcifications
can be hot on PET
dx is
Hamartoma
what to do with hamartoma
nothing
What is bronchial atrewsia
blind ending bronchus, finger in glove.
distal lung hyperinflated from collateral drift and air trapping
apical posterior segment of the left upper lobe
AVM: when to treat
afferent vessel is 3mm (though disputed)
persistent left SVC will drain in to t
coronary sinus
Swyer James cuases what
unilateral lucent lung
post infectious obliterative bronchiolitis
why is extralobar considered the worse sequestration
get fewer infecitons due to pleural covering however the associations are worse
CCAM, diaphragmatic hernia, vertebral anomalies, congenital heart diseases, pulmonary hypoplasia
CCAM is what
malfromation of adenomatoid stuff replacing norma lung.
1 - 4
1 - macrocystic
2 - <2cm
3 - microcystic
4 - looks like 1
5 -
list some cystic lung disease
LCH
LAM
Brit dog dube
LIP
PCP
LCH
affects
location
spares
young smokers
centrilobular nodules in upper lobes.
spares the costophrenic angles
what spares the costophrenic angles
LCH and hypersensitivity pneumonitis
Lymphangiomyomatosis is ax with
Tuberous sclerosis
estrogen (favours woem nof child bearing age)
lymphocytic interstitial pneumonaitis
- what is it
benign lymphoproliferative disorder in the lung
LIP ax
SLE, RA, Sjogrens, HIV
Castlemans .
in a kid then HIV
PCP buzzword
GGO, hilar and mid lung zones
types of emphysema
centri-lobular
pan-lobular
para-septal
pan-lobular emphysema favours where
lower lobes
ax for pan-lobular emphysema
alpha 1 antitrypsin
par-septal found where
adjacent to the pleura and septal line.
peripheral distribuion in the secondary pulmonary lobule
saber sheath trachea is considered pathognomonic of
COPD
vanishing lung syndrome is ax with
20% have alpha antitrypsin deficiency
bullousemphysema
inhaled substance end up in which part of the lung
upper lobes
location of pneumoconiosis nodules
centrilobular - from inhalation
perilymphatic
how ti dfferentiat e Asbestosis from UIP
pareital pleural thickening in asbestosis
What are the benign asbestosis related changes
pleural effusion
plaques (spare the apices)
Malignant mesothelioma
features
extention in to the fissure
pleural ring
who gets silicosis
miners
What is PMF
progressive massive fibrosis
large masses in the upper lobe with radiating strans
Silicotuberculosisi
silicosis raises chances of TB
if cavitation in setting of silicosis then think TB
nodule pattern is perilymphatic
ddx
sarcoid
lymphangitic spread of CA
Silicosis
Random nodule pattern
ddx
Miliary TB
Mets
Fungal
Centrilobular nodule pattern
Infection
RB- ILD
Hypersnesitivity pneumonitis
interlobular septal thickening
usually from
pulmonary oedema
honeycombing is a hallmark of
UIp
how to distinguish between the honeycombing and paraseptal emphysema
two to three rows –> honeycombing
If idiopathic interstitial penumonia aren’t diseases what are they
lung reactions to lung injury
When UIP lung s are considered idiopathic what are they called
IPF
first finding for UIP
reticular pattern in the posterior costophrenic angle
UIP pattern
Apical to basal gradient
traction bronchiectasis
honeycombing
heterogenous in histoloy
NSIP histology
homogenous inflammation / fibrosis
NSIP pattern is seen in what
vascular disease and drug reaction
Types of NSIP
cellular / fibrotic
If NSIP and GGO
cellular
if NSIP
GGO and reticulation
Cellular or fibrotic
NSIP
Reticulation and traction bronchiectasis
Fibrotic NSIP
NSIP
Honeycombing
uncommon
Location for NSIP
lower lobe posterior
peripheral predominance
spares immeidate subpleural lung
GGO
Which fibrosis do scleroderma get
NSI P
Smoking related lung fibrosis are
RB-ILD
DIP
pattern in RB- ILD
apical centrilobular GG nodules
pattern in DIP
diffuse GGO, patchy, subpleural distribution
small cystic spaces
Sarcoid elevated blood marker
ACE
calcium
Sarcoid appearanc e
perilymphatic nodules
upper lobe predominance
which infection common in end stage sarcoid
aspergillomas
3 stages to CHF
redistribution - big vascular pedicle, big heart
interstitial - Kerley Lines, duffing, central vessels contour
alveolar - airpsace fluffy opacity. pleural effusion
TIMEframe for lung transplant complications
Immediate - less than 24 hours
Early complications - 24 hrs to 1 week
intermediate complicaiton - 1 week to 2 months
late complications - 2-4 months
later complications > 4 months
Lung transplant immediate
Donor recipient mismatch
Hyperacture rejection - HLA and ABO antigens. rapid and fatal.
Early complications post lung transplant
reperfusion injury - peak day 4.
air leak - more than 7 days continuous leak.
Intermediate complications post lung transplant
Acute rejection - GGO and interlobular thickening.
bronchial anastomotic complications - leaks occur in the first month, stenosis can develop later.
Late complications post transplant
CMV infeciton
GGO
tree in bud
Late complications post lung transplant
Chronic rejection
cryptogenic organizing pneumonia
PTLD
upper lobe fibrosis
Post lung tranpalnt
air trapping on expiraiton at 6 months
chronic rejection
/ bronchiolitis obliterans
what is the most common recurrent primary disease after transplant
sarcoid
Pulmonary alveolar proetinosis pattern
Craz paving pattern
what is crazy paving
interlobular septal thickening with GGO
how to treat pulmonary Alveolar Proetinosis
bronchoalveolar lavage
Crazsy paving
ddx
oedema
haemorrhage
BAC
Acute interstitial pneumonia
and of course Pulmonary alveolar proteinosis
fat density in the consolidaiton
lipoid pneumonia
with organizing pneumonia
if the cause is not known
Crytpogenic
Causes of orgnaizing pnuemonia
idiopathic
infection
drugs
collagen vascular disease
fumes
appearance of COP
patchy air space consolidaiton or GGO
peripheral / peribronchial distribution
What is the Atoll sign
consolidaiotn around GGO
difference in location of Chronic Esingophilic pneumonia and COP
CEP likes apices
lung transplant complications
what are the timings?
Immediate - 24 hours
Early - 1 week
Intermediate - 2 months
late - 4 months
Later - 4 month ++
immediate massive homogenous infiltration due to
hyperacute rejection
HLA and ABO antigens, rapid and fatal
ground glass opacities, intrtalobular sepctal thickening. Intermediate complications for lung tranplsant
acute rejection
improves with steroids
COP pattern of GGO
peripheral and peribronchial
stages of hypersenstivity pneumonitits
acute
subacute
chronic
HP in subacute phase will look like
patchy ground glass opacities.
ill defined centrilobular ground glass nodules
mosaic perfusion
air trapping
Chronic HP will look like
UIP wth air trapping
reverse halo ddx
COP
fungal pneumonia
TB
Wegeners
Pulmonary infarct
Halo sign
ddx
invasive aspergillosis
other fungus
haemorrhagic mets
wegeners
normal transverse diameter of trachea
no more than 2.5cm
three questions about trachea disease to asnwer
posterior membrane
focal or diffuse
calcification
spares the posterior membrane
diffuse thickneing of trachea
what disease
relapsing polychondritis
focal subglottic curcumferential stenosis, hourglass configuration to trachea
post intubation stenosis
ciurcumferential thickneing of traceha, focal or long segment.
no calc.
wegeners
spares posterior membrane. cartilaginous osseous nodules in the submucosa of tracheal and bronchial walls
Tracheobronchopathia Osteochondraplastica
tracheal tumours types
SCC - most common, prefers lower
Adnoid cystic
Mets
Squamous cell papilloma - most common benign
cystic fibrosis starts as what and finishes as what
bronchiectasis - cylindrical and end as varicoid
predminnace to upper lobes
primary ciliary dyskinesia get what other issues
fertility issues
mastoid ieffusions
conductive hearing loss
only 50% have kartageners
what is kartageners
PCD and situs inversus
massive dilated traches
mounier-kuhn
where will you find tree in bud
5 - 10 mm from the pleural surface
ax centrilobular nodules
what is follicular bronchiolitis?
inflammatory process seen in RA/ Sjogrens.
centrilobular ground glass nodules with bornhcial dilation
what is constrictive bronchiolitis?
2 to viral illnes, tx patients, drug reaction ect.
mononuclear cells form granulation tissue and plug the airway.
causes Swyer-Jame’s hyperlucent lung
List some types of small airways disease
infectious bronchiolitis
RB-ILD
Sub-acute hypersensitivity pneumonitis
follicular bronchiolitis
constrictive bronchiolitis
favoured location of aspiration
posteiror segment of upper lobes
superior segment of lower lobes (if supine)
basal lower lobes id upright
aspiration of gastric acid cayuses
airspace opacity
aspiration of water
fleeting opactiy will resolves in hours
aspiration of bugs (eg mouth)
pneumonia,
aspiration of oil
lipoid pneumonia (low density)
what is caplan syndrome
RA
upper lobe lung nodules can cavitate
pleural effusion
Lupus in the lungs
pleural effusion
pericardiac effusions
Rheumatoid arthritis in lungs
UIP and COP
lower lobes favoured
SCleroderma appearance in lungs
dilated fluid filled osophagus
NSIP>UIP
Sjogrens
LIP
extensive ggo with scattered thin walled cysts
ANk spond
upper lobe fibrobullous disease
shrinking lung affects
lupus
what is hepatopulmonary syndrome
liver patients, short of breath when sitting up
due to distal vascular dilation in the lung bases, dilated subpleural vessels that don’t taper and instead extend to the pleural surface
wegeners lung appearance
nodules with caviation
pleural plaque of asbestosis typically spares the
costophrenic anles
is mesothelioma dose dependnat
no
pleural rind extends int othe fissues
mesothelioma
fibrous tumours of the pleura are ax with
hypoglycaemia
hypertrophic osteoarthropathy
mets to the pleura what are they likely to be
adeno
lung
breast then lymphoma
what to look for in mets to the pleura
pleural effusion
features of an empyema
enhacnement of pleura
obvious septations
gas
what can cause empyema necessitans
TB
actinomyces
what is pancoast syndrome
sholder pain
c8 - t2 radiculopathy
horner syndrome
Normally an SCC
what can cause pancoast syndrome
superior sulcus tumour
- SCC or bronchogenic adenocarcinoma
large thymus
rebound vs residual lymphoma
PET - lymphoma would be hotter
(both still hot though)
MRI - rebound would drop on in and out, due to fat in it.
Thymic cyst on MRI
t2 bright
why image the abdomen in thymic cancer
drop met into the pleural and retroperitoneum
thymoma ax
Myasthenia gravis
pure red cell aplasia
hypogammaglobulinemia
thymolipoma - looks like
fatty mass with interspersed soft tissue
association of mature teratomsas with
linefleters
what are the middle mediastinal masses
fibrosing mediastinitis
bronchogenic cyst
lymphadenopathy
mediastinal lipomatosis
what causes fibrosing mediastinitis
histoplasmosis
or idiopathic
but also tb, radidaiton, sarcoid
bronchogenic cyst will cause obliteration of what chest xr line
asygooesophageal line
posterior mediastinal masses are
neurogenic
- schwannomas, neurofibroams, malignant peripheral nerve sheath tumour
bone marrow
- Extramedullary haemopeis. CML, PCRV, myelofibrosis, sickle cell, thalassemia
causes of a pulmonary artery aneusrysm
iatrogenic
behcets
chronic PE
rasmussen aneurysm is what
pseudloaneurysm seocndary to pulmonary TB
what is pulmonary veno-occlusive disease
variant pof primary pulmonary hypertension.
post capillary pulmonary vasculature is affected .
Normal edgie pressure.
what is the macklin effect?
pneumomdediastinum from truama.
burst alveoli, air dissects backwards.
inversion of the ipsilateral diaphragragm
pneumothorax
low grade carcinoids will have what kind of FDG
low enhacnement
poorly differentiated/high grade ones will have higher enhancement
