Radiology Interactive

Session

Gamal Agmy, MD, FCCP Professor of Chest Diseases, Assiut university

◙ An 81-year-old woman presented to A/E with

a history of recent onset of shortness of

breath. This had come on during dinner the

previous evening and had not resolved.

◙ She had asthma as a child, and cardiac

bypass 5 years ago. Blood tests indicated a

negative troponin and normal D -dimer.

◙ A chest X ray was done followed by CT

Case 1

Case 1

Case 1

What is the MOST LIKELY

diagnosis?

A. Left sided heart failure

B. Bronchial asthma.

C. FB inhalation.

D. Bronchogenic carcinoma.

E. Pulmonary embolism.

Case 1

What is the MOST LIKELY

diagnosis?

A. Left sided heart failure

B. Bronchial asthma.

.FB inhalation. C

D. Bronchogenic carcinoma.

E. Pulmonary embolism.

Case 1

◙ A 52-year-old woman presented to her

primary care physician with a several-week

history of nonproductive cough, mild

dyspnea, chest tightness, and wheezing

◙ A chest X ray was done.

Case 2

Case 2

What is the MOST LIKELY

diagnosis?

A. Pulmonary edema.

B. Pneumonia.

C. Atelectasis.

D. Mediastinal mass.

E. Left apical pneumothorax.

Case 2

What is the MOST LIKELY

diagnosis?

A. Pulmonary edema.

B. Pneumonia.

.. AtelectasisC

D. Mediastinal mass.

E. Left apical pneumothorax.

Case 3 A 54-year-old female nonsmoker complained of

shortness of breath on exertion and a dry

cough.

What is the MOST

LIKELY diagnosis? A. RB_ILD.

B. Non specific interstitial

fibrosis

C. IPF.

D. CVD

E. Subacute hypersensitivity

pneumonitis.

What is the MOST

LIKELY diagnosis? A. RB_ILD.

B. Non specific interstitial

fibrosis

C. IPF.

D. CVD

hypersensitivity SubacuteE.

.pneumonitis

TO SUM UP..

• Random

– touch pleura

– scattered in lung

• Centrilobular

–away from pleura

• Perilymphatic

– around vessels, bronchi

– touch pleura or fissure

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial, fungal, viral)

Metastases, Miliary TB

Microlithiasis, alveolar

Pneumoconioses (silicosis, coal

worker's, berylliosis)

Case 4

A 35-year-old woman presented with fatigue,

chest pain, and weight loss over the past

several months.

What is the MOST LIKELY

diagnosis?

A. Cardiomyopathy.

B. Pericardial effusion.

C. Anterior mediastinal

mass.

D. Pleural effusion.

Case 4

A 35-year-old woman presented with fatigue,

chest pain, and weight loss over the past

several months.

What is the MOST LIKELY

diagnosis?

A. Cardiomyopathy.

B. Pericardial effusion.

mediastinalC. Anterior

mass.

D. Pleural effusion.

Case 5

A 68-year-old asymptomatic

nonsmoking woman underwent

preoperative screening chest

radiography in preparation for a total

knee arthroplasty. The radiographic

findings prompted subsequent chest

CT

Case 5

Case 5

Where is this lesion MOST

LIKELY located?

A. Lung parenchyma.

B. Mediastinum.

C. Pleura.

D. Chest wall..

Case 5

Where is this lesion MOST

LIKELY located?

A. Lung parenchyma.

B. Mediastinum.

C. Pleura.

D. Chest wall..

Case 5

Case 5

Case 5

Case 5

What is the MOST LIKELY

diagnosis?

A. Primary lung cancer.

B. Chest wall chondrosarcoma.

C. Pseudotumor or vanishing

tumor of the pleura.

D. Localized fibrous tumor of the

pleura..

Case 5

What is the MOST LIKELY

diagnosis?

A. Primary lung cancer.

B. Chest wall chondrosarcoma.

C. Pseudotumor or vanishing

tumor of the pleura.

D. Localized fibrous tumor of the

..pleura

Case 6

A 33-year-old man presented with a 3- to 4-

day history of dyspnea and a nonproductive

cough. A chest radiograph revealed bilateral

perihilar air-space opacities with intervening

normal aerated lung. He was admitted to

the general medicine ward with a

presumptive diagnosis of community-

acquired pneumonia and began taking

Moxifloxacin.

Case 6

Over the next 3 days, he developed

progressive hypoxia and was subsequently

transferred to the intensive care unit for

mechanical ventilation and nitric oxide

therapy. Follow-up chest radiography before

intubation revealed progressive bilateral

perihilar air-space disease. Subsequent

chest CT pulmonary angiography on the

same day did not show a pulmonary em-

bolus but did reveal an interesting pattern of

air-space disease .

Case 6

Case 6

Which diagnosis would be

LEAST LIKELY?

A. Tuberculosis.

B. Atypical infection with

associated bronchiolitis.

C. Hypersensitivity

pneumonitis.

D. Multiple septic pulmonary

emboli.

Case 6

Which diagnosis would be

LEAST LIKELY?

A. Tuberculosis.

B. Atypical infection with

associated bronchiolitis.

C. Hypersensitivity

pneumonitis.

D. Multiple septic pulmonary

emboli.

Head cheese sign or

“hog’s head cheese sign

It refers to mixed

densities which includes

# consolidation

# ground glass

opacities

# normal lung

# Mosaic perfusion

• Signifies mixed

infiltrative and

obstructive disease

A 37-year-old woman comes for evaluation of progressive dyspnea on exertion. Her symptoms started insidiously 1 year ago and have progressed to the point that she can climb less then one flight of stairs or walk one city block at a quick pace. She denies nocturnal symptoms. She has a nonproductive cough but does not have any other symptoms. •Her past history is remarkable only for hypothyroidism for which she takes thyroxine. She is a nonsmoker with no recent travel, traditional HIV risk factors, or infectious contacts.

Case 7

•Her physical examination is remarkable only for slight tachypnea and an arterial oxygen saturation of 86% at rest. Saturation decreases to a low of 76% during a 6-min walk. A chest radiograph was reported as abnormal, which led to performing a CT scan .Bronchoscopy , bronchoalveolar lavage (BAL) and transbronchial lung biopsy were performed.

Case 7

Which of the following statements about this condition is true? A. A trial of prednisone therapy is warranted initially. B. Granulocyte-macrophage colony-stimulating factor (GM-CSF) subcutaneous therapy works best in patients with a predisposing condition. C. Inhaled GM-CSF is the primary treatment modality. D. The patient should be offered whole lung lavage.

Which of the following statements about this condition is true? A. A trial of prednisone therapy is warranted initially. B. Granulocyte-macrophage colony-stimulating factor (GM-CSF) subcutaneous therapy works best in patients with a predisposing condition. C. Inhaled GM-CSF is the primary treatment modality. D. The patient should be offered whole lung lavage.

High-resolution CT scan shows diffuse geographic ground-glass attenuation with superimposed intra- and interlobular septal thickening (arrowhead). Note the polygonal appearance, which represents the secondary pulmonary lobule.

Anti-GM-CSF antibodies have been found in the serum and BAL fluid in patients with idiopathic PAP, leading to the use of subcutaneous GM-CSF therapy of the disease. However, patients with PAP secondary to an underlying condition (eg, hematologic malignancies, immunoglobulin deficiency, HIV infection) do not have these antibodies and, therefore, there is no role for GM-CSF therapy.

Although there are reports of successful use of inhaled GM-CSF in PAP, response rates are generally lower than with whole lung lavage, and this would be considered salvage therapy should lavage not work.

High-resolution CT scan shows diffuse geographic ground-glass attenuation with superimposed intra- and interlobular septal thickening (arrowhead). Note the polygonal appearance, which represents the secondary pulmonary lobule.

Case 8 A 45-year-old nonsmoking woman was referred for an opinion regarding management of recurrent pneumothorax. •She was well until age 27 when she had a right-sided spontaneous pneumothorax.

•Two years later, she had another right-sided pneumothorax and underwent thoracotomy and stapling of the right lung apex. She has had no further episodes since that time. •She is seeing a dermatologist for multiple facial papules, but otherwise, her general health is excellent. She denies any respiratory symptoms.

Results of a physical examination are normal other than multiple skin colored papules over the central face and nose.

A. Langerhans cell histiocytosis. B. Lymphangioleiomyomatosis (LAM). C. Sarcoidosis. D. Birt-Hogg-Dubé syndrome (BHDS).

What is the most likely diagnosis?

A. Langerhans cell histiocytosis. B. Lymphangioleiomyomatosis (LAM). C. Sarcoidosis. D. Birt-Hogg-Dubé syndrome (BHDS).

What is the most likely diagnosis?

A history of recurrent pneumothorax, lung cysts, and skin lesions (fibrofolliculomas) with normal lung function is consistent with the diagnosis of Birt-Hogg-Dubé syndrome (BHDS) (choice D is correct). Langerhans cell histiocytosis is characterized by diffuse cystic disease of the lung, spontaneous pneumothorax, and airway obstruction related to cigarette smoking. These findings are not present in this patient (choice A is incorrect).

Similarly, airflow obstruction, recurrent pleural effusions, and diffuse pulmonary disease are characteristic of LAM, features that also are not found in this patient (choice B is incorrect). Sarcoidosis is a granulomatous inflammatory lung disease characterized by diff use parenchymal opacities, airflow obstruction, and possibly, skin lesions.

Lupus pernio, one of the skin manifestations of sarcoidosis, appears as purple nodules on the nose, cheeks, and ears, and none of these features is present in this patient (choice C is incorrect). BHDS is an autosomal dominantly inherited genodermatosis that predisposes a person to the development of cutaneous hamartomas (fi brofolliculomas), kidney neoplasms, lung cysts, and spontaneous pneumothorax.

The BHD locus has been mapped to the short arm of chromosome 17(17p11.2). BHD is composed of 14 exons, and more than 40 unique mutations in BHD have been reported. Most BHD germline mutations are frameshift or nonsense mutations that are predicted to truncate the BHD protein, folliculin.

A 27-year-old man is referred to you for evaluation of an abnormal chest radiograph. About 5 months ago, he consulted a doctor because of excessive thirst. Evaluation resulted in the diagnosis of diabetes insipidus, which responded favorably to desmopressin administered nasally. Recently, he started to notice shortness of breath when climbing stairs, and a chest radiograph was obtained.

Case 9

•Patient history reveals significant tobacco smoking, up to two packs daily, for at least 14 years. The patient noticed the shortness of breath for at least 2 years, and recently, he noted a point of tenderness over the chest wall, lateral to the posterior axillary line on the left. •Oxygen saturation is 94% while breathing room air, and the rest of his vital signs were normal. Auscultation reveals only rare crackles without prolongation of the expiratory phase. There is a point of tenderness over the left sixth and seventh ribs in the posterior axillary line, and a chest CT scan is obtained.

The most likely diagnosis is: A. Metastatic tumor of unknown primary site. B. Sarcoidosis. C. Langerhans cell histiocytosis. D. Idiopathic pulmonary fibrosis.

The most likely diagnosis is: A. Metastatic tumor of unknown primary site. B. Sarcoidosis. C. Langerhans cell histiocytosis. D. Idiopathic pulmonary fibrosis.

This patient exhibits most of the recognized features of pulmonary Langerhans cell histiocytosis (LCH), previously known as eosinophilic granuloma and histiocytosis X: pulmonary changes involving the middle and upper parts of the lungs with irregularly shaped cystic and nodular lesions of varying size; involvement of a flat bone (the rib); and diabetes insipidus in a young person who smokes (choice C is correct). The only frequently en countered complication that is not present in this patient is a history of spontaneous pneumothorax. The radiographic findings, especially when a CT scan shows cystic and nodular lesions

Cystic, nodular, and fibrotic lesions seen on CT scans are the most frequent findings, followed by the presence of bone lesions in up to 20% of patients, and diabetes insipidus in up to 15% of patients. Spontaneous pneumothorax occurs in 15% to 25% of patients, although not in this patient. Other manifestations contributing to morbidity and mortality include pulmonary hypertension and the development of a pulmonary neoplasm. The most important treatment for pulmonary LCH is cessation of smoking.

Glucocorticoids and immunosuppressive agents have not been proven to be effective. Smoking cessation alone will not alleviate pain in the symptomatic rib lesions. Radiation therapy has been useful in controlling progression and reducing pain. Similarly, smoking cessation alone will not control diabetes insipidus; therefore, replacement therapy should continue.

The bone lesion could be due to a metastatic cancer, but the chest radiograph does not show distinct nodules and is not consistent with metastatic cancer. Patients with sarcoidosis may have diabetes insipidus and may have extensive fibrosis late in the disease, but bone lesions are rare (choice B is incorrect). While the fibrotic lesions may be similar to those found in patients with idiopathic pulmonary fibrosis (IPF), bone lesions are not found in IPF and diabetes insipidus is not associated with IPF.

Case 10 A 47-year-old man presented with chronic renal

failure and dyspnea•

Case 10

What is the MOST

LIKELY diagnosis? A. Lobar pneumonia.

B. Primary lung cancer.

C. Acute heart failure.

D. Anterior mediastinal mass.

E. Pericardial effusion.

Case 10

What is the MOST

LIKELY diagnosis? A. Lobar pneumonia.

B. Primary lung cancer.

C. Acute heart failure.

D. Anterior mediastinal mass.

.E. Pericardial effusion

Case 10

Case 10