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Multifocal opacities…

May 12, 2014

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A patient presented to the ED with flu-like symptoms in the height of flu season:

multifocal opacities

Chest CT:

Multifocal opacities CT 2 Multifocal opacities CT

The CT demonstrates multifocal opacities with some cavitation on the larger lesions.  There seems to be a peripheral and lower-lobe predominence.  This could represent atypical pneumonia (legionella, mycoplasma, chlamydia), fungal pneumonia (cocciodomycosis, histoplasmosis, aspergillosis), miliary tuberculosis, metastatic lesions or carcinomatosis, septic emboli, or viral pneumonia.

After a significant inpatient workup the final diagnosis was Human Metapneumovirus.  All others were ruled out and viral testing revealed this culprit.

Image contributors:  David Barnes, MD and Julie Phan, MD

Author:  Russell Jones, MD

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Multiple masses chest..

April 3, 2014

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Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

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19 month old with pneumonia…

November 3, 2013

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Peds PNA

This is an interesting pediatric chest Xray.  Immediately you notice that the right lung is diffusely more dense than the left.  This is because the patient is supine and a pleural effusion is layering behind the right lung in a dependent fashion.  Also notice the hyperinflation of the left side compared to the right.  This patient ended up having a post-obstructive pneumonia due to aspiration!

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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Answer AIDS PNA…

October 22, 2013

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On a previous post I posed a question on the differential diagnosis of pneumonia in an AIDS patient with this chest Xray:

AIDS CXR PNA

This is a multilobar pneumonia vs. ARDS (Acute Respiratory Distress Syndrome).  AIDS patients can have the same bacterial causes of multilobar pneumonia that is present in other patient populations (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus Influenza, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumoniae, etc.).  If they are healthcare associated or hospital-acquired further drug-resistant bugs such as Pseudomonas aeruginosa and MRSA could be implicated.  Infectious organisms specifically involved in immunocompromised hosts could include (among others):

  • Pneumocystis Jiroveci (PCP pneumonia)
  • Coccidioides species
  • Cytomegalovirus (CMV)
  • Tuberculosis (TB)
  • Histoplasma species
  • Aspergillus species
  • Mycobacterium avium complex (MAC)
  • Influenza
  • Herpes simplex virus (HSV)
  • Varicella-zoster virus (VZV)
  • Legionella species
  • Nocardia species
  • Cryptococcus neoformans
  • Mucoraceae species
  • Strongyloides species
  • Toxoplasma species
  • Capnocytophaga species

Non-infectious causes of multilobar infiltrates such as this could include diffuse alveolar hemorrhage, cardiogenic pulmonary edema, ARDS, among others. The multilobar involvement of the Xray above could implicate certain pathogens in favor of others (for example, Pneumocystis Jiroveci is usually multilobar as opposed to Streptococcus pneumonia which usually will cause a dense, lobar pneumonia).  The other interesting feature of the Xray is that it appears multi-nodular.  This can implicate entities such as CMV rather than a bat-wing ground-glass appearance of Pneumocystis Jiroveci.  For further discussion on pneumonia radiographic findings in AIDS, please see radiopaedia.org discussion below:

http://radiopaedia.org/articles/pulmonary-manifestations-of-hiv-aids

Incidentally, the endotracheal tube should be pulled back about 2 cm.

Author:  Russell Jones, MD

References

1.  Jones J, Stanislavski A, et al.  Pulmonary Manifestations of HIV/AIDS.  http://radiopaedia.org/articles/pulmonary-manifestations-of-hiv-aids.  Accessed 10/2013.

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COPD and dyspnea…

October 18, 2013

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This patient has a history of COPD (Chronic Obstructive Pulmonary Disease) and presented with acute shortness of breath:

COPD and PTXCOPD and PTX 2

One of the complications of COPD are pulmonary bullae.  Bullae are thin-walled, air-filled spaces that enlarge over months to years.  Sometimes they can burst, causing pneumothoracies.  This Xray demonstrates a pneumothorax on the left side in which a chest tube was placed for reexpansion.  On the right side the patient has multiple large apical bullae which are also at risk of rupture.  The chest tube is in good position with the side-port visualized inside the thoracic cavity and reexpansion of the lung is demonstrated.

Author:  Russell Jones, MD

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Pneumonia in AIDS patient…

October 14, 2013

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This patient has a history of AIDS with very low CD4 count and came in with respiratory distress:

AIDS CXR PNA

This Xray shows a diffuse pulmonary infiltrates, bilateral pleural effusions.  There is an endotracheal tube near the carina, it could come back a couple centimeters.  He also has a nasogastric tube coursing below the diaphragm. 

What is the differential diagnosis of a multilobar pneumonia such as this in an AIDS patient?  Comments appreciated!

Author:  Russell Jones, M.D.

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Lung Mets…

August 16, 2013

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This patient has a history of recently diagnosed uterine cancer and came in with dyspnea:

Mets

Just a simple CXR showing multiple lesions highly suspect of secondary lung neoplasms (metastasized uterine cancer).

The most common type of uterine malignancy is endometrial carcinoma.  It commonly metastasizes to lung, liver, brain, vagina, bone, and abdominal and pelvic lymph nodes (1).  Almost any malignancy can metastasize to the lung due to its rich blood flow, however here is a list of some of the more common primary sites that metastasize to the lungs:

  • Bladder
  • Colon
  • Breast
  • Prostate
  • Wilm’s Tumor
  • Neuroblastoma

Author:  Russell Jones, MD

References

1.  Endometrial Cancer Treatment.  National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page1.  Accessed 8/2013.

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“Doc I’m a little short of breath…”

July 9, 2013

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I had a man present the other day with dyspnea, mostly on exertion, minimal pleuritic chest pain.  He was hemodynamically stable while sitting in the gurney but would desaturate to the high 80s and become tachycardic with walking several feet.  He had a history of recently diagnosed multiple myeloma and was awaiting treatment initiation.  Here’s what we found on Chest CT:

Central PE 2Central PE 1

 

The chest CT shows a “saddle embolus.”  This is a pulmonary embolus that is very large and located in the proximal pulmonary artery before it bifurcates into the right and left pulmonary arterial tree.  This type of pulmonary embolus represents a large clot burden that can easily lead to hemodynamic instability and sudden death.  In fact, it was very suprising that this patient was so stable sitting in the gurney.  Initially he was reading a book on his tablet which I usually associate with no emergent pathology! 

This is a good time to review the indications for thrombolysis in pulmonary embolus:

  • Severe hypoxemia
  • Intractable hypotension
  • Large perfusion defect on ventilation-perfusion scans
  • Extensive embolic burden on computed tomography
  • Right ventricular dysfunction
  • Free-floating right atrial or ventricular thrombus
  • Patent foramen ovale
  • Cardiopulmonary resuscitation

These are all relative indications and it is important to weigh the risks of thrombolytics on a case-by-case basis.  There are no true indications for thrombolytics.  There are many widely accepted contraindications…I’ll leave it up to the reader to search for these. 

Author:  Russell Jones, MD

References:

1.  Tapson, VF.  Fibrinolytic (thrombolytic) therapy in acute pulmonary embolus and deep venous thrombosis.  www.uptodate.com.  Accessed 7/2013.

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10 month old female throwing up…

July 3, 2013

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This child was referred to the ED after an astute primary care doctor got a chest xray in the setting of a week of throwing up after eating:

FB 2Coin 1

The PA/LAT chest xray views above show a radioopaque object near the thoracic inlet.  The object resembles the shape and size of a penny.  Interestingly, on the lateral it almost looks like two pennies lying on top of each other.  The patient was taken to the OR and esophagoscopy was used to pull two pennies out of her upper esophagus. 

On xray, how can you differentiate between tracheal and esophageal foreign bodies?

Author:  Russell Jones, MD

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What is bronchiectasis…

June 26, 2013

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This patient presented with dyspnea and had “bronchiectasis:”

BronchiectasisBronchiectasis CXR

Bronchiectasis is a disease process in which there is localized, irreversible dilitation of the bronchial tree.  The dilitation occurs because of destruction of the normal musculature and elastic connective tissue surrounding the bronchi.  Clinically it presents as an obstructive respiratory picture similar to asthma and COPD.  The most common causes are cystic fibrosis and multiple infectious organisms (bacterial, aspergillosis, tuberculosis, histoplasmosis).  The dilated bronchi easily collapse causing air and mucus trapping, which in turn can lead to frequent respiratory infections.

Radiographically, CT scan is the diagnostic modality of choice if bronchiectasis is suspected.  Classically on plain radiograph “tram-tracking” occurs (parallel thickening of the bronchial walls) as well as cystic changes.  CT scan can further deliniate bronchiectasis by showing “tree-in-bud” abnormalities as well as multiple other signs.  For more in-depth information on radiographic findings please refer to Radiopaedia.org:

Bronchiectasis

Author:  Russell Jones, MD

References

1.   Sandhyala A, Gaillard F, et al.  Bronchiectasis.  Radiopaedia.org.  http://radiopaedia.org/articles/bronchiectasis.  Accessed 6/12/13

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