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431 Cards in this Set
- Front
- Back
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What are causes of lobar pneumonia?
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Bacteria
Fungus |
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What does lobar pneumonia affect?
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Primarily alveoli
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Why are there air bronchograms?
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Because bronchi are not primarily affected, as alveoli are.
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Why is there no volume loss?
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Because airways remain patent
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What are causes of bronchopneumonia?
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Bacteria
Mycoplasma |
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What does it primarily affect?
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Bronchi, with involvement of adjacent alveoli
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What does this result in?
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Involvement of bronchi results in some volume loss
Involvement of bronchi also results in a patchy alveolar pattern, with air alveolograms, as some bronchi will be affected, and some will just by luck be spared. As person coughs, will spread to other lobes and even other lung. |
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What are infectious causes of pulmonary nodules?
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1) Fungal
2) Bacterial 3) Septic emboli |
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What is appearance of infectious nodules?
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Variable size
Indistinct margins |
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What may nodules do?
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Cavitate
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What causes pneumatocele formation?
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Air leak into the pulmonary interstitium
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What organism is famous for pneumatoceles?
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Staph
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What organisms are famous for cavitary abscesses?
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Anaerobes (i.e. klebsiella)
Fungal Tb |
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What are appearances of diffuse lung opacities?
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Reticulonodular
Nodular (miliary) |
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What causes reticulonodular pattern?
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Peribronchovascular inflammation
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What are causes of this?
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Viral pneumonia
Mycoplasma |
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What is another pathogen that causes diffuse lung opacities?
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PCP
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What is PCP pattern of involvement?
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Primarily interstitial, with alveolar involvement later on.
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What is the extreme of the interstitial involvement?
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Upper lobe cystic changes, with resultant pneumothorax.
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What percent get PTX?
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10%
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What else is result of involvement of interstitium?
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They can also get bronchpleural fistulae
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What is the pattern of alveolar involvement in PCP?
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Scattered involvement
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What does this result in on imaging?
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Ground glass on HRCT. Also see cysts due to interstitial involvement.
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What is distribution on CXR?
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Diffuse or perihilar.
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What is initial CXR appearance of PCP?
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Bilateral symmetric interstial pattern
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What is later pattern?
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Add in different degrees of alveolar consolidation
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What can an organized effusion or empyema do?
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Erode into chest wall or lung
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When should pneumonia resolve by?
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4 weeks
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In what patients can you give up to 8 weeks?
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Diabetics and older patients
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What is differential for nonclearance?
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Abx resistance or wrong pathogen
Recurrent infection Underlying neoplasm |
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What patients get pseudomonas pneeumonia?
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Ventilated patients
Immunocompromised |
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What are presentations?
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There are 3:
1) Extensive bilateral consolidation, lower lobe predominant 2) Abscess formation 3) Nodular disease (rare) |
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What is another bacteria with lower lobe predilection?
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Legionnaires
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What is the most common atypical pneumonia?
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Mycoplasma
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What is appearance?
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Diffuse reticular pattern, with lower lobe predominance
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In what percent is there alveolar consolidation?
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50%
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What is the first stage of primary Tb?
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1-7 cm focus of lung consolidation
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Where does it occur?
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Anywhere. Lower lobe is more common (60%) than upper lobe (40%) probably just because there is more lung and bloodflow in lower lobes
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What is the next stage in primary Tb?
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The consolidation undergoes caseous necrosis.
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What occurs next?
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Lesion calcifies
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What also always occurs in primary Tb?
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Lympadenopathy
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Where is lymphadenopathy?
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Hilar and paratracheal
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What percent of primary Tb gets pleural effusion?
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10%
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What are potential complications of primary Tb?
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Hematogenous spread from the area of consolidation, resulting in miliary Tb, which can go all over the body.
Cavitation of the area of consilidation, with erosion into bronchus, and transbronchial spread to rest of lungs. |
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What is commonly the only finding in primary Tb?
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Adenopathy. The Ghon focus is not visible always.
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What is this called in kids?
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Epituberculosis
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What populations get complicated primary Tb?
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Children
Immunosuppressed |
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What causes secondary Tb infection?
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Reactivation
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Where does reactivation occur?
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Apical and posterior segments of upper lobes
Superior segment of lower lobe |
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What occurs in anterior segment upper lobe?
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Histo commonly does. Tb does not.
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What is appearance of Tb?
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Airspace disease, patchy or confluent.
May see linear densities radiating to hilum |
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What is common in secondary Tb?
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Cavitation
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In what percent?
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40
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What is rare in secondary Tb that is common in primary Tb?
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Adenopathy
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What other space can secondary Tb involve?
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Pleural.
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What occurs?
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Pleuritis, with empyema formation, and subsequent bronchopleural fistula and/or pneumothorax.
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What is empyema that invades chest wall called?
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Empyema necessatatis
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What is Tb vascular invasion with aneurysm formation called?
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Rasmussen aneurysm
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What other way can Tb spread?
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Hematogenously
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What occurs?
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Miliary Tb, which can seed other end organs
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What is most common complication of parenchymal disease?
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Lung fibrosis, which can be severe with cicatricial changes
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What are other complications of parenchymal Tb involvement?
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Bronchial invasion
Rasmussen aneurysm Spread to GI tract via swallowed secretions |
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what is acute complication of bronchial invasion?
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Transbronchial spread to other parts of lung(s)
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What are late complications of bronchial involvement?
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Bronchiectasis
Bronchial stenosis (opposite seeming lesions, but both caused by inflammatory process) |
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Differentiate primary and secondary Tb by location.
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Primary more often lung bases
Secondary in upper lobes and superior seg LLs |
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Differentiate primary and secondary Tb by appearance
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Primary is focal
Secondary is Patchy |
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Where is effusion more common, Primary or secondary Tb?
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Primary
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What is different about mycobacteria avium intracellulare infection versus Tb?
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No primary/secondary crap. All infection is primary.
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What patient populations get MAI?
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AIDS
Elderly people with COPD Elderly women in good health |
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What may MAI be indistinguishable from on imaging?
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Tb
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What features suggest MAI over TB?
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Bronchiectasis and Bronchial wall thickening
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What percent of patients with TB vs. MAI have bronchiectasis?
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30% in TB; almost 100% in MAI.
Similar values for bronchial wall thickening |
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What findings suggest TB over MAI?
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1) Calcified granuloma (rare in MAI)
2) Septal thickening (common in MAI) |
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What types of patients get nocardia pneumonia?
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Immunocompromised in some way
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What patients are most susceptible
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1) Lymphoma patients
2) Steroid therapy patients, especially those who underwent transplant. 3) Pulmonary alveolar proteinosis. |
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What is appearance of Nocardia?
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Focal consolidaton is most comon
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What are other appearances?
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Irregular nodules
Cavitation |
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What are causes of actinomyces pneumonia?
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Aspiration (lives in sputum of people with poor dentition)
Direct penetration into thorax |
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What is appearance?
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Focal consolidation. Less commonly cavitating mass
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What feature is highly suspicious for actinomyces?
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Pleural thickening with invasion of chest wall
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What is not present?
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Lymphadenopathy
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What organism class causes pulmonary abscess?
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Anaerobic bacteria
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What are the varieties of pulmonary infection caused by anaerobes?
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1) Abscess
2) Necrotizing pneumonia 3) Empyema |
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What defines abscess?
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Cavity(ies) greater than 2 cm, usually with fluid level
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What defines necrotizing pneumonia?
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Similar pathology as abscess, but a more diffuse process, with cavities under 2 cm.
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What predisposes to anaerobic infection?
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Aspiration
Intubation Bronchial disease |
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What defines bronchial disease
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Functional bronchial obstruction
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What are examples of this?
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Actual bronchial occlusion, i.e. from mass lesion
Bronchiectasis, resulting in functional bronchial obstruction |
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What are manifestations of viral pneumonia?
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1) Acute interstitial pneumonia
2) Lobular inflammatory reaction 3) Hemorrhagic pulmonary edema |
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What is appearance of acute interstitial edema?
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Thickening of peribronchovascular tissues
Thickening of interlobular septae |
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What is the distribution of acute interstitial pneumonia?
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Diffuse or patchy
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What is appearance of lobular inflammatory reaction?
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5 mm nodules forming within secondary pulmonary lobules
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What virus causes a special variety of this appearance?
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Varicella
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What is special about varicells's nodular appearance?
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Late calcification of nodules
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What is appearance of hemorrhagic pulmonary edema?
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Mimics lobar pneumonia
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What is uncommon in viral pneumonia?
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Effusion
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What is a potential sequela of viral pneumonia?
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Chronic interstial fibrosis
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What is this called?
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Bronchiolitis obliterans
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What percent of patients who get varicella develop pneumonia?
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15%
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What is true of almost all of these patients?
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Over age 20, so normal little kiddies with chicken pox are unlikely to get pneumonia. This also is a reason why they say chicken pox is so much worse in adults than children.
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What is the progression of findings in varicella pneumonia? First stage:
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Formation of numerous 5mm acinar nodules
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What is next stage?
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Coalescence of acinar nodules into diffuse but patchy airspace disease
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What is next stage?
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Healing, resulting in 1-2 mm calcifications throughout lungs.
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In whom does CMV pneumonia occur?
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Neonates
Immunosuppressed |
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What is appearance?
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Interstial pattern, with small nodules
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What other feature is sometimes present in CMV?
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Adenopathy
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What are the two broad categories of pulmonary fungal infection?
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Endemic human mycoses
Opportunistic mycoses |
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What are endemic mycoses?
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The infections limited to certain geographic regions
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What are these?
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Histoplasmosis
Coccidiomycosis Blastomycosis |
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Where are opportunistic mycoses located?
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Everywhrere
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In what population do they occur primarily?
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Immunocompromised
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What are the opportunistic mycoses?
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Aspergillosis
Candidiasis Cryptococcosis Mucormycosis |
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What opportunistic mycoses can also occur in immunocompetent hosts?
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Aspergillosis
Cryptococcosis |
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What are the phases in fungal pulmonary infection?
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1) Acute phase
2) Reparative phase 3) Chronic phase |
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What additional phase can occur in immunocompromised patients only?
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Disseminated disease
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What is appearance of acute phase?
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1) Segmental or nonsegmental confluent opacity
OR 2) Patchy opacities |
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What can this appearance look like in immunocompromised person?
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Miliary pattern
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What is this due to?
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Hematogenous dissemination
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What is the appearance in the reparative phase?
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Nodular lesions
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What is a classic appearance of these nodules?
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May cavitate
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When they cavitate, what is the radiographic appearance?
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Crescent sign
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What is appearance of chronic phase?
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Calcified lymph node or lung focus
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What are the symptoms of histoplasmosis?
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Usually none
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What is appearance early in histo infection?
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Parenchymal consolidation with adenopathy
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What happens when histo heals?
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Adenopathy heavily calcifies
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What is appearance of histo when it goes into chronic infection mode?
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Histoplasmoma
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What is appearance of histoplasmoma?
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Solitary, sharply demarcated nodule
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Where is histoplasmoma usually?
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Lower lobes
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What is another manifestation of chronic histo?
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Fibrocavitary disease of upper lobes
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What is this appearance the same as?
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Post-primary TB
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What is another appearance of chronic histo?
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Cavitary nodules
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What is appearance of disseminated histo?
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Miliary lung nodules
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What else is seen as a sequela of disseminated histo?
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Calcifications in liver and spleen
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What is sometimes a sequela of pulmonary histoplasmosis?
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Mediastinal histoplasmosis
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What are the two entities that can occur due to mediastinal histo?
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1) Mediastinal granuloma
2) Mediastinal fibrosis |
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What is mediastinal granuloma?
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Nothing. Just calcified mediastinal lymph nodes. But heavy mediastinal calcification is different than TB, however.
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What is mediastinal fibrosis?
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Diffuse infiltration of mediastinum with multiple densely calcified nodes and fibrotic change.
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What are effects?
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Constrictive pericarditis
SVC syndrome Pulmonary artery occlusion Airway compression |
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What are symptoms of coccidiomycosis lung infection?
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Usually asymptomatic
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What is appearance in the acute phase?
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"Fleeting" consolidation
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What part of lungs involved?
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Lower lobes
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What is another manifestation sometimes seen?
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Adenopathy (20%)
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What is appearance of coccy in the reparative phase?
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Doesn't really have one, goes into chronic phase in some patients.
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What percent of patients go into chronic coccy infection?
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5%
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What is the appearance of chronic coccy?
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Nodules
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What is characteristic of the nodules?
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Not much
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What percent cavitate?
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15%
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When nodule cavitates, what suggests coccy?
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Thin wall
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What percent of cavitating nodules have thin wall?
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50%
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What does the other 50% that have thick wall suggest?
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Nonspecific
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What can patients who progress to the chronic form of coccy present with?
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PTX, if their nodules cavitate and a bronchopleural connection is created
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What percent of coccy nodules calcify?
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Rare
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What is characteristic of the disseminated form of coccy?
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Nothing. Miliary nodules
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What is appearance of blastomycosis?
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Nonspecific.
Air space disease, more common than nodular disease (15% cavitate, like chronic coccy), more common than miliary disease |
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What is one manifestation of blasto that is somewhat suggestive?
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Paramediastinal infiltrate with an air bronchogram
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When there is nodular disease, what is commonly associated with it?
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Satellite lesions around the nodule
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What is very uncommon in blasto?
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Calcification
Adenopathy Pleural effusion |
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What is involved in 25% of cases of blasto?
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Bone
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How many varieties of aspergillosis are there?
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4
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What is each variety paired with?
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A specific immune status
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What are the immune statuses?
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Hypersensitive
Normal Mild immunosuppression Severe immunosuppression |
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What is the variety of aspergillosis associated with hypersensitive immune response?
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Allergic bronchopulmonary aspergillosis
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What is the variety of aspergillosis assd with normal immune response?
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Aspergilloma
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What other variety can occur in normal host?
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Semiinvasive form, if person is exposed to a large load of inhaled aspergillus.
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What is variety associated with mild immunosuppression?
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Semiinvasive
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What is variety associated with severe immunosuppression?
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Invasive
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What is ABPA?
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Type I hypersensitivity reaction to aspergillus
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What patients does it occur in?
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Asthmatics
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What proportion are asthmatics?
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Almost all affected by ABPA are asthmatics
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What other group is sometimes affected?
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Cystic fibrosis
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What occurs initially?
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Bronchospasm and bronchial wall edema, just like their asthma causes
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What occurs in late stage ABPA?
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Bronchial wall damage
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What does this result in?
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Bronchiectasis
Pulmonary fibrosis |
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What is treatment for ABPA?
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Oral steroids
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What is the most common radiographic finding?
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Fleeting pulmonary opacities
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What is the HALLMARK radiographic feature?
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Central, upper lobe, saccular bronchiectasis with associated mucus plugging
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What is this classic appearance called on CXR?
|
finger in glove
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What is seen on CT?
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Central upper lobe saccular bronchiectasis with mucus plugging and associated bronchial wall thickening
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What occurs if ABPA is not appropriately treated?
|
Goes on to pulmonary fibrosis
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Where does the fibrosis occur?
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Mainly upper lobes, the same part involved with bronchiectasis
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What is another feature sometimes associated with ABPA?
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Cavitation in 10% of cases
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What is required for aspergilloma to occur?
|
Preexisting lung cavity or bulla
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What lesions typically cause such cavities?
|
TB
End stage sarcoid |
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What about bullae?
|
Emphysema
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Where do most fungus balls occur?
|
Upper lobes
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What is treatment for fungus ball?
|
Surgical resection of fungus ball and intracavitary amphotericin
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What is appearance?
|
Intracavitary mass.
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What may be seen specific to aspergilloma?
|
Lucent ring surrounding the ball
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What can this be confused with?
|
Air-crescent sign of invasive aspergillosis.
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How do you differentiate the two?
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1) Clinical history (i.e. patient immunocompromised? Very sick?)
2) Air crescent doesn't go all the way around like air around a fungus ball does |
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What is seen around aspergilloma cavity?
|
Small rind of consolidation
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What else is seen?
|
Adjacent pleural thickening
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What is HALLMARK of aspergilloma?
|
Fungus ball moves with positional changes
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What is progression of invasive aspergillosis?
|
Starts with endobronchial fungal proliferation.
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What does this lead to?
|
Vascular invasion with thrombosis and infarction of lung
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What is this type of infection called?
|
Angioinvasive
|
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When invasion of vessels occurs, what happens?
|
Hematogenous spread
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To where?
|
Brain
Liver Kidney GI tract |
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What is characteristic initial radiographic feature of invasive aspergillosis?
|
Multiple pulmonary nodules
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On CT, what is the characteristic associated feature of the nodules that is seen?
|
Halo of ground glass
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What does this represent?
|
Pulmonary hemorrhage
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What is the characteristic change in the lesion that occurs?
|
Cavitation
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When do the lesions cavitate by?
|
2 weeks
|
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What is the characteristic finding in invasive aspergillosis that signifies reparative phase?
|
Air crescent sign
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Is the sign specific to aspergillosis?
|
No
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What is the DDx for air crescent sign?
|
TB
Septic emboli Tumor Actino Mucor |
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What are the nonspecific findings also seen in invasive aspergillosis?
|
Focal consolidations
Peribronchial opacity |
|
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What is prognosis of invasive aspergillosis
|
Very poor. 70% to 90% mortality
|
|
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What is treatment?
|
Amphotericin, systemic and intracavitary
|
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Who is at risk for semi-invasive aspergillosis?
|
Diabetics, alchoholics, COPDers, malnourished, pneumoconiotics.
|
|
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What is difference between this and regular invasive form?
|
Progresses more slowly (doesn't cavitate until 6 months, versus 2 weeks!)
Lower mortality (30%) |
|
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What is imaging appearance?
|
Same as invasive, just slower progression
|
|
|
Where is cryptococcus primarily endemic?
|
Not endemic to one region. Found everywhere.
|
|
|
Who gets infected with crypto?
|
AIDS
Lymphoma patients Diabetics Steroid therapy |
|
|
What are the 3 most common appearances of crypto lung disease?
|
Pulmonary mass
Multiple nodules Lobar or segmental consolidation |
|
|
What does not occur in crypto?
|
Cavitation
Adenopathy Effusion |
|
|
What patients get candidal pneumonia?
|
Lymphoma/leukemia patients
Bone marrow transplant patients |
|
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What are plain film findings?
|
Nonspecific opacities, usually lower lobe.
|
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What is appearance of mucormycosis?
|
Similar to invasive aspergillosis, because also angioinvasive
|
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|
What are characteristics of AIDS?
|
1) Lymphadenopathy (Think of CT of axilla with Gordon)
2) Opportunistic infections 3) Tumors |
|
|
What are the infections associated with AIDS: Most common?
|
PCP
|
|
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What percent of AIDS related opportunistic infection does PCP represent?
|
70
|
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What CD4 count is needed to get PCP?
|
<200
|
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What percent of AIDS related infx is mycobacterial infx (TB, MAI)?
|
20%
|
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What CD4 count is needed for MAI?
|
<50
|
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What percent of AIDS related infx are bacterial pneumonia?
|
10%
|
|
|
What are other AIDS defining infections?
|
Fungal infx (5%)
Nocardia (5%) |
|
|
What tumors do AIDS patients get?
|
Kaposi Sarcoma
Lymphoma |
|
|
What can not exclude PCP?
|
A normal CXR
|
|
|
What does CMV infection do to AIDS patients?
|
Nothing much, just high titers
|
|
|
When is CT indicated in AIDS patient?
|
1) Symptomatic patient with normal CXR
2) Confusing CXR 3) Work up of focal opacities, adenopathy, or nodules |
|
|
What is top 3 DDx for lung nodules in AIDS patient?
|
Septic infarcts/necrotizing pneumonia
Kaposi Sarcoma Fungal disease |
|
|
What defines septic infarcts?
|
Rapid increase in size
|
|
|
What fungal diseases present with nodular pattern in AIDS?
|
Aspergillosis
Crypto |
|
|
What is top 3 DDx of large opacity in AIDS?
|
1) Pneumonia (incl TB)
2) Non-Hodgkins pneumonia 3) Hemorrhage |
|
|
What is top 3 DDx of linear interstitial opacities in AIDS?
|
1) PCP
2) Atypical mycobacteria 3) Kaposi |
|
|
Top 3 for lymphadenopathy in AIDS?
|
AIDS itself can probaby do it.
1) Mycobacterial 2) Kaposi 3) Lymphoma |
|
|
Top 3 for pleural effusion?
|
1) Kaposi
2) Mycobacterial or fungal 3) Pyogenic empyema |
|
|
What percent of PCP has normal CXR?
|
10
|
|
|
What is appearance of PCP on HRCT?
|
Ground glass opacity with cystic changes
|
|
|
What does MAI usually cause?
|
Extrathoracic disease
|
|
|
What is most salient difference in appearance of TB in AIDS versus immunocompetent?
|
Prominent mediastinal adenopathy
|
|
|
What is DDx for mediastinal lymphadenopathy in AIDS?
|
Mycobacterial (TB, MAI)
KS Lymphoma |
|
|
How do you differentiate infection from tumor in AIDS patients on CT?
|
MAI and TB have low attenuation centers, and only exhibit rim enhancement.
Adenopathy in lymphoma enhances uniformly, unless treated. KS enhances uniformly. |
|
|
What is another finding more common in AIDS related TB?
|
Pleural effusion
|
|
|
What is appearance o/w?
|
Same as regular, with upper lobe consolidations and cavitations.
|
|
|
What percent of AIDS patients get fungal infection?
|
Less than 5%, so quite uncommon
|
|
|
What is the most common systemic fungal infection in AIDS?
|
Cryptococcus
|
|
|
What organ system does cryptococcosis usually involve in AIDS patients?
|
CNS
|
|
|
What percent of crypto patients have CNS involvement?
|
90%!
|
|
|
What are the other two systemic fungal infections in AIDS?
|
Histo
Coccidiomycosis |
|
|
What are the most common tumors in AIDS?
|
Kaposi (most common)
Lymphoma (more uncommon) |
|
|
What percent of AIDS patients get lymphoma?
|
About 5%
|
|
|
What always precedes pulmonary Kaposi sarcoma?
|
Cutaneous (and visceral) involvement
|
|
|
What is most common pulmonary appearance in KS?
|
Nodules
|
|
|
How big are the KS nodules?
|
1-3 cm
|
|
|
How many nodules are seen?
|
Usually multiple, but can be single
|
|
|
What is another appearance of KS?
|
Coarse linear opacities emanating from hilum
|
|
|
What percent of KS has pleural effusion?
|
40%
|
|
|
What is another parenchymal finding seen in KS?
|
Lymphangitic spread of tumor
|
|
|
What are auxilliary findings often seen in KS?
|
Pleural effusion
Adenopathy |
|
|
What is appearance of AIDS related lymphoma in lungs?
|
Solitary or multiple pulmonary masses
|
|
|
What is an associated finding seen in 25% of cases?
|
Air bronchogram
|
|
|
What is not much seen in pulmonary lymphoma?
|
Lymphadenopathy
|
|
|
Why?
|
AIDS related lymphoma is an extranodal disease
|
|
|
What are organ systems involved typically by AIDS related lymphoma?
|
CNS
GI tract Liver Bone marrow |
|
|
What is a common auxilliary finding in AIDS related lymphoma?
|
Pleural effusion
|
|
|
What interstitial lung disease is common in pediatric AIDS patients?
|
Lymphoid interstitial pneumonia
|
|
|
What is appearance of lymphoid interstitial pneumonia?
|
Diffuse reticulonodular pattern
|
|
|
When a neoplasm is seen in the throax, what basic categorization is made?
|
Primary location
|
|
|
What are the choices?
|
Lung
Mediastinum Pleura Airway Chest wall |
|
|
What are the broad categories of lung tumors?
|
Malignant
Low grade malignancies Benign |
|
|
Which is more uncommon: Benign or malignant lung tumors?
|
Benign
|
|
|
What is the only really important benign tumor?
|
Hamartoma
|
|
|
Where are they located?
|
Peripherally in lung
|
|
|
What is the general appearance?
|
Well circumscribed
|
|
|
What features are diagnostic of hamartoma on CXR?
|
Popcorn calcification
|
|
|
What percent of hamartomas have popcorn calcs?
|
Only 20%
|
|
|
So how is the diagnosis made?
|
When solitary pulmonary nodule found on CXR or regular CT, you must do thin section CT for characterization.
|
|
|
How is diagnosis of hamartoma made on thin section CT?
|
Fat attenuation in the lesion is diagnostic. Of course, you must be sure you are not volume averaging soft tissue with adjacent lung.
|
|
|
What are the low grade malignant lung neoplasms?
|
Carcinoid and tumors that resemble salivary tissue
|
|
|
What is the most common one?
|
Carcinoid. 90% of low grade malignancies.
|
|
|
What are the names of the ones that resemble salivary tissue?
|
Adenoid cystic carcinoma
Mucoepidermoid |
|
|
What did adenoid cystic used to be called?
|
Cylindroma
|
|
|
What is the most common appearance for carcinoid in the thorax?
|
Segmental or lobar collapse, or a patient with recurrent episodes of atelectasis. They could develop asthmatic symptoms because of carcinoid syndrome, but this is not so common.
|
|
|
What needs to be seen when you encounter a patient with atelectasis?
|
Endobronchial evaluation.
|
|
|
What is most common appearance of the carcinoid tumor?
|
Endobronchial lesion
|
|
|
What is a less common appearance of carcinoid?
|
Pulmonary nodule.
|
|
|
What are the broad categories of malignant lung tumors?
|
Bronchogenic carcinoma
Metastatic disease Lymphoma Sarcomas (rare) |
|
|
What are contraindications to percutaneous lung mass biopsy?
|
Severe COPD
Pulmonary HTN Coagulopathy Contralateral pneumonectomy Suspected echinococcal cyst |
|
|
Where is the needle passed?
|
Over top of rib
|
|
|
Where is needle not passed?
|
Through fissures
|
|
|
What percent get PTX?
|
25%
|
|
|
What percent of those require a chest tube?
|
about 25%
|
|
|
What are criteria for chest tube?
|
Symptomatic PTX
OR PTX greater than 25% (So just remember 25%--25% get PTX, 25% of those need chest tube, and max allowed ptx without chest tube is 25%) |
|
|
What are the varieties of malignant tumors called bronchogenic tumors?
|
Adenocarcinoma (40%)
SCCA (30% Small cell CA (15%) Large cell CA (1%) |
|
|
What percent of heavy smokers develop lung CA?
|
10%
|
|
|
What are other risk factors for lung CA?
|
1) Radiation exposure (radon, uranium miners)
2) Asbestos exposure (remember, it greatly increases risk for bronchogenic CA, which is more likely than mesothelioma to occur) 3) Genetic |
|
|
What are signs of bronchogenic CA?
|
Spiculated mass
Cavitating mass (esp SCCA) Unilateral hilar enlargement Mediastinal widening |
|
|
What are secondary signs that should alert you to possibility of malignancy?
|
Atelectasis
Pneumonia that does not clear Pleural effusion Interstitial marking pattern suggestive of lymphangitic spread |
|
|
When you see a lung cavity, you should include CA in your differential, except when?
|
When wall is paper thin.
|
|
|
What type of lung cavity is almost definitely CA?
|
Wall thicker than 1.5 cm
|
|
|
Does air bronchogram seen in a mass exclude neoplasm?
|
NO. Adenocarcinomas COMMONLY have air bronchograms on CT, and the bronchioloalveolar variety of adenocarcinoma has air bronchgrams on CXR!!!!!
|
|
|
What is a special type of atelectasis that is always due to tumor?
|
RUL collapse with reverse S sign of Golden. The medial aspect of the collapsed segment is bulkier and presses down on minor fissure. This is due to the mass expanding this area.
|
|
|
What percent of lung CA has a paraneoplastic syndrome?
|
2%
|
|
|
What are the paraneoplastic syndromes?
|
Carcinoid syndrome
Cushings's (ACTH prod by SCCA) SIADH (ADH produced by Small cell) Hypercalcemia (can be produced by mets, which is expected, but also by parathyroid hormone made by SCCA) Hypoglycemia (tumor produces insulin like factor). Migratory thrombophlebitis |
|
|
Does radiation to lung cause changes?
|
Yes
|
|
|
When are they seen?
|
Acute phase--3 weeks
Fibrosis--6mo to 1 year |
|
|
What are typical symptoms of acute phase?
|
Asymptomatic usually.
Can have cough/fever. |
|
|
What is appearance?
|
Acute: Diffuse opacities in port distribution
Chronic: Lung scarring |
|
|
What is T staging of lung CA:
T1? |
limited to lung and less than 3 cm
|
|
|
T2?
|
Limited to lung and greater than 3 cm
|
|
|
T3?
|
Any size tumor with direct extension to any pleural surface (except fissures?). Deep to the pleura, it can involve chest wall, diaphragm, superior sulcus, or pericardium.
OR Any size tumor within 2 cm of the carina |
|
|
T4?
|
Invasion of carina, vertebral bodies, mediastinal organs (i.e. esophagus)
OR Malignant pleural effusion |
|
|
What does this mean?
|
If you have a cancer patient with a pleural effusion, must tap effusion before decision to resect is made.
|
|
|
Why?
|
Malignant effusion will seed pleura. Then when patient is post-op and in a weakened state, they will deteriorate very quickly.
|
|
|
What is N staging for bronchogenic tumor:
N1? |
Ipsilateral HILAR nodes
|
|
|
N2?
|
Ipsilateral MEDISTINAL or SUBCARINAL nodes
|
|
|
N3?
|
Nodes CONTRALATERAL to primary
OR Any SUPRACLAVICULAR node |
|
|
When are tumors unresectable?
|
T4
N3 M1 |
|
|
Where are the important anterior mediastinal lymph nodes?
|
Internal mammary
Prevascular Cardiophrenic |
|
|
Why are tumors that involve the carina unresectable when ones that involve a central main bronchus are not?
|
Because you cant remove both lungs
|
|
|
Where do lung tumors metastasize to most commonly?
|
Liver
Adrenal Brain Also bone and kidney |
|
|
What are the appearances of bronchioloalveolar carcinoma?
|
Small peripheral nodule
Multiple nodules Chronic air space disease |
|
|
What is most common appearance?
|
Single nodule
|
|
|
What is not seen in BAC?
|
Adenopathy
|
|
|
What are appearances of SCCA?
|
Cavitating mass
Peripheral nodule Central obstructing lesion causing lobar collapse Chest wall invasion |
|
|
What are most common appearances?
|
Cavitating mass and peripheral nodule
|
|
|
What is presentation of small cell CA usually?
|
Massive bilateral adenopathy, with or without lobar collapse
|
|
|
What else is typically present?
|
Brain mets
|
|
|
How does large cell usually present?
|
Large peripheral mass
|
|
|
What are the ways mets get to the lung, most common to least common.
|
1) Hematogenous
2) Spread via lymph nodes from elsewhere to posterior mediastinal and paraesophageal nodes, and eventually into lung parenchyma. (Lymphangitic spread) 3) Direct extension |
|
|
What tumors tend to have lymphangitic spread to the lung?
|
Breast CA
Stomach Pancreas Laryngeal Cervical |
|
|
Where are most lung mets, peripheral or central?
|
90% peripheral
|
|
|
What are margins of mets usually?
|
Sharp
|
|
|
When they are fuzzy, what does it mean?
|
Peritumoral hemorrhage
|
|
|
What mets cavitate?
|
Just like primary of lung, SCCA from head/neck do too.
|
|
|
What lung mets calcify? Broad categories---
|
Bone tumor mets
Mucinous tumors Mets post chemotherapy |
|
|
What bone tumors show calcified mets to lung?
|
Osteosarcoma
Chondrosarcoma |
|
|
What are the mucinous tumors that calcify when metastasizing to lung?
|
Ovarian
Thyroid Pancreas Colon Stomach |
|
|
What causes cannonball mets?
|
Head and neck tumors
Breast CA Colon CA Renal CA Testicular/ovarian Soft tissue tumors |
|
|
What is sterile metastasis?
|
A met under treatment with no viable tumor. Made of necrotic and/or fibrous tissue
|
|
|
What is other name for idiopathic pulmonary fibrosis?
|
UIP (usual interstitial pneumonia)
|
|
|
What is appearance in IPF?
|
Nonspecific, with changes also occurring in other diseases such as collagen vascular, drug reactions, and pneumoconioses.
|
|
|
What is appearance?
|
Primarily lower lung zones
Peripheral subpleural involvement |
|
|
What is early appearance of IPF on HRCT?
|
early--ground glass
later--reticular pattern, primarily lower lobes endstage--honeycombing |
|
|
What else is seen in IPF?
|
Cardiomegaly due to pulm HTN from loss of so much functional lung
|
|
|
What is appearance of stage 1 sarcoid?
|
Symmetric hilar adenopathy
Right paratracheal adenopathy |
|
|
What percent of sarcoid patients have calcified lymph nodes?
|
5%
|
|
|
What is typical appearance?
|
Eggshell
|
|
|
What is pulmonary appearance in stage 2?
|
Reticulonodular pattern or acinar pattern which can coalesce and consolidate
|
|
|
What is stage 4 sarcoid?
|
Pulmonary fibrosis
|
|
|
What is appearance of stage 4?
|
Cicitricial changes of upper lobes, like post TB
|
|
|
What can complicate lung disease in sarcoid?
|
PTX due to blebs
Aspergillus fungus ball |
|
|
What percent of sarcoid has pleural effusion?
|
10%
|
|
|
What are CT features of sarcoid?--most common
|
Nodules along lymphatic distribution
|
|
|
What percent of carcoid with lung dz has this appearance?
|
90%
|
|
|
What are other appearances?
|
Linear pattern
Ground glass subpleural thickening |
|
|
What are two other CT findings in sarcoid that will almost alway be present?
|
Adenopathy
Bronchial wall abnormalities |
|
|
What are the lympoproliferative disorders of the chest?
|
Accumulation of lymphocytes and plasma cells in the pulm interstitium or mediastinal/hilar nodes.
|
|
|
What are the lymphoproliferative disorders that affect the nodes?
|
Castleman's dz
Mononucleosis Angioimmunoblastic lymphadenopathy |
|
|
What is angioimmunoblastic lymphadenopathy?
|
Drug hypersensitivity reaction
|
|
|
What are the parenchymal disorders?
|
Plasma cell granuloma
Pseudolymphoma Lymphoid interstitial pneumonia |
|
|
How can you identify left lower lobe atelectasis?
|
1) Obliteration of the outline of descending aorta
2) Obliteration of medial aspect of left hemidiaphragm |
|
|
If a mass is seen at the level of the aortic knob, but the knob is still well seen, where do you know it is NOT?
|
Superior segment of left lower lobe
|
|
|
How do you identify lingular consolidation?
|
Loss of left cardiac border
|
|
|
When is collapse of the right middle lobe not seen so well on AP view?
|
When the collapse is of the medial segment of RML.
|
|
|
Where is it seen clearly?
|
Lateral view.
|
|
|
What is a sign of right middle lobe collapse that is subtle on PA view?
|
Loss of clarity of right heart border
|
|
|
What are the most common reasons for air bronchogram?
|
Pneumonia
Pulmonary edema |
|
|
What are the other causes of air bronchogram?
|
ARDS/HMD
Nonobstructive atelectasis Fibrotic scarring Severe interstitial disease Certain neoplasms |
|
|
What are the neoplasms known to cause air bronchograms?
|
Bronchioloalveolar
Lymphoma |
|
|
What is CT angiogram sign? (Armstrong, 73)
|
Branching enhancing vessels coursing through lower density pulmonary consolidation. Looks like liver.
|
|
|
What is DDx for CT angiogram sign?
|
Pneumonia
Bronchioloalveolar carcinoma Lymphoma |
|
|
What are the different types of pulmonary opacities?
|
1) Airspace filling
2) Atelectasis 3) Mass 4) Line or band shadows 5) Ring shadows (cysts and bullae) 6) Diffuse nodular, reticulonodular and honeycomb shadows |
|
|
What are appearances of airspace filling?
|
1) Consolidation
2) Acinar shadows and air alveolograms 3) Ground glass opacity |
|
|
What is DDx for solitary (solitary meaning just one, but can still be large) airspace filling leisons?
|
1) Pneumonia
2) Atelectasis 3) Infarct or hemorrhage due to PE. 4) Contusion 5) Neoplasm (if it causes post-obstructive pneumonia or atelectasis) 6) Radiation pneumonitis or fibrosis (conforms precisely to port) 7) Collagen vascular disease (rare to cause solitary airspace lesion) |
|
|
What varieties of pneumonia cause solitary air space shadow?
|
All kinds: Bacterial (incl TB), viral, fungal and parasitic.
|
|
|
In adult pneumonia what does associated hilar mass suggest?
|
Underlying neoplasm causing postobstructive pneumonia
|
|
|
In pediatric pneumonia what does associated hilar mass suggest?
|
Primary TB
|
|
|
When you see a relatively small airspace opacity, about the size of a segment, and it has a base on the pleura, what does this suggest?
|
Infarct
|
|
|
When do pulmonary contusions form?
|
Within hours of injury
|
|
|
When do they clear?
|
Within a few days
|
|
|
What is a common complicating feature of contusion?
|
Pneumatocele formation
|
|
|
What if there is chest trauma and within the area of airspace disease there is a mass?
|
It is a hematoma.
|
|
|
What makes this situation different than regular contusion?
|
Takes much longer to get better. Can cavitate and get infected.
|
|
|
What a patient with known collagen vascular disease has solitary airspace shadow, what is DDx?
|
Most likely pneumonia, or sometimes infarct.
Unlikely but possible to be due to underlying disease itself. |
|
|
What neoplasms can cause focal air space disease?
|
Bronchioloalveolar
Lymphoma |
|
|
What suggests one of these diagnoses?
|
The patient is not presenting with typical pneumonia symptoms, and the "pneumonia" doesn't get better radiographically.
|
|
|
What is the broad differential for multifocal airspace filling lesions?
|
1) Pulmonary exudates and transudates
2) Hemorrhage 3) Neoplasm 4) Miscellaneous |
|
|
What falls into the exudate/transudate category?
|
Pneumonia (including aspiration pneumonia)
Pulmonary edema (both transudative and exudative types) Toxic inhalation (including hydrocarbon ingestion) Near drowning Allergic and drug reactions Collagen vascular disease Eosinophilic pneumonia Alveolar proteinosis Amyloidosis |
|
|
What is the exudative variety of pulm edema?
|
ARDS, due to increased membrane permeability
|
|
|
What are the hemorrhagic causes of multifocal airspace filling lesions
|
Contusion
PE Goodpasture's (Wegener's?) Anticoagulant therapy |
|
|
What are neoplastic causes of this appearance?
|
Lymphangitic spread of metastatic disease
Bronchioloalveolar Lymphoma |
|
|
What are miscellaneous causes of this appearance?
|
Sarcoid
Silicosis Alveolar microlithiasis |
|
|
What is the next pattern of airspace filling disease?
|
Widespread airspace disease
|
|
|
What familiar pattern is present in a type of this?
|
Bat wing pattern
|
|
|
What are common causes of widespread airspace disease?
|
Pulmonary edema (both trans and exud)
Pneumonia Toxic inhalation Hemorrhage Alveolar proteinosis |
|
|
What conditions occasionally cause this pattern?
|
Drug/allergic reactions
Collagen vasc disease/vasculitis Lymphangitic spread Lymphoma Bronchioloalv CA |
|
|
What is "bat wing" pattern actually?
|
Just bilateral perihilar shadowing
|
|
|
What is DDx for sperical conolidative process?
|
Pneumonia
Neoplasm |
|
|
What pneumonias are most likely to cause round appearance?
|
Bacteria, TB, and fungi
|
|
|
What is the DDx of bat wing appearance?
|
1) Pulm edema
2) Lymphangitic spread of mets 3) Pneumonia 4) Toxic inhalation 5) Aspiration 6) Multifocal pulm hemorrhage |
|
|
What if bat wing appearance does not go away for few weeks?
|
Alveolar proteinosis
Neoplasm (lymphangitic spread or BAC or lymphoma) |
|
|
What is DDx for bat wing appearance with Kerley B lines?
|
1) Pulm edema
2) Lymphangitic spread 3) Alveolar proteinosis |
|
|
Patient with sx of pulm edema but normal CXR. What is not the cause?
|
Not cardiogenic, unless acute heart failure in previously normal person (i.e. papillary muscle rupture, severe acute MI).
|
|
|
Widespread pulm consolidation and patient with hemoptysis. Likely cause?
|
Pulmonary hemorrhage
|
|
|
What appearance is almost diagnostic of pneumonia
|
Opacity of more than 1/2 a lobe without volume loss
|
|
|
What is DDx of this?
|
Bronchioloalveolar CA.
|
|
|
How does bronchioloalveolar CA create its appearance?
|
Spreading through alveolar spaces without occluding central bronchi
|
|
|
Lobar consolidation with lobar expansion?
|
Strep pneumo, klebsiella, pseudomonas or staph
Obstructive pneumonia due to CA |
|
|
What is this appearance called when caused by obstructing neoplasm?
|
"Drowned lung"
|
|
|
What is DDx of lucencies within consolidated lung?
|
1) partial resolution
2) Necrosis with cavitation 3) Pneumatocele |
|
|
Nonsegmental airspace shadows that are clearly peripheral?
|
Chronic eosinophilic pneumonia
|
|
|
Causes of airspace opacity that resolves, then a new one appearing in same area or different location?
|
Pulmonary edema
Eosinophilic pneumonia, acute or chronic Asthma |
|
|
What type of asthmatic is this most typical of?
|
Patient with ABPA
|
|
|
What is the classic appearance of ARDS?
|
Uniform opacity of both lungs without pleural effusion.
|
|
|
What else is often seen in the lungs of these patients?
|
air bronchograms
|
|
|
What other findings increase the likelihood of ARDS?
|
PTX
Pneumomediastinum |
|
|
Back to Weissleder
|
Back
|
|
|
What lung findings are seen in Castlemans?
|
None
|
|
|
What is the appearance of plasma cell granuloma?
|
Solitary pulmonary mass, 1-12 cm.
|
|
|
What is true of its epidemiology?
|
Most common tumor-like abnormality in kids under 15
|
|
|
What is its growth pattern?
|
No growth to very slow growth
|
|
|
How often does it calcify?
|
rare
|
|
|
How do you differentiate lymphoproliferative disorder from lymphoma?
|
Lympoproliferative disorders will involve either the nodes or the parenchyma, but not both. Lymphoma will affect both the parenchyma and the nodes.
|
|
|
What is the pathology in lymphangioleiomyomatosis?
|
As the name implies, there is proliferation of smooth muscle cells along the lymphatics.
|
|
|
What is LAM often associated with?
|
Tuberous sclerosis
|
|
|
What is most important finding?
|
Lung hyperinflation
|
|
|
What is the most striking finding?
|
Lung is full of thin walled cystic spaces
|
|
|
What are the collagen vascular diseases that affect the lung?
|
Rheumatoid
Lupus Systemic sclerosis Ankylosing spondylitis |
