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Imaging: Multiple Pulmonary Cavitary Lesions
 

Imaging: Multiple Pulmonary Cavitary Lesions

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    Imaging: Multiple Pulmonary Cavitary Lesions Imaging: Multiple Pulmonary Cavitary Lesions Presentation Transcript

    •  
      • Mr.rajan
      • 38 yr old smoker
      • C/O swelling all over the body - past 4 months
      • 5months back-he developed
      • Cough-productive,scant mucoid sputum
      • chest pain-diffuse pricking increases with cough
      • Breathlessness-Class iii(NO orthopnoea/PND)
      • No chest pain/palpitation
      • No haemoptysis/fever
      • No oliguria/dysuria/haematuria
    • On Examination
      • Pt conscious oriented
      • Afebrile
      • No pallor /icterus / cyanosis/clubbing
      • B/L pitting pedal edema
      • Not dyspnoeic
      • No generalised lymphadenopathy
      • JVP not elevated
      • PR 86/min BP 110/70mm Hg
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      • INFECTIVE CAUSES
      • mycobacterial –
      • Bacterial-
      • staph aureus,klebsiella,psuedomonas,nocardiosis, anaerobes
      • Fungal-
      • aspergillus,blastomycosis,coccioidomycosis, histoplasmosis
      • Septic emboli
      • Lung abscess
      DIFFERENTIALS FOR MULTIPLE CAVITARY LESIONS
      • TRAUMA
      • Pulmonary contusion
      • Septic emboli
      • Lung abscess
      • GRANULOMATOUS, INFLAMMATORY DISORDERS
      • Necrotizing sarcoid granulomatosis/lung
      • Wegeners granulomatosis
      • COLLAGEN VASCULAR DISORDERS
      • Polyarteritis nodosa
      • Rheumatoid lung disease
      • VASCULAR DISORDERS
      • Pulmonary infarction with cavitation
      • NEOPLASTIC DISORDERS
      • Lymphomas
      • Metastatic lung disease
      • carcinoma of lung
    • LOOKING AT CAVITIES
      • What is the anatomic distribution?
        • Is It single or multiple?
        • If multiple , are they focally located or diffusely seen in multiple lobes of both lungs?
      • Is are the characteristics of the cavity?
        • Is the cavity wall thick or thin?
        • Is the interior lining nodular, shaggy, or smooth?
      • Are there any other associated radiographic abnormalities?
    • INVESTIGATIONS
      • Urine routine-protein 2+, 3-5 RBCs
      • TC 13800
      • DC P66 L 32 E2
      • ESR 56mm/hr
      • Platlets 1,45,000
      • Hb 12.8 g
      • Urea -17 mg
      • Creatinine 0.8 mg
      • HIV – NR
      • SPUTUM AFB negative
      • Sputum c/s no growth
      • RF – neg
      • ANA – Neg
      • CRP elevated
      • ENT OPINION : Polyp from Lt middle meatus, VLS-normal
    • FNAC OF A NODULE(CT GUIDED)
    •  
    • POSSIBILITIES
      • 1.WEGENER’S GRANULOMATOSIS
      • 2.PULMONARY LANGERHANS CELL HISTIOCYTOSIS
    • P-ANCA … POSITIVE Approximately 90% of patients with active Wegener’s granulomatosis have a positive antiproteinase-3 ANCA. A small percentage of patients with Wegener’s granulomatosis may have antimyeloperoxidase rather than antiproteinase-3 antibodies.
    • Points in favour
      • Renal involvement
      • P-ANCA positivity
      • Radiolgical features
      • Paranasal sinus involvement
    • Wegener granulomatosis
      • Granulomatous, necrotizing, small & medium vessel vasculitis
      • Any age (40-55 yrs.)
      • Frequency of 3 per 100,000 persons
      • TRIAD
      • RENAL -Microscopic hematuria, proteinuria, and rapidly progressive RF
      • UPPER AIRWAYS- recurrent / nonresolving sinusitis, epistaxis, nasal septal perforation (saddle nose deformity)
      • LOWER AIRWAY- subglottic stenosis. Single or multiple cavitating/noncavitating Pulmonary nodules or diffuse alveolar hemorrhage
    • Wegener granulomatosis
      • Skin rash, migratory arthritis
      • Ocular involvement (scleritis, corneal ulceration,orbital dis.)
      • Mononeuritis multiplex or CNS involvement with or without pachymeningitis
      • ANCA (180pt., 96%with severe dis.,83%with limited dis.)
      • Lung biopsy yield 91% of cases
      • Upper airway biopsy yield only 21%of cases
      • Renal biopsy:focal, segmental necrotizing, crescentic glomerulonephritis with few to no immune complexes
    • ANCA
      • ANCA plays a central role
      • Antibodies directed against certain cytoplasmic proteins in neutrophils and monocytes
      • Two major categories based on IF– C & P ANCA
      • Present in high percentage in systemic vasculitis
    • Kallenberg CGM et al. (2006) Mechanisms of Disease: pathogenesis and treatment of ANCA-associated vasculitides Nat Clin Pract Rheumatol 2: 661 – 670 doi:10.1038/ ncprheum0355 Figure 1 Cytoplasmic components of ethanol-fixed neutrophils, stained by indirect immunofluorescence, in a serum sample from a patient with active Wegener's granulomatosis and antineutrophil cytoplasmic autoantibodies to proteinase 3
    • RENO-PULMONARY SYNDROMES
      • 1.ANTI-GBM ANTIBODIES: Goodpasture’s syndrome
      • 2.ANCA-POSITIVE VASCULITIS
      • Wegener’s granulomatosis
      • Microscopic polyangiitis
      • Churg–Strauss syndrome
      • 3.ANCA-NEGATIVE VASCULITIS
      • Henoch–Schönlein purpura
      • Mixed cryoglobulinaemia
      • Behçet’s disease
      • IgA nephropathy
      • 4.INFECTIONS
      • 5.DRUGS
      • Propylthiouracil
      • D-Penicillamine
      • Hydralazine
      • Allopurinol
      • 6.RHEUMATIC DISEASES
      • (immune complexes)
      • Systemic lupus erythematosus
      • Scleroderma
      • Polymyositis
      • Rheumatoid arthritis
      • Mixed collagen vascular disease
    •