Anwser,s 11

Anwser,s
Dr :ANAS SAHLE
1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
4. MRCP exam.
:http://www.facebook.com/dranas224

Saturday, January 19, 2013

chest xr cases
Dr :anas sahle
http://www.facebook.com/dranas224

CXR53b
Diagnosis is: Superior Vena Caval Syndrome

Small Cell Cancer
Lung
Mass in the region
of superior vena
cava

CXR54

"Potato" Nodes
Sarcoidosis
Bilateral symmetrical hilar nodes
Clear space between hilar nodes and heart
Sign name is:"Potato" Nodes AP window nodes
Paratracheal nodes
RLL alveolar lung infiltrate

CXR55

Bilateral upper lobe disease
Calcified mediastinal nodes
Egg shell calcification
Stable over years

Diagnosis is: Silicosis

CXR56

Bilateral upper lobe disease
Calcified mediastinal nodes in CT
Calcification in the mass like densities in CT

Diagnosis is:Progressive Massive Fibrosis

CXR57

1-2-3 sign or Garland triad
is the classic pattern of lymphadenopathy Sign name is: 1-2-3 sign
seen in sarcoidosis with
•bilateral hilar lymphadenopathy and
•right paratracheal nodal enlargement.

CXR58b

Diagnosis is: Thyroid Mass

CXR59b

Diagnosis is: Malig Thymoma

CXR60b

Diagnosis is: Fat Pad

chest clinical cases
Progressive Dyspnea in an
Submitted by
W. Alex Wade MD
Appalachian Coal Miner
Pulmonary Fellow
Section of Pulmonary and Critical Care Medicine , Department of Medicine
West Virginia University School of Medicine
Morgantown, WV
Jack L. Kinder, MD
Chair
West Virginia State Occupational Pneumoconiosis Board
Charleston, WV
Edward. L. Petsonk MD
Professor of Medicine
Section of Pulmonary and Critical Care Medicine, Department of Medicine
West Virginia University School of Medicine
Morgantown, WV

History
Physical Exam
• A 32-year-old male initially presented in 1991 complaining of dyspnea on
exertion and a non-productive morning cough for two years.
• He was a lifelong nonsmoker and had worked for 15 years as an
underground coal miner, transporting coal in a rubber-tired vehicle.
• Five years later, he sought reevaluation due to worsening dyspnea and
productive cough.
• His lungs were clear and the cardiovascular examination was normal.


Lab

• The chest radiograph in 1991 was normal
(Figure 1.1)
• Five years after initial presentation, blood
gases at rest on room air showed mild hypoxia
(PaO2 73 mm Hg).
• The radiograph then demonstrated multiple
bilateral small opacities, as shown in Figure
1.2.

cxr

(Figure 1.1)

Figure 1.2.


Question 1
• What is the most likely diagnosis for this
patient?
• A. Silicosis
• B. Asbestosis
• C. Lung cancer
• D. Coal Workers’ Pneumoconiosis (CWP)
• E. Chronic Obstructive Pulmonary Disease
(COPD)


DISCUSSION
• CWP is an interstitial lung disease that occurs due to the inflammatory reaction to inhaled coal mine dusts.
• When lung clearance mechanisms are overwhelmed, numerous black coal macules develop in the lung parenchyma
adjacent to the respiratory bronchioles (1).
• As CWP progresses, the macules enlarge and develop into fibrotic coal nodules with associated emphysema.
• Radiographically, the pathologic changes of CWP manifest as small rounded opacities less than 10 mm in diameter.
Historically, the opacities generally have generally appeared after at least 15-20 years of exposure, although there are
recent reports of more rapidly progressive disease (2).
• The International Labor Office (ILO) has devised a classification system to describe and quantify the changes of
pneumoconiosis on chest radiograph (3).
• The ILO classification scores the profusion (number of small pneumoconiotic opacities per unit area of lung) from 0 to 3.
• Early (category 1) CWP may produce few or no symptoms.
• However, dust exposure can also lead to chronic bronchitis (even in the absence of smoking tobacco), which results in
cough, sputum production and wheeze. As CWP progresses, dyspnea becomes severe, and affected patients can develop
cor pulmonale, respiratory failure and death (4, 5).
• Although silicosis can be a more rapidly developing disease which occurs in underground coal miners, the specific mining
job of this patient does not involve activities (e.g., drilling or roof bolting) that typically generate exposure to airborne
silica.
• However, mining of thin coal seams can create silica exposures in general mining activities, as performed by this worker.
• Asbestosis typically causes interstitial lung changes that are more pronounced in the lower lung zones, and have a more
reticular rather than nodular appearance.
• Although both COPD and CWP can cause changes of obstruction and hyperinflation on a chest radiograph, the small
nodules seen on this patient’s chest radiograph would not be typical for COPD.
• Lung cancer can cause multiple pulmonary nodules, but the time course and clinical picture in this patient are more
consistent with CWP.

History Continued:
• The patient ceased employment in 1997 due to a
back injury, after having worked 21 years in the
mines.
• He was seen with worsening dyspnea in 2000, at
the age of 41.
• He denies any other complaints, such as fevers,
chills or sputum production.
• Pulmonary function tests (PFTs) showed an FEV1
of 58% predicted and an FVC of 74% predicted.
• A chest radiograph was taken at that time (Figure
1.3).

(Figure 1.3).

(Figure 1.3).

Question 2
• What is the most likely diagnosis to explain this
patient’s new findings?
• A. Multiple Arterio-Venous (AV) Malformations
• B. Primary Adenocarcinoma of the Lung
• C. Active M. tuberculosis infection
• D. Progressive Massive Fibrosis (PMF)
• E. Metastatic Cancer from an unknown primary
source


DISCUSSION
• Both coal and silica dust exposures trigger inflammation of the airways and the interstitium, and
pneumoconiosis can continue to progress for years after termination of all dust exposure (1).
• This is one reason why primary prevention through dust control is critical.
• Inflammatory nodules can coalesce to form PMF (also called complicated pneumoconiosis), which is
recognized on the chest radiograph as one or more lesions 10mm in diameter or greater.
• After PMF develops, the fibrosis and associated emphysema often progress even without further dust
exposure, as was the case with this patient.
• Adjacent lung parenchyma is pulled towards the lesions, which most typically occur in the upper lung.
• The large airways are distorted as lung volume is lost and lung function may show obstructive and/or
restrictive impairments.
• An enlarging PMF lesion can be difficult to distinguish from malignancy, particularly if unilateral.
• Silica dust exposure is known to increase the risk of primary lung cancer Also, PMF lesions are frequently
PET-positive, which can add to the diagnostic confusion (6).
• However, the bilateral masses on this nonsmoking patient’s chest radiograph are typical of PMF, and his
clinical course makes primary or secondary lung cancer unlikely.
• Exposure to silica dusts increases the risk of developing TB and nontuberculous mycobacterial infections
(7).
• This is likely due to a dysfunction in cellular immunity.
• Miners who have inhaled excessive respirable silica and are subsequently exposed to mycobacteria are
more likely to develop active disease.
• Although mycobacterial disease should be considered in this patient, there is no cavitation and the
radiographic appearance is more typical of CWP than TB.
• Arteriovenous malformations can present as large masses, typically in the lower lung zones.
• They are usually accompanied by feeder vessels that can sometimes be identified on a chest radiograph.
• Bilateral upper lung zone lesions, as seen in this case, are not suggestive of AV malformations. 19, 2013
Saturday, January

History Continued:
• Over the next four years, the patient’s
dyspnea progressively worsened, and he died
in 2004 at the age of 45 from respiratory
failure secondary to coal workers’
pneumoconiosis with PMF.


Question 3
• Which of the following measures is/are likely to
be effective in preventing development of PMF
among US coal miners?
• A. Decreasing the prevalence of smoking and the
number of cigarettes smoked
• B. Decrease the number of infections with M.
tuberculosis among coal miners
• C. Decreasing the exposure to inhaled coal mine
dust
• D. Decrease the work intensity required by
miners

DISCUSSION
• Advanced CWP, defined as ILO category 2 or greater, is caused by
excessive exposure to respirable coal and/or silica dusts, and greatly
increases the risk of development of PMF and important physiologic
impairment (8).
• As part of the Federal Coal Mine Health and Safety Act of 1969, coal
mine operators are required to observe a permissible exposure limit
(PEL) for respirable dust of 2.0 mg/m3 (9) .
• The goal of this dust limit is not only to decrease the overall incidence of
CWP, but also to decrease the incidence of advanced CWP to nearly zero,
and thus prevent miners from developing PMF.
• However, a small proportion of miners have been observed to develop
PMF with an underlying profusion category of 1 or 0 and thus PMF was
not completely prevented (10).
• A number of studies have shown that PMF development is not
accelerated by tobacco smoking, nor is it dependent on Mycobacterial
infection.
• Most operating coal mines are highly mechanized, which generally has
reduced work intensity during mine work, but also results in high rates of
dust generation. Saturday, January 19, 2013

chest ct cases-10
Dr :anas sahle
http://www.facebook.com/dranas224

HRCT-1

• 1. Is the disease unilateral or bilateral?
• 1. Disease is bilateral.
• 2. What is the anatomic location of the linear
structures that reach the pleura?
• 2. The structures are in part interlobular septa, but
may also include some intralobular fibrosis.
– Note that these lines extend over more than one
lobule. They are referred to as parenchymal or
septal bands or long scars.

HRCT-1

• Find 2 examples of architectural distortion--
tenting of the pleura--one in each lung.
• Find 2 adjacent centrilobular nodules in the
left lung.
• Find 2 examples of subpleural lines, one in
each lung.

HRCT-2

• Find a group of 3 centrilobular nodules in the
right lung.

Parenchymal Bands and Subpleural Lines

• This lung shows many long, thin lines. The long, non-
branching ones correspond to parenchymal bands. Most of
the lines form polygons, indicating a patchy fibrosis of
interlobular septa. In addition, there are subpleural lines that
parallel the pleura, probably representing, in part, interlobular
septa bordering partially collapsed lobules. A few
centrilobular nodules can be seen.
• Find and follow a parenchymal band.
• Find a subpleural line.
• Find two centrilobular nodules.

• This view of an entire section shows several
long, thin, parenchymal bands, as well as
thickening of the bronchovascular
interstitium.
• More detail is shown below.
• Trichrome stain (collagen is green)

• At higher magnification of the above section, deposition of
collagen in a long, thin, parenchymal band can be seen.
• The alveolar parenchyma is mostly normal. Centrilobular
interstitium is also fibrotic (see below).
• Find and follow a long, fibrotic parenchymal
band that spans several lobules.

• At higher magnification of the section above, two
regions of centrilobular fibrosis can be seen.
• Find the two regions of centrilobular fibrosis.
• In time, this fibrosis and that in the interlobular
septum will radiate in an irregular fashion into the
lobule to cause lobular architectural distortion with
centrilobular to interlobular septal bridging and
lobular shrinkage.

• This entire section (detailed below) shows
more advanced interstitial fibrosis with
bridging from interlobular septa to
bronchovascular interstitium and distortion of
the lobule.
• Note that the more central lung parenchyma
is spared.
• (Trichrome stain for connective tissue)

• This H&E-stained section shows the result of prolonged
subpleural, interlobular septal, and centrilobular fibrosis.
The fibrosis has distorted the lobular architecture and
linked centrilobular and interlobular septal structures.
Inflammatory cells are sparse.
• Find an example of a bronchiolovascular bundle.
• Note how it is connected to a thickened interlobular
septum to its left.
• Find a portion of an interlobular septum with a vein
cut longitudinally.
• Note areas of subpleural fibrosis.
• The radiating fibrosis in the right lower quadrant (outline it)
represents linked lobular and interlobular septal fibrosis.

• Here, peribronchiolar fibrosis, which represents a
centrilobular nodule on HRCT, is present. Nearby
peribronchiolar air spaces have been obliterated, but
more distal ones are intact.
• Find the bronchiolar lumen.
• Find the pulmonary artery.
• Find 2 collections of brown pigment in air
spaces.
• What does the pigment represent?
• Collections of hemosiderin pigment.

• In this lung, note the marked thickening of the visceral
pleura.
• Find where the pleura has folded into the lung
parenchyma.
• Find the curved deviation of the interlobar
fissure caused by the scar.
• Find the mild deviation of 2 large vessels toward
the pleural infolding.
• In HRCT image 1 above, the architectural distortion in the
anterior right lung is an example of this pleural infolding.
• Note that there is no honeycombing (see below) in this
lung.

• This is an example of a lung with more advanced
disease.
• Note pleural thickening at the base.
• The normally smooth, lateral pleural margin shows
architectural distortion, which is caused by
irregular, subpleural fibrosis (causing subpleural
nodules on HRCT).
• Find a small subpleural scar (subpleural nodule)
• Compare the abnormal parenchyma in the upper
lateral, subpleural region to the more normal
parenchyma medially. What is the abnormality?
• Honeycombing, consisting of small cystic spaces with thick
walls (more on honeycombing later).

What is it

• The cause of the changes noted above is
shown here. What is it?
• This is an asbestos body, which is a thin asbestos
fiber that has been coated with an iron-protein coat
within a macrophage.
• The asbestos body is often found in areas of
hemosiderin pigment.

Differential diagnosis

• Differential diagnosis of parenchymal bands
with architectural distortion on HRCT:
– Asbestos-related lung disease,
– Atelectasis.
– Tuberculosis.
– Sarcoidosis.
– diffuse pulmonary fibrosis.

Differential diagnosis

• Differential diagnosis of pleural infolding
(rounded atelectasis):
– Asbestos-related pleuropulmonary disease.
– chronic renal failure.
– post coronary artery bypass graft surgery.
– healed pneumonias.
– healed infarcts.

Histologic differential diagnosis:

• Histologic differential diagnosis:
• The presence of asbestos bodies and a history
of asbestos exposure distinguish this entity
from other fibrosing diseases such as:
– usual interstitial pneumonia.
– and fibrosis caused by a drug.
– organic and other inorganic dusts.
– radiation, or collagen vascular diseases.

Diagnostic features of asbestosis on HRCT:

• Diagnostic features of asbestosis on HRCT: In a
person with a history of asbestos exposure, the
diagnosis of asbestosis can be based on the HRCT
if three or more of the following abnormalities
are present :
• Interlobular septal thickening and centrilobular
nodules.
• Parenchymal bands.
• Architectural distortion of the lobule.
• Honeycombing.
• Subpleural lines.

MRCP EXAM
Respiratory

1/19/2013

Q1
• Regarding respiratory surfactant:
• A- It is produced by alveolar type 2 epithelial cells.
• B- It is composed primarily of phospolipids such as
dipalmitoyilelecithin.
• C- It reduces lung compliance by changing surface
tension.
• D- Production may be enhanced by the administration
of antenatal steroids to mother.
• E- At 24 weeks gestation, production is 75% of that at
term.


A1
• Regarding respiratory surfactant:
• A- It is produced by alveolar type 2 epithelial cells.
(True)
• B- It is composed primarily of phospolipids such as
dipalmitoyilelecithin. (True)
• C- It reduces lung compliance by changing surface
tension. (False)
• D- Production may be enhanced by the administration
of antenatal steroids to mother. (True)
• E- At 24 weeks gestation, production is 75% of that at
term. (False)


Q2
• The following syndromes are associated with
respiratory tract abnormalities:
• A- CHARGE Syndrome
• B- Ciliary dyskinesia
• C- Hurler's Syndrome
• D- Tay Sachs Disease
• E- Cri-du-Chat Syndrome


A2
• The following syndromes are associated with
respiratory tract abnormalities:
• A- CHARGE Syndrome(True)
• B- Ciliary dyskinesia(True)
• C- Hurler's Syndrome(False)
• D- Tay Sachs Disease(False)
• E- Cri-du-Chat Syndrome(True)


Q3
• Characteristic features of idiopathic diffuse
interstitial fibrosis of the lung (HAMMAN-
RICH) include:
• A- Cyanosis on exercise .
• B- Inspiratory crackles on auscultation .
• C- Hypercapnia .
• D- Decreased FEV1/FVC ratio .
• E- Decreased gas transfer factor

A3
• Characteristic features of idiopathic diffuse
interstitial fibrosis of the lung (HAMMAN-
RICH) include:
• A- Cyanosis on exercise . (True)
• B- Inspiratory crackles on auscultation . (True)
• C- Hypercapnia . (False)
• D- Decreased FEV1/FVC ratio . (False)
• E- Decreased gas transfer factor(True)

Q4
• The following conditions are associated with
sleep apnoea:
• A- Anorexia nervosa .
• B- Large uninflammed tonsils .
• C- Guillain-Barre Syndrome .
• D- Ondine's Curse .
• E- Diencephalic Syndrome


A4
• The following conditions are associated with
sleep apnoea:
• A- Anorexia nervosa . (False)
• B- Large uninflammed tonsils . (True)
• C- Guillain-Barre Syndrome . (True)
• D- Ondine's Curse . (True)
• E- Diencephalic Syndrome(False)


Q5
• A 7 year old girl presents with acute cough and
wheeze, and is given nebulised salbutamol.
The following are indications for admission to
hospital:
• A- A peak flow rate of 80% of that predicted for
height.
• B- Continuing cough.
• C- Respiratory rate of 40/min.
• D- Saturation of 90% in air.
• E- She looks tired.


A5
• A 7 year old girl presents with acute cough and
wheeze, and is given nebulised salbutamol.
The following are indications for admission to
hospital:
• A- A peak flow rate of 80% of that predicted for
height. (False)
• B- Continuing cough. (False)
• C- Respiratory rate of 40/min. (False)
• D- Saturation of 90% in air. (True)
• E- She looks tired. (True)


Q6
• Chest signs that are reliable diagnostically
are found in:
• A- A neonate with meconium aspiration.
• B- A 3 month old child following aspiration
pneumonia.
• C- A 4 month old child with bronchiolitis.
• D- A 6 month old with lobar pneumonia.
• E- A 2 year old with inhaled foreign body.

A6
• Chest signs that are reliable diagnostically are
found in:
• A- A neonate with meconium aspiration. (False)
• B- A 3 month old child following aspiration
pneumonia. (False)
• C- A 4 month old child with bronchiolitis. (True)
• D- A 6 month old with lobar pneumonia. (False)
• E- A 2 year old with inhaled foreign body. (False)


Q7
• In the normal adolescent lung:
• A- There is an intrapleural pressure of 30cmH2O
(3kPa) at the end of normal expiration.
• B- There is a resting pulmonary blood flow of
10L/min.
• C- The V:Q ratio is greater in apical than basal
segments of the lung when upright and at rest.
• D- The majority of airway resistance is from large
airways.
• E- Cartilage is present in all respiratory bronchioles.


A7
• In the normal adolescent lung:
• A- There is an intrapleural pressure of 30cmH2O (3kPa)
at the end of normal expiration. (False)
• B- There is a resting pulmonary blood flow of 10L/min.
(False)
• C- The V:Q ratio is greater in apical than basal
segments of the lung when upright and at rest. (True)
• D- The majority of airway resistance is from large
airways. (False)
• E- Cartilage is present in all respiratory bronchioles.
(False)


Anwser,s 11

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Anwser,s 11