Cxr-12 This sign name:Air Bronchogram• In a normal chest x-ray, the tracheobronchial tree is not visible beyond the 4th order.• As the bronchial tree branches, the cartilaginous rings become thinner, and eventually disappear in respiratory bronchioles.• The lumen of the bronchus contains air and the surrounding alveoli contain air. Thus, there is no contrast to visualize the bronchi.• The air column in the bronchi beyond the 4th order becomes recognizable if the surrounding alveoli is filled, providing a contrast or if the bronchi get thickened.• The term air bronchogram is used for the former state and signifies alveolar disease.
Cxr-13 This sign name is: Halo SignIn a cavity with a fungus ball, there is a crescentic lucent space along the upper portion of thedensity giving the appearance of a halo.This phenomenon is seen with two clinical presentations of pulmonary aspergillosis:Fungous ballNecrotizing subacute pneumonia during recovery phase from leukopenic episodes (as in thiscase)
Cxr-14 This sign name is:? Crossing Mid-line When a mediastinal density crosses mid- line, most of the time it is a bowel. This is a case of a hiatal hernia
Cxr-15Differential diagnosis for this air-fluid level is:…….
Cxr-15The x-ray on left is an example of lung abscess and tuberculosis.LUL lung abscess•Fluid level•Necrotic mass along wallsRUL infiltrate: Tuberculosis•This appearance can also come from branchiogenous spread of abscess contents to the rightlung. AFB was positive in this case.
Cxr-15 Air Fluid LevelYou can encounter air fluid level in an upright chest film in:1. Cavities2. Pleural space: Hydropneumothorax3. Bowel: Hiatal hernia4. Esophagus: Obstruction5. Mediastinum: Abscess6. Chest wall7. Normal stomach8. Dilated biliary tract9. Sub diaphragmatic abscess
Cxr-16 Differential diagnosis for this sign is:……..
Cxr-16Expanding lesions of structures in the chest wall give rise to thissign.This sign helps to recognize the site of the lesion.The characteristic features of the density are:1. Peripheral location2. Cat under the rug appearance3. Concave edges4. Sharp inner edge and indistinct outer edge Extrapleural Sign5. Equal length and width in early stages
Cxr-17Differential diagnosis for this sign is:….
Cxr-17Differential diagnosis for this sign is:Inhomogeneous Cardiac Density / Double Density
Cxr-17 Inhomogeneous Cardiac Density / Double DensityThe heart should be of uniform density, except over the vertebra anddescending aorta. Left atrial enlargement can be recognized by the circular double density.Any time you see increased density in one portion compared to the rest ofthe heart, consider an abnormal density either in front of or behind theheart. Consider the following when you encounter inhomogeneous cardiacdensity: Esophageal diseasePosterior mediastinal massesHiatal herniaLeft lower lobe diseaseDescending aorta This is an example of an aorta aneurysm.
chest clinical cases A Trans-sexual with Acute Dyspnea and Diffuse InfiltratesSubmitted byMisbah Baqir, MDSenior FellowMayo ClinicRochester, MNAlvaro Velasquez, MDStaff PhysicianDivison of Pulmonary, Allergy and Critical Care MedicineEmory University School of MedicineAtlanta, GAOctavian C. Ioachimescu, MD, PhDStaff PhysicianDivision of Pulmonary, Allergy and Critical Care MedicineEmory University School of Medicine, Atlanta VA Medical CenterAtlanta, GA
History• A 38 year-old transsexual male presented to the emergency department with a three-day history of progressive dyspnea associated with a mild, non-productive cough.• He also complained of a pleuritic-type chest pain and of dyspnea while speaking in longer sentences.• He admitted feeling "hot and cold" at times, with no objective measurements of body temperature.• Along with these symptoms he also reported lethargy.• He denied wheezing, hemoptysis, sore throat, rash, significant weight changes, sick contacts or any recent travel.• Past medical history: the patient reported getting hormonal "shots" since age 16.• Past surgical history: none.• Medications at home: hormonal "shots"• Social History: denied smoking cigarettes, alcohol or illicit drugs.• Personal History: works as a hair stylist.• Family History: diabetes mellitus (mother) Saturday, December 08, 2012
Physical Exam(Upon arrival to the emergency room)• The patient was alert and oriented.• Pulse was 110 beats per minute, blood pressure 100/73 mm Hg, respiratory rate 30 per minute, temperature 37.8 ºC, Oxygen saturation was 90% on room air.• No cyanosis or clubbing was noted.• Pupils were equal and reactive to light.• Neck examination revealed no abnormality.• Precordial examination revealed tachycardia, but no murmurs, rubs or gallops.• Patient demonstrated a rapid, shallow breathing pattern, but was not using accessory respiratory muscles.• On auscultation he had normal vesicular breath sounds bilaterally.• Abdomen was soft, with normal bowel sounds.• Skin examination revealed several pinpoint, needle-like marks on the chest, buttocks and thighs.• No peripheral edema was noted.• His joints were non-tender, not warm to touch and free of swelling or deformity.• Neurologic examination was within normal limits.MORE INFORMATION:• Upon further questioning triggered by the observed skin needle marks, the patient attributed them to hormonal injections and multiple subcutaneous inoculations with a substance which on the vial had no name, but the following chemical structure: Si(CH3)3-[C(CH3)2-Si-O]n-Si(CH3)3 . Saturday, December 08, 2012
Lab• Hemoglobin 8.8 g/dL, hematocrit 26.5%, MCV 106 fL.• WBCs 10,000 /mm3,• Differential: 77% segmented neutrophils, 12% lymphocytes, 3% eosinophils and 3% monocytes.• Platelets 181,000/mm3,• Creatinine 0.7 mg/dL,• AST 47 U/L, ALT 40 U/L, alkaline phosphatase 40 U/L.• PT, PTT and INR were normal.• The patient’s electrolytes and serum glucose were within normal limits. Saturday, December 08, 2012
Bronchoscopy The patient was admitted to the medical floor and was started empirically on antibiotics. Cultures were obtained and an HIV test was done. Bronchoscopy was planned the next day which revealed diffuse erythema and hemorrhage in both the bronchial treesBAL wasgrosslybloodyandcultureswerenegative. Saturday, December 08, 2012
Question 1• What is the most likely diagnosis?• A. Community-acquired Pneumonia• B. Pulmonary embolism• C. Silicone pulmonary microembolism.• D. HIV related pulmonary infection Saturday, December 08, 2012
DISCUSSIONThis is a case of liquid silicone embolism, 4 days after a large injection with silicone inhis breasts.The patient received multiple "augmenting" liquid silicone injections to differentareas of the body, including lips, hips, thighs, breasts and buttocks.The chemical structure from the label is that of poly-dimethylsiloxane (liquidpolymeric silicone).CT scan on admission showed diffuse, bilateral, peripheral consolidations andground-glass opacities with septal thickening bilaterally. In the lower lobes, wedge-shaped, peripheral opacities suggestive of pulmonaryinfarcts were seen .There was also extensive stranding within the anterior chest wall, with multiple fluiddensity areas, which were suggestive of silicone injection content .Bronchoscopy showed diffuse bronchial mucosa erythema and active bleedingbilaterally .Bronchoalveolar lavage (BAL) was performed and revealed increasingly bloodieraliquots.BAL sediment included many erythrocytes, siderophages and foamy macrophageswith intracytoplasmic vacuoles, suggestive of an exogenous inert substance,likely silicone . Saturday, December 08, 2012
Question 2The patient was treated with a short course of glucocorticoids and was discharged in stable condition, with normal gas exchange.• What is the proposed mechanism of silicone toxicity?• A. Inflammatory response to silicone• B. Absorption of the silicone through the vascular route causing acute cerebral embolism• C. Both A and B Saturday, December 08, 2012
DISCUSSION• Two distinct patterns of silicone toxicity are observed in patients reported in the medical literature (5).• The more common pattern is one in which patients predominantly have respiratory symptoms like the case we have presented above.• The most common presenting symptoms in these cases were respiratory distress and hypoxia seen within first 72 hours after the injection.• The cytological findings in BAL were consistent with signs of inflammation.• The presence of silicone globules in the alveolar space, inter-alveolar walls, pulmonary capillaries and macrophages have been confirmed by spectrophotometry (6).• Silicone becomes encapsulated in delicate cysts when massive volumes are given subcutaneously.• This apparently causes significant alteration of the tissue structure of the subcutis, as evidenced by the transformation of the adipose tissues into cysts of different sizes and shapes.• Silicone may be distributed to the viscera by gaining entrance to the general circulation or lymphatic channels from the site of injection.• Another proposed mechanism is phagocytosis by histiocytes (3).• Once in the circulation, silicone may get trapped in the lung capillaries.• The phagocytosis by alveolar macrophages provoke inflammatory response by increasing vascular permeability, activating endothelial cells, inducing the accumulation of activated neutrophils, and modulating immunoregulatory responses in the lung.• The fact that most of these patients improved with steroids suggests that an immune-mediated response may be present (7).• The second pattern of disease is an acute change in mental status including coma.• The symptoms develop within several hours after injection and the patients deteriorate rapidly, with a reported 100% mortality.• This is explained by possible cerebral embolism. In some patients silicone was detected in the brain on autopsy (8). Saturday, December 08, 2012
Question 3• Which test is diagnostic of silicone embolism?• A. CT chest• B. Bronchoscopy• C. Electron Microscopy with Energy Dispersive X-ray Analysis (EDXA)• D. Ventilation-perfusion (V/Q) scan Saturday, December 08, 2012
DISCUSSION• The definite diagnosis can be made by EDXA that gives a clear-cut silicone peak (9).• Other tests, including CT chest, bronchoscopy with BAL, transbronchial biopsy and ventilation-perfusion (V/Q) scan can suggest the diagnosis of silicone toxicity, but they are not diagnostic.• CT scan typically shows patchy consolidation with ground- glass opacities, predominantly in the peripheral and subpleural areas of the lung.• These opacities are sometimes wedge-shaped, suggesting a possible embolic origin (9).• Bronchoscopy usually reveals hemorrhage.• V/Q scan can show decrease peripheral uptake without segmental defects (10). Saturday, December 08, 2012
HRCT-1• 1. What are the abnormalities in this case? • a) Linear opacities • b) Nodules • c) Consolidation • d) Ground-glass opacity• 2. What is the distribution of the abnormalities?
HRCT-1• 1. What are the abnormalities in this case? • a) Linear opacities • b) Nodules • c) Consolidation • d) Ground-glass opacity• 2. What is the distribution of the abnormalities? • Centrilobular and confluent lobular, right upper lobe
HISTOLOGY-2• Find the area of necrosis in the granuloma.• Find palisading histiocytes at the margin of the necrosis.• Find a small, non-necrotizing granuloma.• Find aerated alveolar parenchyma (which allows the nodule to be identified radiographically).
Differential diagnosisof clusters of centrilobular nodules, tree-in-bud pattern, and masses on HRCT:• The findings are most consistent with focal endobronchial infection with areas of confluent spread.• This pattern is most commonly seen with – tuberculosis. – Tumor mass with post-obstructive endobronchial infection should also be considered.