This document summarizes 14 chest radiology cases presented at a case conference. Case 1 involved a 30-year-old male with severe diffuse alveolitis and inflammatory nodules consistent with pulmonary inhalational injury. Case 2 involved a 33-year-old female with diffuse ground-glass opacities concerning for interstitial edema, pneumonia, or acute injury. Unfortunately, the first patient in Case 2 succumbed to her illness. Case 3 involved a 39-year-old female with centrally distributed ground-glass opacity concerning for pulmonary edema or infection. Case 4 involved a 39-year-old female with reduced ejection fraction consistent with cardiogenic pulmonary edema.

1. Chest Case Conference
March 1, 2017
Dr. Jayanth H. Keshavamurthy. M.B.B.S.

2. Case 1

3. CXR- 30 yr old male acute shortness of breath

4. CT CHEST

5. IMPRESSION:
• 1. Severe diffuse alveolitis and inflammatory nodules
consistent with pulmonary parenchymal inhalational
injury. No pneumothorax.
•
2. Trachea and central bronchi are patent.

6. FINDINGS
• Ground glass centri lobular nodules.
• Apical predominance
• So likely route of exposure via airway

7. Silo-fillers disease

8. Case 2 A

9. 33 year old female acute shortness of breath

10. CT chest with contrast

11. IMPRESSION:
•
1. Diffuse bilateral groundglass opacities with
peribronchial thickening concerning for interstitial edema
which may be cardiogenic (correlate with BNP) versus
atypical pneumonia versus acute noxious injury .
2. Trace pericardial effusion.
3. No CT evidence for pulmonary embolism or aortic
dissection.

12. Better
• 1. Is there Cardiogenic pulmonary edema.
• 2. Is there PH?
• 3. Is there centrilobular nodules?
• 4. Is there pleural effusion, etc or other signs of
pulmonary edema?

13. Case 2 B

14. 53 year old male -acute shortness of breath

15. CT chest with contrast

16. IMPRESSION:
1. Bilateral segmental and subsegmental pulmonary embolism
with left lobar pulmonary embolism. There is straightening of the
intraventricular septum, consistent with right heart strain. Mild
cardiomegaly.
2. Diffuse bilateral airspace opacities with bilateral crazy paving
and subpleural sparing. Findings are highly concerning for
bilateral multifocal pneumonia.
3. Reactive hilar lymphadenopathy.

17. How could you have done better ?

18. Marijuana induced acute necrotizing
bronchiolitis- unfortunately first patient
succumbed to her illness.

19. Ivan A. Morales, Caralee J. Forseen, Paul W. Biddinger, Jayanth H. Keshavamurthy, Norman B. Thomson, Thomas Fortson
Medical College of Georgia at Augusta University
Augusta, GA
• Use of marijuana for recreational and medicinal
purposes has been prevalent for thousands of
years in many cultures
• Advent prior to 2700 BCE in China
• Recent data shows trends of increased use
worldwide
• Lifetime use in the U.S. reached a prevalence of
42.8%
• Marijuana's safety is brought into question
• Here we describe a case necrotizing
bronchiolitis after marijuana use
• With other etiologies ruled out, this case was an
example of necrotizing bronchiolitis secondary
to inhalation of noxious stimuli likely from the
marijuana from a new dealer
• Marijuana has been shown to have a wide
variety of beneficial uses, but the question
remains, is it safe?
• Inhalation of the smoke produced by igniting
marijuana is the most common route for use
• Combustion of marijuana emits hundreds of
compounds, including the primary psychoactive
ingredient THC and over 100 other cannabinoids
• Marijuana smoke also deposits tar and an array
of noxious chemicals including NH3, HCN, NOx,
aromatic amines, and polycyclic aromatic
hydrocarbons at equal or higher concentrations
than tobacco smoke
• Respiratory symptoms including chronic cough,
bronchitis, and wheezing were reported at
similar percentages for marijuana and tobacco
smokers
• Analysis of respiratory mucosa biopsies in
marijuana smokers show extensive airway
inflammation comparable to tobacco smokers,
which is likely responsible for the increased
respiratory symptoms
1. United Nations Office on Drugs and Crime. World Drug Report 2014. United Nations publication,
Sales No. E.14.XI.7.
2. Joshi M, et al. Marijuana and Lung Diseases. Curr Opin Pulm Med. 2014; 20(2): 173-9.
3. Moir D, et al. A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke
produced under two machine smoking conditions. Chem Res Toxicol. 2008; 21(2):494-502.
4. Moore, BA et al. Respiratory Effects of Marijuana and Tobacco Use in a U.S. Sample. J Gen Intern
Med. 2005; 20(1): 33–37.
5. Tetrault, JT, et al. Effects of Marijuana Smoking on PulmonaryFunction and Respiratory
Complications: A Systematic Review . Arch Intern Med. 2007; 167(3): 221–228.
Marijuana: Is It Safe?
A Case of Fatal Necrotizing Bronchiolitis
• 31-year-old female presented to the emergency department (ED) with shortness of breath, cough, and chest
pain for 2 weeks
• Diagnosed with an upper respiratory infection at an urgent care clinic 4 days prior and prescribed a steroid
taper and azithromycin with no improvement
• History of cigarette smoking 1 pack/day and smoking marijuana
• In the ED she has a pulse of 110 bpm, a respiratory rate of 24 breaths/min, and a SaO2 of 77% on room air.
• Lungs clear to auscultation
• Laboratory findings showed ↑ WBC count, ↑ BNP of 223, and ↑ troponin of 0.24.
• Portable CXR demonstrated nodular changes bilaterally (below)
• Echocardiogram revealed no abnormalities
• CTA revealed no evidence of pulmonary embolism but showed severe diffuse bilateral groundglass
opacification with diffuse centrilobular nodules (below)
• Treatment for pneumonia was initiated
• Lung biopsies revealed necrotizing bronchiolitis associated with diffuse interstitial and intralveolar pneumonia
• The samples were negative for fungi, acid-fast bacilli, bacteria, HSV 1/2, and CMV
• Inhalation of a toxic substance was suspected
• Patient admitted to smoking marijuana from a new dealer 2 weeks ago when the symptoms began
• Unfortunately, she succumbed to her illness due to diminished gas exchange from severe acute necrotizing
bronchiolitis.
Conclusion
Discussion
References
Introduction Clinical Presentation
AP Portable Chest X-Ray:
Demonstrated nodular changes bilaterally with no
consolidation
CT Angiogram:
Revealed no evidence of pulmonary embolism
Showed severe diffuse bilateral groundglass
opacification with diffuse centrilobular nodules,
bronchiolar thickening, and interspersed
parenchymal blebs.
A. Diffuse effacement of lung architecture and
bronchiole containing necrotic cell debri,
macrophages, and lymphocytes
B. Bronchiole showing squamous metaplasia,
necrotic cell debris; intralveolar inflammatory
exudate
A. B.

21. Case 3

22. 39 year old female acute shortness of breath

24. IMPRESSION
1. Centrally distributed groundglass opacity involving all lobes
possibly representing pulmonary edema, but multilobar infection is
a concern given leukocytosis. Specifically, there are no cavitary
lesions to suggest septic emboli.
2. Mild centrilobular emphysema with 6 mm right lower lobe
pulmonary nodule.
3. Likely reactive prominent mediastinal and hilar lymph nodes.
4. Multivessel coronary artery calcifications advanced for the
patient's age.

25. How could you have done better ?

26. Non cardiogenic pulmonary edema
likely from acute methadone lung injury.

27. Case 4

28. 39 year old female acute shortness of breath

30. Echo
• Compared to prior echo done
The left ventricle is mildly dilated with normal wall thickness.
There are multiple wall motion abnormalities; the
anteroapical area appears
more hypokinetic than on previous echo 11/2014.
• Left ventricular systolic function is moderately to severely
reduced;ejection fraction is 31% by the biplane method of
disks.
The left ventricular filling pattern is pseudonormal.

31. Cardiogenic pulmonary edema.

32. Case 5

33. 2 days later

34. • Neurogenic pulmonary edema.
• Alveolar edema more than interstitial edema.

35. Case 6

36. CLINICAL STATEMENT: "desatting and rales post op,concern
for pulm edema"

37. Negative pressure edema

38. Case 7

39. 57 year old with APML and
recently started treatment

41. Old name retinoic acid
syndrome, now
differentiation syndrome

42. http://posterng.netkey.at/esr/viewing/index.php?module=vi
ewing_poster&task=viewsection&pi=117520&ti=379439&
si=1166&searchkey=#poster

43. Case 8

44. 27 year old

45. Pulmonary alveolar proteinosis

46. Case 9

47. Day1

48. Day 3

50. After treatment

51. Alveolar hemorrhage from
pulmonary renal hemorrhagic
syndrome

52. Case 10

53. CT lung screening MIP

54. RB -ILD

56. Case 11

57. 58 year old smoker and restrictive lung disease

60. Case 12

61. 31 year old male smoker

65. http://pubs.rsna.org/doi/fu
ll/10.1148/rg.285075223

66. Case 13

68. TS with LAM

69. http://thoracicrad.org/assets/index/2015/Case_of_the
_Month/cardio/10-2015/index.htm

70. Case 14

71. 41 year old with fever and cough

72. Did you identify all the support devices correctly?

73. Severe pneumonia needing a
VV ECMO catheter
placement

74. 2 years later