Imaging: Multiple Pulmonary Cavitary Lesions

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Imaging: Multiple Pulmonary Cavitary Lesions

  1. 2. <ul><li>Mr.rajan </li></ul><ul><li>38 yr old smoker </li></ul><ul><li>C/O swelling all over the body - past 4 months </li></ul><ul><li>5months back-he developed </li></ul><ul><li>Cough-productive,scant mucoid sputum </li></ul><ul><li>chest pain-diffuse pricking increases with cough </li></ul><ul><li>Breathlessness-Class iii(NO orthopnoea/PND) </li></ul><ul><li>No chest pain/palpitation </li></ul><ul><li>No haemoptysis/fever </li></ul><ul><li>No oliguria/dysuria/haematuria </li></ul>
  2. 3. On Examination <ul><li>Pt conscious oriented </li></ul><ul><li>Afebrile </li></ul><ul><li>No pallor /icterus / cyanosis/clubbing </li></ul><ul><li>B/L pitting pedal edema </li></ul><ul><li>Not dyspnoeic </li></ul><ul><li>No generalised lymphadenopathy </li></ul><ul><li>JVP not elevated </li></ul><ul><li>PR 86/min BP 110/70mm Hg </li></ul>
  3. 12. <ul><li>INFECTIVE CAUSES </li></ul><ul><li>mycobacterial – </li></ul><ul><li>Bacterial- </li></ul><ul><li>staph aureus,klebsiella,psuedomonas,nocardiosis, anaerobes </li></ul><ul><li>Fungal- </li></ul><ul><li>aspergillus,blastomycosis,coccioidomycosis, histoplasmosis </li></ul><ul><li>Septic emboli </li></ul><ul><li>Lung abscess </li></ul>DIFFERENTIALS FOR MULTIPLE CAVITARY LESIONS
  4. 13. <ul><li>TRAUMA </li></ul><ul><li>Pulmonary contusion </li></ul><ul><li>Septic emboli </li></ul><ul><li>Lung abscess </li></ul><ul><li>GRANULOMATOUS, INFLAMMATORY DISORDERS </li></ul><ul><li>Necrotizing sarcoid granulomatosis/lung </li></ul><ul><li>Wegeners granulomatosis </li></ul><ul><li>COLLAGEN VASCULAR DISORDERS </li></ul><ul><li>Polyarteritis nodosa </li></ul><ul><li>Rheumatoid lung disease </li></ul><ul><li>VASCULAR DISORDERS </li></ul><ul><li>Pulmonary infarction with cavitation </li></ul><ul><li>NEOPLASTIC DISORDERS </li></ul><ul><li>Lymphomas </li></ul><ul><li>Metastatic lung disease </li></ul><ul><li>carcinoma of lung </li></ul>
  5. 14. LOOKING AT CAVITIES <ul><li>What is the anatomic distribution? </li></ul><ul><ul><li>Is It single or multiple? </li></ul></ul><ul><ul><li>If multiple , are they focally located or diffusely seen in multiple lobes of both lungs? </li></ul></ul><ul><li>Is are the characteristics of the cavity? </li></ul><ul><ul><li>Is the cavity wall thick or thin? </li></ul></ul><ul><ul><li>Is the interior lining nodular, shaggy, or smooth? </li></ul></ul><ul><li>Are there any other associated radiographic abnormalities? </li></ul>
  6. 15. INVESTIGATIONS <ul><li>Urine routine-protein 2+, 3-5 RBCs </li></ul><ul><li>TC 13800 </li></ul><ul><li>DC P66 L 32 E2 </li></ul><ul><li>ESR 56mm/hr </li></ul><ul><li>Platlets 1,45,000 </li></ul><ul><li>Hb 12.8 g </li></ul><ul><li>Urea -17 mg </li></ul><ul><li>Creatinine 0.8 mg </li></ul>
  7. 16. <ul><li>HIV – NR </li></ul><ul><li>SPUTUM AFB negative </li></ul><ul><li>Sputum c/s no growth </li></ul><ul><li>RF – neg </li></ul><ul><li>ANA – Neg </li></ul><ul><li>CRP elevated </li></ul><ul><li>ENT OPINION : Polyp from Lt middle meatus, VLS-normal </li></ul>
  8. 17. FNAC OF A NODULE(CT GUIDED)
  9. 19. POSSIBILITIES <ul><li>1.WEGENER’S GRANULOMATOSIS </li></ul><ul><li>2.PULMONARY LANGERHANS CELL HISTIOCYTOSIS </li></ul>
  10. 20. 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.
  11. 21. Points in favour <ul><li>Renal involvement </li></ul><ul><li>P-ANCA positivity </li></ul><ul><li>Radiolgical features </li></ul><ul><li>Paranasal sinus involvement </li></ul>
  12. 22. Wegener granulomatosis <ul><li>Granulomatous, necrotizing, small & medium vessel vasculitis </li></ul><ul><li>Any age (40-55 yrs.) </li></ul><ul><li>Frequency of 3 per 100,000 persons </li></ul><ul><li>TRIAD </li></ul><ul><li>RENAL -Microscopic hematuria, proteinuria, and rapidly progressive RF </li></ul><ul><li>UPPER AIRWAYS- recurrent / nonresolving sinusitis, epistaxis, nasal septal perforation (saddle nose deformity) </li></ul><ul><li>LOWER AIRWAY- subglottic stenosis. Single or multiple cavitating/noncavitating Pulmonary nodules or diffuse alveolar hemorrhage </li></ul>
  13. 23. Wegener granulomatosis <ul><li>Skin rash, migratory arthritis </li></ul><ul><li>Ocular involvement (scleritis, corneal ulceration,orbital dis.) </li></ul><ul><li>Mononeuritis multiplex or CNS involvement with or without pachymeningitis </li></ul><ul><li>ANCA (180pt., 96%with severe dis.,83%with limited dis.) </li></ul><ul><li>Lung biopsy yield 91% of cases </li></ul><ul><li>Upper airway biopsy yield only 21%of cases </li></ul><ul><li>Renal biopsy:focal, segmental necrotizing, crescentic glomerulonephritis with few to no immune complexes </li></ul>
  14. 24. ANCA <ul><li>ANCA plays a central role </li></ul><ul><li>Antibodies directed against certain cytoplasmic proteins in neutrophils and monocytes </li></ul><ul><li>Two major categories based on IF– C & P ANCA </li></ul><ul><li>Present in high percentage in systemic vasculitis </li></ul>
  15. 25. 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
  16. 26. RENO-PULMONARY SYNDROMES <ul><li>1.ANTI-GBM ANTIBODIES: Goodpasture’s syndrome </li></ul><ul><li>2.ANCA-POSITIVE VASCULITIS </li></ul><ul><li>Wegener’s granulomatosis </li></ul><ul><li>Microscopic polyangiitis </li></ul><ul><li>Churg–Strauss syndrome </li></ul><ul><li>3.ANCA-NEGATIVE VASCULITIS </li></ul><ul><li>Henoch–Schönlein purpura </li></ul><ul><li>Mixed cryoglobulinaemia </li></ul><ul><li>Behçet’s disease </li></ul><ul><li>IgA nephropathy </li></ul><ul><li>4.INFECTIONS </li></ul><ul><li>5.DRUGS </li></ul><ul><li>Propylthiouracil </li></ul><ul><li>D-Penicillamine </li></ul><ul><li>Hydralazine </li></ul><ul><li>Allopurinol </li></ul><ul><li>6.RHEUMATIC DISEASES </li></ul><ul><li>(immune complexes) </li></ul><ul><li>Systemic lupus erythematosus </li></ul><ul><li>Scleroderma </li></ul><ul><li>Polymyositis </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Mixed collagen vascular disease </li></ul>

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