1
Q
Intra parenchymal Cystic lung Disease:
A
Associated GGO:
- PJP infection in setting of AIDs: bilateral thin walled upper zone cysts. Gallium +ve.
- DIP: smoker
Associated Nodules:
- LIP: CT disorder (SKE, Sjogrens, RA) or HIV.
- Amyloid: Sjogrens or MM
- LCH: young smoker, bizarre cysts, spares costophrenic angles.
Multifocal / Diffuse:
- LAM (tuberous sclerosis)
- LCH
- Lymphoid Interstitial Pneumonia: CT disorder
- Birt Hogg Dube: lower lobes subpleural, bilateral renal chromophobe RCC, oncocytomas, and facial fibrofolliculomatosis.
- Infection: atypical bacteria, staph, coccidiomycosis.
- Adenocarcinoma.
LCH: bizarre shaped, thick walled
LAM: round shaped, thin walled
Birt Hogg Dube: oval shaped, thin walled.
2
Q
Nodular Lung Disease:
A
Sub pleural nodules: Diffuse - Random pattern:
- Miliary Infection: TB, Mycobacterium, Histioplasmosis.
- Haematogenous Mets.
Sub Pleural Nodules: patchy, subpleural, peribronchovascular, interlobular septa - Perilymphatic pattern:
- Sarcoidosis: upper zone, symmetric, peribronchovascular, hilar nodes.
- Lymphangetic Carcinomatosis: smooth / nodular septal thickening.
- Silicosis / coal workers pneumoconiosis: upper zone posterior, symmetrical.
No subpleural nodules, with Tree and Bud Opacity:
- Infection: acute, typical and atypical, if cavitary - TB.
- Aspiration
- Infectious bronchiolitis: air trapping
- CF bronchiectasis
- ABPA setting of asthma, finger in glove.
No subpleural nodules, with no tree and bud opacity:
- Infection: acute, GGO
- aspiration: acute, dependent
- Oedema: acute, GGO
- Haemorrhage: acute, GGO.
- Hypersensitivity Pneumonitis: GGO, mid/upper zone, but can be diffuse in CC plane wi inflammatory HP, mosaic attenuation, sparing costophrenic angles.
- Respiratory Bronchiolitis ILD: chronic, smoker, uuper zones, GGO.
- Follicular Bronchiolitis: RA or Sjogrens, or immunosuppressed.
- Invasive Mucinous Adenocarcinoma: Chronic, soft tissue with consolidation and lucent bubbly appearance, multi lobar.
- LCH: soft tissue nodules with cysts / cavitations, young smoker, upper zones, sparing costophrenic angles.
3
Q
Acute GGO:
A
Infection - usually atypical Oedema - usually dependent Acute lung injury / ARDS Haemorrhage Aspiration Acute hypersensitivity pneumonitis Acute eosinophilic pneumonia
4
Q
Chronic GGO:
A
Hyper sensitivity pneumonitis NSIP DIP / RB LIP / Follicular bronchiolitis Invasive mucinous adenocarcinoma Organising pneumonia Eosinophilic pneumonia Sarcoidosis Lipoid pnuemonia Alveolar proteinosis
5
Q
Peripheral distribution GGO:
A
NSIP DIP OP Eosinophilic pneumonia Atypical or viral pneumonia Oedema - usually non cardiogenic.
6
Q
Patchy geographic GGO with central predominance:
A
Hypersensitivity pneumonitis RB LIP Follicular bronchiolitis OP Sarcoidosis Alveolar proteinosis
7
Q
Unilateral / highly asymmetric distribution of GGO:
A
Invasive pulmonary mucinous adenocarcinoma
Lipoid pneumonia
8
Q
GGO with mosaic perfusion / air trapping:
A
Hypersensitivity pneumonitis
9
Q
Crazy paving
A
ACUTE:
- oedema
- atypical infections
- diffuse alveolar damage / ARDS
- Haemorrhage
- Acute hypersensitivity pneumonitis
- Acute eosinophilic pneumonia.
CHRONIC:
- Alveolar proteinosis (Favoured Dx)
- Hyper sensitivity pneumonitis
- NSIP
- DIP / RB
- LIP / Follicular bronchiolitis
- Invasive mucinous adenocarcinoma
- Organising pneumonia
- Eosinophilic pneumonia
- Sarcoidosis
- Lipoid pnuemonia
10
Q
GGO with centrilobular nodules:
A
Hypersensitivity pneumonitis
RB
Follicular bronchiolitis
Invasive mucinous adenocarcinoma
11
Q
GGO with signs of fibrosis (honey combing, traction bronchiectasis, irregular reticulation)
A
NSIP
Hypersensitivity Pneumonitis
Indeterminate UIP.
12
Q
Peripheral distribution chronic consolidation:
A
Chronic eosinophilic pneumonia
Organising pneumonia (Polymyositis / dermatomyositis)
COVID
PEs
13
Q
Causes of organising Pneumonia:
A
Cryptogenic organising pneumonia Drugs CT disease Toxic Inhalation Immunodeficiencies Graft vs Host.
14
Q
DDx for organising pneumonia / Atoll sign:
A
Chronic eosinophilic pneumonia
Hypersensitivity pneumonitis: centrilobular nodules.
Infections - fungal: neutropenia.
Granulomatosis polyangiitis.
Pulmonary infarction: peripheral wedge shaped
15
Q
Head Cheese Sign:
A
Hypersensitivity - most likely!
Respiratory bronchiolitis / desquamative interstitial pneumonia
Follicular bronchiolitis / lymphoid interstitial pneumonia
Atypical infections
Sarcoid
2 seperate processes: oedema and asthma.
16
Q
Upper lobe predominant fibrosis: “ STROLA”C
A
Sarcoidosis TB Radiation Occupation: pneumoconioses LCH Ankylosing spondylitis Chronic HP
17
Q
Lower lobe predominant fibrosis:
A
UIP / Idiopathic pulmonary fibrosis Connective tissue disease Drug fibrosis Asbestosis Hypersensitivity pneumonitis (mid zones, can be diffuse) Chronic aspiration.
18
Q
Reticulonodular pattern: “VOTE SSSX”
A
ACUTE:
- Viral (lymphadenopathy)
- Oedema (effusion)
- TB (middle to upper lobe predominance, lymphadenopathy)
- Eosinophilic pneumonia / HP
CHRONIC:
- Sarcoidosis (middle to upper lobe, lymphadenopathy)
- Silicosis (middle to upper lobe, lymphadenopathy)
- Secondaries (carcinomatosis, effusion, lymphadenopathy)
- Langerhans Histiocystosis X (normal to increased lung volumes, middle to upper lobe).
- Asbestosis: pleural thickening / calcification.
- LAM: associated pneumothorax.
19
Q
Mid to upper zone bronchiectasis:
A
CF
ABPA
TB
20
Q
Lower zone bronchiectasis:
A
Chronic infection
Aspiration
Immunodeficiency
Primary ciliary dyskinesia
21
Q
Tree in Bud opacities:
A
Bacterial infection
mycobacterial infection
Fungal ingection
Viral infection
Cystic fibrosis
ABPA
Primary ciliary dyskineasia
Immunodeficiency
Diffuse panbrochiolitis
Follicular bronchiolitis
Invasive mucinous adenocarcinoma
Aspiration
22
Q
CT findings of parenchymal lung disease as cause of pulmonary HTN
A
Fibrosis, emphysema, or cystic lung disease
23
Q
CT findings of chronic pulmonary thromboembolism as cause of pulmonary HTN:
A
Pulmonary artery filling defects or occlusion, mosaic perfusion.
24
Q
CT findings of idiopathic pulmonary HTN:
A
Dilated main pulmonary artery, centrilobular nodules of GGO
25
CT findings of pulmonary veino-occlusive disease as cause of pulmonary HTN:
Smooth interlobular septal thickening, dilated main pulmonary artery, normal sized pulmonary veins
26
CT findings of pulmonary capillary haemangiomatosis as cause of pulmonary HTN:
Centrilobular nodules of ground glass opacity, progression of findings after treatment with vasodilators.
27
CT findings of IV injection of oral medications as cause of pulmonary HTN:
Diffuse small homogenous branching centrilobular nodules.
28
CT findings of sickle cell disease as cause of pulmonary HTN:
Dense bones, rugger jersey spine
29
CT findings of liver disease as cause of pulmonary HTN:
Small nodular liver
30
CT findings of left sided heart disease as cause of pulmonary HTN:
Left atrial or ventricular dilation, smooth interlobular septal thickening.
31
Asymmetric / focal pulmonary oedema:
```
Patient position
Asymmetric emphysema / bulls disease.
Mitral regurgitation.
Pulmonary embolism / vascular obstruction
Neurogenic pulmonary oedema
```
32
UIP Terminology:
Typical UIP pattern:
- Reticulation
- Honeycombing
- Sub pleural / basilar distribution
- Absence of atypical features.
Probable UIP pattern:
- Reticulation
- No honey combing
- Sub pleural / basilar distribution
- Absence of atypical features.
CT pattern indeterminate for UP:
- Findings of fibrosis
- Variable or diffuse distribution
- Inconspicuous features suggestive of non-UIP pattern.
CT features most consistent with non-IPF diagnosis:
- Peribronchovascular distribution
- Mid - upper distribution
- Atypical features: mosaic perfusion, air trapping, ground glass opacity, consolidation, nodules, cysts.
- Etiologies of non IPF fibrotic disease: NSIP, Hypersensitivity pneumonitis, sarcoid, silicosis, coal workers pneumoconioses.
33
Etiologies of UIP:
Idiopathic pulmonary fibrosis
Connective tissue disease
Drug toxicity
Asbestosis
34
CT findings of NSIP:
```
Sub pleural, basilar predominant pattern
GGO,
irregular reticulation,
traction bronchiectasis
No / minimal honey combing
Immediate sub pleural sparing.
```
35
Etiologies of NSIP:
- Idiopathic NSIP
- Connective tissue disease - check oesphagus ? scleroderma.
- Drug toxicity
- Hypersensitivity Pneumonitis
36
CT Findings of Desquamative Interstitial Pneumonia:
```
Subpleural basilar predominant
GGO
Cysts or emphysema
Fibrosis may develop over time
May see centrilobular nodules of GGO with a mid to upper zone predominance and mosaic perfusion, implying background of RB.
```
37
DDx for symmetrical mediastinal hilar lymphadenopathy:
Sarcoid
Pneumoconioses
Amyloidosis
Castleman's disease
Mets - usually asymmetric, can be seen in mets from GI / GU / Lung / breast cancers and leukaemia.
Lymphoma - usually asymmetric.
Mycobacterial / fungal infection - usually asymmetric.
38
DDx for patchy consolidation:
```
Sarcoid
Organising pneumonia
Chronic eosinophilic pneumonia
Invasive mucinous adenocarcinoma
Lymphoma
Lipoid pneumonia
```
39
Head cheese sign:
Hypersensitivity pneumonitis
Desquamative interstitial pneumonia / respiratory bronchiolitis.
Follicular bronchiolitis / lymphoid interstitial pneumonia
Sarcoidosis
Atypical infections.
40
Causes of pulmonary Haemorrhage:
Pulmonary Renal Syndromes:
- ANCA +ve vasculitis
- granulomatosis with polyangiitis
- Microscopic polyangiitis
- Anti GBM
- Auto immune connective tissue disease
- SLE
- Polymyositis
- Scleroderma
- HSP
- Drug induced vasculitis
- idiopathic pulmonary renal syndrome
Without renal disease:
- Anticoagulation
- Pulmonary embolism
- Idiopathic pulmonary haemosiderosis
- Trauma
- Bone marrow transplantation.
41
Chronic Alveolar Lung Disease:
```
"SALA"
Sarcoidosis
Alveolar proteinosis
Lymphoma / lipoid pneumonia.
Adenocarcinoma in Situ
```
42
Middle Mediastinal Mass: 3A's
```
Adenopathy:
- infection (Tb, Histoplasmosis)
- Neoplasm (lung cancer, Mets, Lymphoma)
- Sarcoidosis
Aneurysm / vascular
Anomalies:
- Bronchogenic cyst
- Pericardial cyst
- Oesophageal duplication cyst.
```
43
Posterior mediastinal Mass:
Neural Tumours:
- Neurogenic: neuroblastoma, ganglioneuroma, ganglioneuroblastoma.
- Nerve root tumours: schwannoma, neurofibroma, malignant schwannoma.
Paraganglionic tumours: intra thoracic pheochromocytoma.
Spinal tumour: mets, primary bone tumour.
Lymphoma
Invasive thymoma
Mesenchymal tumour: fibroma, lipoma, leiomyoma, haemangioma.
Abscess
Extramedullary haematopoiesis.
Oesophageal varices / diverticulum.
*Dont forget extra pulmonary lesions, such as chest wall / pleural.
Chest wall lesion will have a lucent halo surrounding the mass. Lateral will help - check soft tissues.
44
Causes of solitary Pulmonary Nodule:
Malignant:
- lung cancer
- solitary met
- Lymphoma
- Carciniod
Benign Neoplastic:
- Hamartoma
- benign connective tissue (lipoma, fibroma)
Inflammatory:
- Granuloma
- Lung abscess
- Rheumatoid nodule
- Inflammatory pseudotumour
Congenital:
- AV malformation
- Lung cyst
- Bronchial atresia with mucoid impaction
Other:
- pulmonary infarct
- intrapulmonary lymph node
- Mucoid impaction
- Haematoma
- amyloidosis.
45
Fast growing pulmonary Mets: "Loves to Multiply Swiftly"
Lymphoma
Testicular germ cell tumour
Melanoma
Soft tissue sarcoma.
46
Cancerous solitary nodule growth rate:
between 1 - 18months to double in volume = change in diameter by 1.25times previous diameter.
47
Single pulmonary nodule doubling times faster than 1 month:
Infection
Infarction
Histiocytic lymphoma
Fast growing Mets: Lymphoma, testicular germ cell, melanoma, soft tissue sarcoma.
48
Single pulmonary nodule doubling time slower than 18 months:
```
Granuloma
Hamartoma
Bronchial carcinoid
Salivary gland adenoid cystic carcinoma
Thyroid carcinoma mets
Round atelectasis.
```
49
Causes of multiple pulmonary nodules:
Neoplastic:
- Mets
- Malignant lymphoma / lymphoma proliferative disease
Inflammatory:
- Granulomas
- Fungal and opportunistic infections
- Septic emboli
- Rheumatoid nodules
- Granulomatosis with polyangiitis
- Sarcoidosis
- LCH
Congenital:
- AV malformations.
Other:
- haematomas
- Pulmonary infarcts
- Silicosis.
50
Causes of Cavitary pulmonary lesion: CAVITY
C: Carcinoma: lung primary (usually single) or Mets (SCC). (usually multiple).
A: Autoimmune: granulomatosis with polyangiitis, RA. usually multiple.
V: Vascular: bland and septic emboli: multiple
I: Infection: mycobacterial and fungal: single, but can be multiple.
T: Trauma: pneumatocele
Y: Young: congenital anomalies such as sequestration, diaphragmatic hernia, bronchogenic cyst.
* Wall thickness <4mm usually benign
* Wall thickness > 15mm usually malignant.
**See cavities, look for air crescent sign, and consider underlying aspergilloma or semi invasive aspergillosus.
51
Large unilateral pleural Effusion: "ITCH"
```
Infection / empyema
Tumour:
- primary lung cancer,
- mesothelioma,
- Mets,
- lymphoma.
Chylothorax
- secondary to lymphoma or ruptured thoracic duct.
Haemorrhage
- Trauma
- Iatrogenic
```
52
Unilateral Elevated Diaphragm: "PAPER"
```
Phrenic nerve paralysis:
- malignant involvement
- surgical trauma
Atelectasis / Abdominal mass
Post surgical abdominal abscess
Effusion (subpulmonic)
Rupture (trauma)
```
53
Upper zone lung disease "CA SHRIMP"
C: Cystic Fibrosis
A: Ankylosing Spondylitis
```
S: Sarcoidosis
H: Histiocystosis, LCH
R: Radiation pneumonitis
I: Infection: Tb and fungal included.
M: Metastases
P: Pneumoconioses: CWP and silicosis
```
54
Egg Shell Calcification: "SIT"
Sarcoidosis
Silicosis
Infection: Tb and fungal
Treated Lymphoma
55
Peripheral opacities: "AEIOU"
```
Alveolar sarcoid
Eosinophilic pneumonia
Infarcts
Organising pneumonia
UIP
contUsions
```
56
Eosinophilic Lung Disease: "Idiopathic NAACP"
```
Idiopathic:
- Acute Eosinophilic pneumonia (Loffler syndrome)
- Chronic eosinophilic pneumonia
N: Neoplasm:
- Lung cancer
- Mets
- Lymphoma
A: Asthma
A: Allergic disorders:
- Allergic bronchopulmonary aspergillosis
- Drug Induced disease
- Hypersensitivity pneumonitis
C: Collagen vascular granulomatous diseases:
- Rheumatoid lung disease
- Churg Strauss syndrome
- Granulomatosis with Polyangiitis (Wegners)
- Sarcoidosis
P: Parasitic:
- Tropical eosinophillia
- Helminth infectino
- Fungal infection.
```
57
Causes of unilateral hyper lucent hemithorax:
Patient position: rotation / scoliosis
Chest wall defect:
- Mastectomy
- Poland syndrome
Pleural abnormality:
- ipsilateral pneumothorax
- Contralateral pleural thickening / effusion
Airway obstruction:
- Bronchial compression: hilar mass / cardiomegaly
- Endobronchial obstruction with air trapping
- Constrictive bronchiolitis
- Swyer James syndrome: Small hyper lucent lung.
- Pulmonary emphysema
- Congenital lobar emphysema
Pulmonary vascular abnormality:
- PE
- Pulmonary artery hypoplasia
58
Common extra thoracic sites for lung cancer Metastases: "LABB"
L: Liver
A: Adrenals
B: Bone
B: Brain.
59
Post pneumonectomy complications:
```
Early:
- Bronchopleural fistula (stump leak)
- Empyema
- Haemothorax
- Chylothorax
Late:
- Recurrent neoplasm
- Bronchopleural fistula
- Empyema
- Haemothorax
- Chylothorax.
```
60
Sparing costophrenic angles:
LCH
| HSP
61
Crazy paving:
ACUTE:
- Oedema
- PCP
- Haemorrhage
- AIP
- DAD
- Radiation
- Acute eosinophilic Pneumonia
SUB ACUTE / CHRONIC:
- NSIP
- PAP (Pulmonary Alveolar Proteinosis)
- COP
- Haemorrhage
- adenocarcinoma in situ
- Lymphangitic tumour
- Lipoid pneumonia
- Chronic Eosinophilic pneumonia
FOCAL:
- Haemorrhage
- Adenocarcinoma in situ
- Lymphangitic carcinoma
- Lipoid pneumonia
UPPER ZONE PREDOMINANT:
- Chronic eosinophillic pneumonitis
- PCP
BASILLAR PREDOMINANT:
- Oedema
- NSIP
- COP
- Lipoid pneumonia.
62
Halo sign: Nodule with GGO around it:
Represents haemorrhage of invasion:
"Ask is the patient immunocompromised"
- Invasive aspergillosis
- Other fungus
- Haemorrhagic Mets
- Adenocarcinoma in situ
- Wegners.
63
Atoll Sign: Ground glass opacity with rim of consolidation:
COP
Chronic eosinophilic pneumonia
Pulmonary Infarct: peripheral wedge shaped
Invasive fungal - neutropenic
Wegners granulomatosis: cANCA
Hypersensitivity pneumonitis: centrilobular GGO nodules.
64
Pulmonary Sinus and Renal lesions
Think Granulomatosis with polyangiitis
65
DDx smooth interlobular septal thickening:
```
Pulmonary oedema
Lymphangitic carcinomatosis
Lymphoproliferative disease
Amyloidosis (rare)
Pulmonary veno-occlusive disease (rare)
Lymphangiomatosis (rare)
```
Pulmonary alveolar proteinosis
Pulmonary haemorrhage
atypical pneumonia: pneumocystis jiroveci.
66
DDx nodular interlobular septal thickening: THink peri lymphatic nodules
```
Lymphangitic carcinomatosis
Sarcoidosis,
Lymphoproliferative disease
Amyloidosis (rare)
Silicosis/ CWP
LIP
```
67
Fleischner Nodule follow up:
SINGLE SOLID NODULE:
< 6mm: Low risk, no follow up.
< 6mm: high risk, optional 12/12 follow up.
6-8mm: follow up 6-12months, repeat 18-24months in high risk patients.
>8mm: CT follow up 3months, PET/CT, or tissue biopsy.
MULTIPLE SOLID NODULES:
<6mm: low risk - no follow up.
<6mm: high risk - optional 12/12 follow up.
> 6mm: CT follow up 3-6 months, repeat 18-24 months in high risk.
SUBSOLID SINGLE NODULE:
Single ground glass nodule <6mm: no follow up.
Single ground glass nodule >6mm: CT 6-12 months, then if persists, CT every 2 yrs for 5 years.
Single part solid nodule >6mm: CT 3-6 months, if persists and solid component remains <6mm - annual CT 5 years.
MULTIPLE SUBSOLID NODULES:
Multiple subsolid nodules < 6mm: repeat CT 3-6 months, if stable, consider CT at 2 and 4 years in high risk.
Multiple subsolid nodules >6mm: CT 3-6 months, management based on most suspicous nodule.
68
Lung cancer TNM staging:
T1: <3cm, not main bronchus.
T2: 3-5cm, or
- involves main bronchus
- Invades visceral pleura
- Atelectasis / obstructive pneumonitis extending to hilar region.
T3: 5 -7cm, or
- associated seperate nodules in same lobe
- Invades chest wall
- Phrenic nerve
- Parietal pericardium.
T4: > 7cm, or
- separate nodules in different ipsilateral node.
- Invades diaphragm
- Invades mediastinum
- Invades heart
- Invades great vessels
- Invades trachea
- Recurrent laryngeal nerve
- vertebral body
- Carina.
N1: metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes
N2: metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3: metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
M1a: separate tumour nodule(s) in a contralateral lobe; tumour with pleural or pericardial nodule(s) or malignant pleural or pericardial effusions
M1b: single extrathoracic metastasis, involving a single organ or a single distant (nonregional) node
M1c: multiple extrathoracic metastases in one or more organs
69
Stage groupings:
stage Ia
TNM equivalent: T1, N0, M0
5-year survival: up to 92%
stage Ib
TNM equivalent: T2a, N0, M0
5-year survival: 68%
stage IIa
TNM equivalent: T2b, N0, M0
5-year survival: 60%
stage IIb
TNM equivalent: T1/T2, N1, M0 or T3, N0, M0
5-year survival: 53%
stage IIIa
TNM equivalent: T1/T2, N2, M0 or T3/T4, N1, M0 or T4, N0, M0
5-year survival: 36%
stage IIIb
TNM equivalent: T1/T2, N3, M0 or T3/T4, N2, M0
5-year survival: 26%
stage IIIc
TNM equivalent: T3/T4, N3, M0
5-year survival: 13%
stage IVa
TNM equivalent: any T, any N with M1a/M1b
5-year survival: 10%
stage IVb
TNM equivalent: any T, any N with M1c
5-year survival: 0%
70
Airway tumour:
```
SCC
Adenoid cystic carcinoma
Carinoid
Mucoepidermoid carcinoma
Haemangioma
Glomus tumour
Papilloma
```
71
Sparing costophrenic angles:
LCH
| Hypersensitivity pneumonitis
72
Tracheal Diseases DDx:
```
SPARES POSTERIOR MEMBRANE
Relapsing polychondronitis:
- Diffuse thickening
- No Ca++.
- Recurrent episodes cartilage inflam and pneumonia.
```
Tracheobronchopathia Osteochondroplastica:
- Cartilagenous and osseous nodules.
- Men > 50yrs
```
INVOLVES POSTERIOR MEMBRANE:
Amyloid:
- irregular focal or short segment thickening
- Ca++ common
- Confined trachea and main bronchi
```
Post intubation:
- Focal subglottic circumfrential stenosis
- Hour glass configuration
Wegners:
- Circumferential thickening
- Focal or long segment
- No Ca++
- c-ANCA +ve.
73
Pleural plaque calcifications DDX:
Asbestos
Old haemothorax
Old infection
TB
--> Fibrothorax secondary to prior Infection / haemorrhage
Extra skeletal osteosarcoma
74
DDx honeycombing:
```
UIP pattern:
IPF
Connective tissue disease
Drug related fibrosis (cyclophosphamide, nitrofurantoin)
Asbestosis
```
```
Hypersensitivity pneumonitis
Sarcoidosis
NSIP - mild honey combing
Other pneumoconiosis
Post ARDS.
```
75
Fibrotic Lung disease CC distribution DDX:
Upper lobe predominant:(STROLA)
- Sarcoidosis
- Prior TB
- Prior Fungal infection
- Radiation fibrosis
- Pneumoconioses (silicosis, CWP, beryllium, talc)
- Pleuroparenchymal fibroelastosis.
- ankylosing spondylitis.
Lower Lobe preodminant:
- IPF
- CT disease
- Drug fibrosis
- asbestosis
- Hypersensitivity pneumonitis
- Chronic aspiration
76
Fibrotic lung disease axial distribution DDX:
Sub pleural:
- IPF
- CT disease
- Drug fibrosis
- asbestosis
- Post ARDS
Diffuse / central:
- Sarcoidosis
- Pneumoconioses
- HP
- Chronic aspiration
- Prior Tb / fungal infection.
77
DDx of mosaic perfusion as an isolated finding:
```
Asthma
Hypersensitivity pneumonitis
Constrictive bronchiolitis
Chronic PE
Vasculitis.
```
78
DDx cystic bronchiectasis:
```
ABPA
CF
Primary ciliary dyskinesia
Immunodeficiency
Childhood infection
Williams Campbell syndrome and Tracheo-bronchomegaly.
```
79
CXR features of common disorders in AIDS:
PCP:
- No effusions or lymphadenopathy
- Bilateral perihilar or diffuse alveolar or reticunodular ground glass opacities.
- Lung cysts, can have PTx.
TB:
- primary or reactivation
Mycobacterium avium intracellulare:
Kaposi sarcoma:
- associated mucocutaneous nodules
- Bilaeral perihilar opacities bronchovascular distribution
- flame shaped opacities
- Pleural effusions common
- Kerly B lines common
AIDS related lymphoma:
- solitary or multiple nodules or masses
- Pleural and or pericardial effusions
- lymphadenopathy
- rapidly progressive.
80
Hilar and mediastinal lymphadenopathy in AIDS:
```
TB
MAC
Fungal - cryptococcus
Lymphoma
Kaposi
Lung cancer
```
*PCP does NOT cuase lymphadenopathy*
81
Fat containing mediastinal mass:
- mediastinal lipomatosis
- tumours arising from fat (lipoma, liposarcoma, hibernoma)
- tumours containing fat (teratoma, thymolipoma)
82
DDx for lucent / lytic rib lesion: FAME B
```
F: Fibrous dysplasia
A: ABC
M: Mets / myeloma
E: Eosinophilic granuloma / Enchondroma
B: Brown Tumour
```
83
DDx for pleural based mass:
```
Pleural Metastasis
Empyema
Mesothelioma
Fibrous tumour of pleura
Fibrothorax.
```
84
Calcifed nodes
Sarcoid
85
Enhancing mediastinal nodes
Kaposi
Castelmann
Hypervascular mets
86
Unilateral ILD
carcinomatosis
oedema
aspiration
Radiation
87
Calcified pulmonary nodules:
Micro:
- Microlithaisis
- haemasoiderosis
- Silicosis
- Amyloid
- healed varicella
Large
- Mets
- Granuloma
- chondroma
- metastatic pulmonary Ca++
88
Small Heart
Anorexia / cachexia
Adrenal insufficnecy / Addisons
Emphysema
Contrictive pericarditits
89
Mets Ca++
BOTM
- breast
- osteosarc
- Thyroid
- Mucinous colorectal
90
Radiological types of bronchiectasis:
Cylindrical
Varicose
Cystic
Traction
* Central bronchiectasis - think ABPA
91
Unilateral Hilar enlargement:
Infection:
- TB,
- Viral in kids
Vascular:
- pulmonary artery stenosis,
- pulmonary artery aneurysm
Tumour:
- mets,
- lymphoma,
- bronchial carcinoma.
92
Bilateral Hilar enlargement:
```
Sarcoid
Tumour:
- Mets
- LYmphoma
Vascular:
- pulmonary artery HTN
Infection: Tb
```
93
Osteolysis distal clavicle: SHIRT Pocket
```
S: scleroderma
H: hyperparathyroidism
I: infection (osteomyelitis)
R: rheumatoid arthritis
T: trauma
P: progeria
```
94
Expansile or lytic Rib Lesion: "FAME B":
F: fibrous dysplasia (ground glass)
A: ABC (expansile)
M: Mets / myeloma (soft tissue component)
E: Enchondroma (chondroid matrix) (EG in child)
B: Brown tumour (radiographic signs of secondary hyperPTH).
95
Cardiac Mass:
```
Thrombus
Myxoma:
- Commonly left atrium, lobulated, can be Ca++.
Rhabdomyoma:
- Children, tuberous sclerosis
- Ventricle location.
Fibroma:
- children, ventricular wall, calcified.
Metastatic disease.
Sarcoma:
- Aggressive vascular invasion.
```
96
Calcified pericardium:
Thin and linear:
- Uraemia
- Viral pericarditis
- trauma / surgery
- Collagen vascular disease
- Radiation
Thick and shaggy:
- TB
97
Bone check:
H Shaped vertebrae:
1) Sickle cell disease
- Associated splenic autoinfarction
2) Gaucher disease:
- Spleenomegaly.
Humeral head infarcts: sickle cell.
Absent ribs: lucent mets / surgical resection.
Check scapula and ribs for absent / lucent lesion
98
Diffuse bony sclerosis: 3Ms PROOF
M:Malignancy
- Mets
- Lymphoma
- Leukaemia
M: Myelofibrosis (>50yrs, spleenomegaly, extramedullary haematopoiesis).
M: Mastocytosis (thickened small bowel folds with nodules)
S: Sickle Cell Disease (Bone infarcts, H-vertebrae, splenic autoinfarction)
P: Paget disease
R: Renal osteodystrophy (sub periosteal resorption, Rugger jersey spine)
O: Osteopetrosis (diffusely dense, bone in bone, Sandwhich spine)
O: Other:
- Sclerotic dysplasias: osteopoikilosis, melorheostaosis
- Hyperthyroididm
- Hyperparathyroidism
- Pynknodysostosis (short, hypoplastic mandible, pointed and dense chalk pencil like distal phalanges)
F: Fluorosis (ligamentous calcification).
99
Calcified Miliary Nodules
Healed Varicella, or histoplasmosis.
Calcified Metastatic disease: Medullary thyroid / Osteosarcoma.
Pneumoconiosis: silicosis / CWP.
Metastatc Pulmonary Calcification: Ca/PO4 metabolism diseases, e.g. renal failure, myeloma.
Pulmonary Haemosiderosis: Mitral stenosis.
Pulmonary alveolar microlithiasis.
100
Miliary Nodules
Infection:
- TB
- Fungal
- Viral, such as varicella.
Metastases:
- Thyroid
- Renal
- Breast
- Osteosarcoma
- Trophoblastic disease.
Inflammatory / interstitial:
- Sarcoid
- Pneumoconioses
- Hypersensitivity pneumonitis
101
Normal CXR: Check Areas:
Neck: clips, displaced trachea
Trachea and Bronchi: Endo-luminal mass, especially if history of "wheeze"
Ribs: notching and Aortic arch: coarctation
Hyper lucent hemithorax: Poland, mastectomy, bronchial atresia, Swyer James, Westermark sign and PE.
Diaphragm: liver and spleen pathology.
Bones: diffuse lucency / density, widening: sclerotics mets, renal osteodystrophy, sickle cell, myelofobrosis, thalaessaemia.
Bones: ribs / spine / scapula: lucent metastasis.
Paravertebral lines
Ask myself:
- Why is this not Sarcoid
- Is this Tb
- Could the patient be immunosuppressed.
102
Carotid Vascular US:
| PSV values:
Stenosis / narrowing:
Plaque description:
- Hypoechoic plaque associated with laerge amount of lipid and increased risk of embolic event.
Presence of aliasing.
Waveform morphology:
- Spectral broadening.
Wave form values:
PSV < 125cm/s. PSV ratio < 2.0 --> <50% stenosis.
PSV 125-229cm/s. PSV ratio 2-3.9 --> 50-69% stenosis.
PSV >230cm/s. PSV ratio > 4.0 --> > 70% stenosis.
--> if symptomatic, endarterectomy should be considered.
103
Unilateral lung disease:
Radiation Treatment: fibrosis
Lymphangitic carinomatosis
Scimitar syndrome
Assymetric oedema
Aspiration
Post lung transplant.
