-
4 patterns of interstitial lung disease
- •Nodular
- •Reticular
- •Septal lines
- •Cystic
-
DDx: Nodular interstitial lung disease
- •Acute
- –atypical infection ( miliary tuberculosis - hematogenous, lower; disseminated fungal)
- •Chronic
- –Mets - hematogenous, lower lung
- –Sarcoid - upper lung
- –Silicosis / Coal worker’s - upper lung
- –Eosinophilic granuloma - upper lung
- –Hypersensitivity: subacute - upper lung
-
Hematogenous spread mets tends to go where?
Lower lung distribution
-
DDx: Calcified "egg shell" lymph nodes on CXR
Silicosis vs Sarcoidosis vs TB
If the nodules themselves calcify, think silicosis
-
DDx: Reticular opacities (irregular lines on CT)
- •Acute - normal lung volumes
- –interstitial edema
- –atypical infection (Pneumocystis-perhilar, viral infection)
- •Chronic
- –fibrosis - decreased lung vol
- –emphysema - inc lung vol
- –cystic lung disease - inc lung vol
- –bronchiectasis-normal to inc lung volumes
-
DDx: Upper lobe fibrosis
- –sarcoid - adenopathy
- –chronic hypersensitivity
- –cystic fibrosis
- –XRT (head and neck)
- –prior tuberculosis
- –ankylosing spondylitis
-
DDx: Lower lobe fibrosis
- –UIP, NSIP
- –(chronic aspiration)
- -asbestosis
-
DDx: Progressive massive fibrosis (confluent perihilar masses)
Silicosis (parallel chest wall) vs sarcoidosis (rounder)
-
Calcified pleural plaques
Asbestosis
-
Esophageal dilation and lower lobe predominant fibrosis
Scleroderma
-
DDx; Septal lines
- •Acute
- –edema
- –atypical infection
- •Chronic
- –lymphangitic ca
- –amyloid, sarcoid
- –Kaposi’s sarcoma
-
DDx: Cysts/Ring Lucencies
- •Acute
- –Pneumocystis pneumonia - upper
- –(necrotizing pneumonia)
- •Chronic
- –honeycombing (sarcoid, EAA/HP-upper) (UIP-lower)
- –bronchiectasis - (aspiration,Kartagener's-lower) (CF-upper)
- –eosinophilic granuloma - upper, inc vol
- –lymphangioleiomyomatosis - diffuse, inc vol
- –emphysema - (a1 anti-lower)
-
DDx: Septal lines and nodules
- •Acute
- –atypical infection
- •Chronic
- –lymphangitic carcinoma
-
Septal thickening and GGO's on CT
edema
-
Reticulation on CXR is known as what on CT?
Irregular lines (interlobular septal thickening)
-
Peripheral reticulation/irregular lines
IPF
-
Irregular lines/reticulation extending from the hilum to the periphery
Sarcoidosis
-
peripheral reticulation and pleural plaques
asbestosis
-
air-filled cysts with a central dot
centrilobular emphysema
-
DDx: Air-filled cysts in lung with peripheral dot sign
- •Cystic lung disease
- -LAM, LCH (EG) (LAM-well rounded, LCH more irregular)
- -Sjogren syndrome
- •Infection
- -PCP
- •Honeycombing
-
DDx: Honeycombing on CT
- •Fibrosis
- -Idiopathic (UIP)
- -Asbestos
- -Collagen vascular disease
- -Chronic HP
- -Drug exposure
- •Sarcoidosis
-
Solid, perilymphatic nodules
Sarcoidosis
-
DDx: Solid, centrilobular nodules
"BAIL"
- •Bronchiolitis
- •Aspiration
- •Infection -(TB, NTMB)
- •LCH
-
DDx: Solid, diffuse nodules
"MeLDS"
- •Metastatic disease
- •Langerhans cell histiocytosis
- •Disseminated infection (miliary)
- •Silicosis, CWP
- •Sarcoidosis
-
DDx: Ground glass, centrilobular nodules
"EBB"
- •Extrinsic allergic alveolitis
- •Bronchiolitis
- -respiratory
- -infectious
- •Bronchioloalveolar CA
-
DDx: Ground glass opacities
"PIE PAD"
- •Pulmonary edema
- •Interstitial pneumonia
- •Extrinsic allergic alveolitis
- •Pneumocystis pneumonia
- •Alveolar proteinosis or hemorrhage
- •Drug toxicity
-
DDx: Crazy-paving
"BALD"
- •Bronchioloalveolar carcinoma
- •Alveolar proteinosis
- •Lipoid pneumonia
- •Drug toxicity
-
DDx: Consolidation
"CoNES"
- •Cryptogenic organizing pneumonia
- •Neoplasm- (Bronchioloalveolar carcinoma-Lymphoma/BALT)
- •Eosinophilic pneumonia
- •Sarcoidosis
-
DDx: Pulmonary nodule
- Mimics (not pulmonary)
- Infection–Bacterial (round pneumonia)–Granulomatous
- Neoplasm–Malignant–Benign
- Vascular: AVM
- Infarct
- Cyst
- Mucoid impaction
- Trauma/hematoma
-
Benign calcification patterns in a pulmonary nodule
- Lamellated
- Popcorn
- Central
- Diffuse
-
Malignant calcification patterns in a pulmonary nodule
- Eccentric
- Amorphous
- Stippled - frequently carcinoid
-
DDx: Multiple diffuse calcified pleural nodules
- Granulomatousdz(TB, histo)
- Silicosis (not truly calcified; upper > lower)
- Healed varicellapneumonia
- Pulmonary microlithiasis(2-3 mm in size)
- Metastatic osteosarcoma/ chondrosarcoma
- If not sure of calcified on CXR:
- Fungal infection, disseminated
- Hypersensitivity pneumonitis
- Thyroid metastases
-
Fat-attenuation nodule in lung
Diagnostic of hamartoma
-
Partly solid ground glass nodule has what percent risk of being malignant
67% or 2/3
-
What percent of pure ground glass nodules are going to be benign
80%
-
Ground glass nodule greater than 1cm is high risk for
BAC
-
Popcorn calcification in a lung lesion?
Hamartoma
-
Size discriminator for mass vs nodule
Larger size has greater likelihood of being malignant
-
smooth marginated pulmonary nodule has what chance of being malignant?
30%
-
DDx: Multiple pulmonary nodules greater than 1cm
- Neoplasm
- –Metastases
- –BAC
- –Lymphoma
- –KS
- Infection
- –Fungal
- –Septic emboli
- –MAC
- Inflammatory
- –Wegener’s
- –Rheumatoid
- –Sarcoid
-
DDx: Multiple 5-10mm pulmonary nodules
- Infection:
- –Varicella
- –Fungal
- Neoplasm
- –Metastases
- –BAC
- Pneumoconiosis
- Sarcoidosis
-
DDx: Multiple cavitary pulmonary nodules
- Infectious - (–Gram negative–Anaerobic–Angioinvasive fungi)
- Metastases - (SCC, cervical)
- Wegener’s and rheumatoid
- Septic Emboli
- Hematoma/laceration
- Papillomatosis
- (EG)
-
DDx; Focal pleural opacity
- Fluid loculation
- Lipoma
- Solitary fibrous tumor
- (Solitary metastasis)
-
DDx: Diffuse pleural opacities
- Fibrosis
- Fluid
- Tumor
- –Mesothelioma
- –Metastatic disease
- Plaque: more multifocal, often bilateral, frequently calcified
-
DDx: Pleural air fluid level
- Instrumentation
- Bronchopleural fistula
- –Empyema
- –Trauma
- –Other causes of spontaneous pneumothorax
-
DDx: Parenchymal air fluid level
- Necrotizing infection
- Malignancy
- Inflammatory (Wegener’s)
-
Differential for airspace disease
- Blood (Acute)
- Pus (Acute)
- Fluid (Chronic-PAP, Acute-edema)
- Cells (Chronic)
-
DDx: Airspace disease, pulmonary hemmorhage
- •Diffuse
- -Vasculitis (WG, MPA)
- -Goodpasture syndrome
- -Idiopathic hemorrhage
- •Focal
- -Trauma (contusion)
- -Infarct
-
Neutropenic fever with area of focal consolidation
Think angioinvasive aspergillus
-
CT halo sign
Invasive aspergillus
-
CT reverse halo sign
Cryptogenic organizing pneumonia
-
CXR Air crescent sign
Cavitary lesion suggesting invasive aspergillus
-
Infections that invade the chest wall
- •Actinomycosis, TB
- •Blastomycosis
-
Infections with extensive lymphadenopathy
- •Primary TB
- •Fungal pneumonia
- possibly Histo
-
DDx: Fluid in the airspaces
- •Pulmonary edema
- -Hydrostatic (cardiogenic)
- -Permeability (non-cardiogenic)
- •Aspiration
- •Alveolar proteinosis
-
DDx: Increased cells in the airspaces
- •Tumor
- -•Bronchioloalveolar cell CA
- -Pulmonary lymphoma
- •Inflammatory
- -Eosinophilic pneumonia
- -Organizing pneumonia
- -Sarcoidosis
-
peripheral fleeting opacities
eosinophilic pneumonia
-
DDx: Peripheral opacity
- Pneumonia (bacterial, fungal)
- Infarct
- Primary lung neoplasm
- COP
- Eosinophilicpneumonia
- Pleural mass (solitary fibrous tumor; mesolthelioma, metastatic disease)
-
causes of eosinophilic pneumonia
- •Idiopathic
- -Simple (Loffler syndrome)
- -Chronic eosinophilic pn.
- •Secondary
- -Drugs
- -parasites
- -ABPA
- •Churg-Strauss vasculitis
-
spiculated mass with internal low density
lipoid pneumonia
can be caused by aspiration of mineral oil (sometimes used for constipation)
-
4 main airway disease processes
- •Narrowing
- •Atelectasis
- •Bronchiectasis
- •Mucoid impaction
- and small airways disease
-
DDx: Narrowing of the airway
- •Stricture
- -focal
- -long-segment
- •Solitary Mass
- •Multiple Masses
-
DDx: Long-segment stricture of the airway
- •Inflammatory
- -relapsing polychondritis
- -Wegener granulomatosis
- -infection (histo)
- •Cancer
-
DDx: Focal, short-segment narrowing of the airway
- "TIE"
- •Trauma
- •Iatrogenic
- -ETT/tracheostomy
- -lung transplant
- •Extrinsic mass
-
DDx: Airway malignancies
- -Adenoid cystic carcinoma - younger adults, well marginated good prognosis
- -SCC - older adults, invasive, poor prognosis
- -Carcinoid - younger adults, Ca2+, iceberg sign
-
DDx: Solitary airway mass
- •Malignancy
- •Benign (10%)
- •Inflammatory
- •Foreign body
-
DDx: Multiple airway masses
- •Metastases
- •Papillomatosis- - can become SCC
- •Tracheopathia Osteochondroplastica
- •Amyloidosis
-
Common airway mets
- •renal cell
- •breast
- •melanoma
-
Atelectasis in an adult should always alert to the process of
Malignancy compressing or occluding the airway
-
DDx: Bronchiectasis
- Congenital
- -cystic fibrosis
- -primary ciliary dyskinesia
- -immune deficiency
- --Mounier Kuhn
- --Williams Campbell
- --Yellow nail
- Acquired
- -infection
- -toxic fume exposure
- -central obstruction
- -recurrent aspiration
- -traction (pulmonary fibrosis)
-
Causes of mucoid impaction
- •Bronchiectasis
- •Asthma
- •ABPA
- •Bronchial atresia
- •Foreign body
- •Central tumor
-
DDx: Anterior mediastinal mass
- Lymph nodes-lymphoma, mets, inlammatory/infectious (TB)
- Thyroid-goiter, malignancy
- Parathyroid-adenoma, carcinoma
- Thymus-thymoma, carcinoma, thymolipoma, thymic cyst
- Germ cell tumors-teratoma
- Hematoma
-
DDx: Middle mediastinal mass
- Lymphadenopathy-mets, infection, idiopathic
- Tracheal abnormalities
- Aneurysms
- Foregut malformations
- Pericardial lesions
-
DDx: Posterior mediastinal mass
- Esophageal lesions-duplication cyst, neoplasm, varices, achalasia, hiatal hernia
- Neurogenic tumors-schwannoma, neurofibroma
- Vascular-descending thoracic aortic aneurysm/dissection
- Vertebral/paraspinal-hematoma, parapsinal abscess, metastases, extramedullary hematopoiesis
-
DDx: Cardiophrenic angle masses
- Fat pad
- Pericardial cyst
- Lymph nodes
- Diaphragmatic hernia (Foramen of Morgagni)
-
DDx: Low-density lymph nodes
- Infection-mycobacterial, fungal
- Malignancy with central necrosis (SCC, lymphoma)
-
DDx: Hypervascular lymph nodes
- Castleman disease
- Mets-especially RCC, thyroid
-
DDx: Eggshell calcification in lymph nodes
silicosis, sarcoid
-
DDx: Central calcification in lymph nodes
mycobacterial, fungal infection
-
DDx: Lucent lobe of the lung with some nodular opacities
- ABPA
- Endobronchial neoplasm vs. foreign body
- Bronchial atresia
-
DDx: Cavitary apical lesion
- Reactivation (secondary) TB
- Fungal infection
- Cavitary lung ca
- Sarcoidosis
- Silicosis
- Wegener
- Septic emboli
-
DDx: Lung hyperlucency
- Emphysema:
- Panlobular
- Centrilobular
- ParaseptalAir trapping:
- Foreign body (“ball and valve”)-unilateral
- SwyerJames-unilateral; not hyperexpanded
- Bronchiolitis/ small airway disease
-
DDx: Perilymphatic nodules
- Sarcoidosis(symmetric; upper lobes)
- Lymphangiticcarcinomatosis(asymmetric; lower lobes)
- Silicosis; coalworker’spneumoconiosis
- Amyloid
- LIP
-
Stages of sarcoid
- •Stage 0-Dx, but no evidence of dz.
- •Stage 1-Adenopathyonly
- •Stage 2-Adenopathy+ lung findings
- •Stage 3-Lung disease only
- •Stage 4-Fibrosis
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