anwser,s 5

Wednesday, April 12, 2023

Anwser,sDr :ANAS SAHLE

1. Chest xr cases.2. Chest clinical case.

3. Chest ct cases.4. Collicum exam.

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chest xr casesDr :anas sahle

http://www.facebook.com/dranas224

Cxr-11

Diagnosis is??:

Cxr-11

Diagnosis is:PANCOST TUMOR

Cxr-12

This sign name:

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-13This sign name is?:

Cxr-13This sign name is:

Halo Sign

In a cavity with a fungus ball, there is a crescentic lucent space along the upper portion of the density giving the appearance of a halo. This phenomenon is seen with two clinical presentations of pulmonary aspergillosis: Fungous ball Necrotizing subacute pneumonia during recovery phase from leukopenic episodes (as in this case)


DDX.……:


Crossing Mid-lineWhen a mediastinal density crosses mid-

line, most of the time it is a bowel.

This is a case of a hiatal hernia

Cxr-15

Differential diagnosis for this air-fluid level is.……:

Cxr-15

The x-ray on left is an example of lung abscess and tuberculosis. LUL lung abscess •Fluid level •Necrotic mass along walls RUL infiltrate: Tuberculosis •This appearance can also come from branchiogenous spread of abscess contents to the right lung. AFB was positive in this case.

Cxr-15

Air Fluid Level You 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-16

Extrapleural Sign

Expanding lesions of structures in the chest wall give rise to this sign. This sign helps to recognize the site of the lesion. The characteristic features of the density are: 1. Peripheral location 2. Cat under the rug appearance 3. Concave edges 4. Sharp inner edge and indistinct outer edge 5. Equal length and width in early stages

Cxr-16

Extrapleural Sign

DDX:Chest wall lesions Rib Mets Callous Hematoma PlasmacytomaParietal pleura Mesothelioma Metastatic massesIntercostal nerve Neurofibroma Intercostal muscle Rhabdomyosarcoma Internal mammary ode Plumbage Mediastinal lesions Masses Cystic hygroma Diaphragm lesions Lipoma

Cxr-17

Differential diagnosis for this sign is.…:

Cxr-17

Differential diagnosis for this sign is:Inhomogeneous Cardiac Density / Double Density

Cxr-17

Inhomogeneous Cardiac Density / Double Density The heart should be of uniform density, except over the vertebra and descending 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 of the heart, consider an abnormal density either in front of or behind the heart.

Consider the following when you encounter inhomogeneous cardiac density: Esophageal diseasePosterior mediastinal masses

Hiatal herniaLeft lower lobe diseaseDescending aorta

This is an example of an aorta aneurysm.

chest clinical casesA Trans-sexual with Acute

Dyspnea and Diffuse InfiltratesSubmitted by

Misbah 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)


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 .


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.


CXR


CHEST CT


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 trees

BAL was grossly bloody and cultures were

negative .


Question 1

• What is the most likely diagnosis?• A. Community-acquired Pneumonia • B. Pulmonary embolism • C. Silicone pulmonary microembolism.• D. HIV related pulmonary infection


DISCUSSIONThis is a case of liquid silicone embolism, 4 days after a large injection with silicone in his

breasts .The patient received multiple "augmenting" liquid silicone injections to different areas of

the body, including lips, hips, thighs, breasts and buttocks .The chemical structure from the label is that of poly-dimethylsiloxane (liquid polymeric

silicone) .CT scan on admission showed diffuse, bilateral, peripheral consolidations and ground-glass opacities with septal thickening bilaterally.

In the lower lobes, wedge-shaped, peripheral opacities suggestive of pulmonary infarcts were seen.

There was also extensive stranding within the anterior chest wall, with multiple fluid density areas, which were suggestive of silicone injection content.

Bronchoscopy showed diffuse bronchial mucosa erythema and active bleeding bilaterally. Bronchoalveolar lavage (BAL) was performed and revealed increasingly bloodier aliquots .

BAL sediment included many erythrocytes, siderophages and foamy macrophages with intracytoplasmic vacuoles, suggestive of an exogenous inert substance, likely silicone.


DISCUSSION


Question 2

The 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


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).


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


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).

chest ct cases-4Dr :anas sahle

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HRCT-1

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

HRCT-2

HRCT-2

• Find 2 centrilobular nodules.• Find an area of partially confluent, lobular

consolidation.• Find an area of homogeneous, mass-like*

consolidation.

HRCT-2

HRCT-3

HRCT-3

• Find an example of centrilobular nodules connected by linear structures: tree-in-bud.

HRCT-3

HISTOLOGY-1

HISTOLOGY-1

• This histologic section illustrates partially confluent, lobular consolidation.

• Find two of several centri-lobular nodules, which represent endo-bronchial spread of this disease.

HISTOLOGY-1

HISTOLOGY-2

HISTOLOGY-2

• Here is a closer view of a typical lesion.• What is the diagnosis?

HISTOLOGY-2

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).

Histologic differential diagnosis:

• Mycobacterial or fungal infection, • Wegener's granulomatosis.• rheumatoid nodule

Differential diagnosis

of 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.

Diagnosis:

• Tuberculosis

Summary diagnostic features of endobronchial tuberculosis on

HRCT

• Tree-in-bud pattern • Clustered centrilobular nodules • Mass-like areas of consolidation • Cavitation in larger nodules or masses

04/12/202360

Collicum EXAMRespiratory

A1 من أهم األسباب الغير مهيأة لذات الرئة

: االستنشاقيةA-. الصرع

B-. رضوض الصدرpseudobulbar palsy الشلل البصلي الكاذب .-C

bronchoscopy تنظير القصبات .-Drecumbent position االستلقاء الظهري .-E

A2 ما هو التدبير الغير مناسب عند معالجة ذات رئة ناجمة

:عن استنشاق مفرزات المعدةAعطاء المريض ستيروئيد جهازي لتخفيف الوذمة الشديدة إ

المخاطية القصبية. في

وضع المريض علي المنفسة بضغوط رئوية إيجابية مرتفعة .gا B .نسبي

Intravenous fluids اإلماهة الوريدية الجيدة .CTracheal suction المص المتكرر للمفرزات

D. الرغاميةAntibiotic التغطية بالصادات الحيوية .E

A3 جيدة • بصحة شاب عند المناسب العالج هو ما

رئة بذات أصيب مهمة مرضيه سوابق وبدونرشح : بعد

•Macrolides .A•Moxifloxacin .B•Cefpodoxime .C•Linezolid .D•Paracetamol .E

A4 موضوع مزمن تنفسي قصور لدية مريض في المناسب التدبير هو ما

أكسجه بشكل على استجابت شهرين من رئة بذات أصيب منزلية،على Amoxicillin and clavulanate potassiumجيد

إل الثالثة درجة من عنده التنفسية الزلة خالل ىازدادت الرابعةإلنتان صريحة عالمات وبدون حوالي يومين إشباع على% 90مع

األنفية 2أكسجة بالقنية لMoxifloxacin إعطاء .-A

/ 5إلى أنفية قنيه دقيقة لتر O 2رفع .-B/ 3إلى وجهي قناع دقيقة لتر . O 2رفع .-C

للمراقبة للمشفى D-. نقلهالسابق الصاد نفس E-. .إعطاء

A5 أي من العوامل التالية يرفع احتمال حدوث ذات

:رئة شعاعيه في مرضى سرطان الرئةسم 4عندما يكون حجم الورم أكبر من . . .-A

سنة 60عندما يكون عمر المريض فوق . .-B18أقل من . BMI عندما يكون مشعر الجسم

C-. الكتليمن المتوقع % 60أقل من . FEV1 -.D

E-. .األمر يتعلق بجرعة األشعة الوسطية المطبقة

A6 علبة/السنة 100سنة في المشفى، العادات: تدخين 61قبل مريض عمره ،

:األعراض ،حمى وسعال غير منتج وزلة تنفسية

اللمفاوية بالطبقي المحوري األشعة: ارتشاحات سنخية منتشرة مع ضخامة بالعقد .السوابق المرضية:داء كرون من عشر سنوات عولج من عدة أسابيع

.TNFبمضادات سنة مع لقاح السل في الطفولة.15تفاعل السلين إيجابي من

ما هو التشخيص األكثر احتماال:.A هجمةCOPD.حادة .Bذات رئة مشفوية.Cسل مفعل.D ذات رئة ناجمة عنHANTAVIRUS.ESARS

A7 ما هو الخيار األقل احتماال فيما يلي:

sputum: من أهم استطبابات الفحص الجرثومي للقشعGram stains and culturesوالزرع .

.Aمريض ورمي لديه حرارة مع نقص بالعدالت

.B فشل معالجة مريض خارج المشفى شخص له ذات رئة مكتسبة في المجتمع.

.C .وجود تكهفات رئوية بصورة الصدر

.D مريض لديه حالة ربوية وموجود بالعناية المركزةICU.للمراقبة والعالج

.E مريض لدية حالة صرعيه وضع على المنفسة وظهر لدية39تكثف رئوي شديد لم يكن موجودا سابقا مع حرارة

A8 احتم • األقل الخيار هو � ما بذات اًال يتعلق فيما

عن الناجمة :mycoplasmaالرئة.A حوالي الحضانة .3فترة التعرض بعد أسابيع.B تستجيبعلىazithromycin

.C. الحدوث نادرة الجلدية المظاهر.D التهاب من بعضحاًالت تحدث أن يمكن

. األطفال عند الدماغ.E. وعرواءات عضلية وآًالم بصداع غالبا� تترافق

A9 الرئة بذات يتعلق فيما g احتماال األقل الخيار هو ما

عن الناجمة المجتمع في P. Aeruginosaالمكتسبة.A الليفي الكيسي الداء في شائعة.B المناعة وأسوياء ناقصي أشخاص في شائعة.C مرضى في صادات COPDتشاهد يتناولون الذين

. بالكورتيزون معالجة مع مكثف بشكل.D األعضاء زرع مرضى في شائعة.ETazobactam and Piperacillin sodium : من

. المقترحة العالجات

A10 احتما • األقل الخيار هو في لما g Loeffler's syndrome:ا

.A. الرئتين إلى األسكاريس بيوض عبور عن ينجم

.B بالحمضات رئة ذات eosinophilicيحدثpneumonitis

.C من أيام أربع أول شري من يعانون المرضى نصفاإلصابة .

.D. وزيز من يشكون المرضى ثلث.E . كبدية ضخامة المرضى بعض في يحدث

Hepatomegaly

A11 األقل • الخيار هو g ما بالمكورات احتماال يتعلق فيما

:الرئوية.A النقوي الورم مرضى تصيب ما ا gنادر

Multiple myelomaالمتعدد

.B . الرئة لذات gا إحداث الجراثيم أشيع من

.C. غيرهم من أكبر بنسبة المدخنين تصيب.D المناعة ناقصي المرضى بها يصاب أن يمكن.E . الحامل عند الحدوث نادرة

anwser,s 5

Health & Medicine

chest clinical cases

chest wall7

normal chest xray

differential diagnosis

uniform density

abnormal density

increased density

chest xr cases dr