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71 Cards in this Set
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Lymphangioleiomyomatosis (LAM)
Abnormal proliferation of smooth muscle cells Regular and uniform thin-walled cysts and normal intervening lung, diffuse distribution, young females Complication of pneumothorax and chylous effusions DDX cystic lung disease: LCH: UL, cyst walls may be thicker and irregular, interstitial nodularity, young male smokers Emphysema PCP: UL cystic disease of varying size and wall thickness |
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Bronchial atresia
CXR: Well-expanded lungs with no pleural effusion Tortuous nodular opacity in the left lower lobe (arrows) CT: Tubular branching opacity in LLL Opacity has no identifiable connection with the adjacent vascular structures and does not extend to the hilum Mass is surrounded by an area of extensive hyperlucent lung parenchyma Classic: Branching, tubular mass (mucoid impaction of a bronchus) surrounded by hyperinflated lung with decreased vascular markings CT: segmental emphysematous changes distal to mucoid impacted bronchus CXR: V-shaped mass and a localized area of hyperinflation are visible distal to the mass (which represents a mucocele) Hyperlucent LUL, adjacent ovoid densities (mucocele) surrounded by paucity of vessels Cylindrical area of enhancement surrounded by hyperinflated parenchyma Focus of hyperinflation unchanged with inspiration and expiration (not shown) |
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Bronchiectasis
CXR: parallel line shadows (tram-lines) (arrows), ring shadows, and hyperexpansion CT: tubular dilated central bronchi (without tapering) and mosaic oligemia Chronic irreversible dilatation of bronchi, tram-tracking (bronchial wall thickening) Types: Cylindrical: least severe form Varicose: beaded appearance Saccular/cystic: advanced stage, may have air-fluid levels Infection: MC acquired cause CF: cylindrical, MC congenital cause, MC UL Mucoid impaction causes obstruction and secondary infection MC S. aureus and Pseudomonas aeruginosa ABPA: central bronchiectasis Kartagener’s (dyskinetic cilia syndrome): AR, bronchiectasis (MC RML), situs inversus, paranasal sinusitis Asthma Tracheobronchomegaly, Williams-Campbell syndrome (defective cartilage), a1-antitrypsin disease Bronchiectasis in LLL showing mucoid impactions filling the lumen of the dilated bronchi Cylindrical bronchiectasis seen as a lack of distal tapering of the bronchial lumen Saccular/cystic bronchiectasis |
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Mesothelioma
Case findings: Circumferential irregular lobular opacity in the right hemithorax with a well defined inner border Mass effect on trachea and mediastinum No calcification is present, no rib destruction MC primary pleural neoplasm Associated with asbestos exposure: contralateral pleural plaques, focal pleural thickening, pleural calcifications, effusions Features: diffuse pleural thickening, circumferential, nodular, invades mediastinal surface DDX: Metastases: MC adenocarcinoma (lung, breast, GI, kidney, ovaries), thyroid melanoma peripheral pulmonary tumor emboli with pleural involvement Malignant thymoma: Anterior mediastinal mass that contiguously spreads to involve pleura Pleural drop metastases can mimic malignant mesothelioma Tumor may also invade locally into the lung Lymphoma Loculated pleural effusion |
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Bronchiolitis obliterans
Case findings: CXR: MC normal, mild hyperinflation, peripheral attenuation of vascular markings unilateral hyperlucent lung CT: mosaic pattern of low attenuation areas air trapping or hypoxic vasoconstriction Concentrically scarred or stenotic small airways in lung periphery Etiology: Infection: Swyer-James (MC post-viral infection) Toxic and fume exposure (MC nitrogen dioxide) Collagen vascular disease: RA, SLE Bone marrow and heart-lung or lung transplantation Drug reaction (penicillamine) Idiopathic BRONCHIOLITIS OBLITERANS “CRITTERS” COP/BOOP Rheumatoid Infectious-Swyer James Transplant Toxins Sarcoid Mosaic perfusion evaluation Perform expiratory CT Normal: uniform decrease in lung volume and increase in density Abnormal: lung volume and low density maintained Infiltrative process High density abnormal, NO air trapping, vessels uniform Etiology: alveolitis, infection (PCP), hemorrhage, BAC Airway process Low density abnormal, air trapping, vessels small in low density area Etiology: bronchiolitis obliterans, obstructive processes Vascular process High and low density may be abnormal, NO air trapping Vessels small in low density area, and vessels may be increased in denser areas Etiology: PAH, vasculitis Bronchiolitis obliterans DDX hyperlucent lung: Emphysema Asthma Swyer-James DDX mosaic perfusion: Bronchiolitis obliterans Occlusive vascular disease Alveolar hemorrhage Desquamative interstitial pneumonia Bronchoalveolar carcinoma Pulmonary alveolar proteinosis |
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Allergic bronchopulmonary aspergillosis (ABPA)
Case findings: CXR: linear opacities which may form parallel tram lines (central bronchiectasis) CT: dilated mucus filled airways, seen "Y" or "V" shaped opacities (mucoid impaction) MC in central areas and UL, peripheral airways are usually spared DDX: Asthma Cystic fibrosis Bronchiectasis Endobronchial tumor BRONCHIECTASIS “CAPT KANGAROO HAS MOUNIER KUHN” Cystic fibrosis ABPA Postinfectious TB Kartagener’s Mounier Kuhn |
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Wegener's granulomatosis
Autoimmune condition involving the upper and lower respiratory tract and kidneys Vasculitis involving the medium-sized vessels, with formation of granulomas and necrosis of lung parenchyma Lung abscess: development of a cavity within preexisting consolidation Features: Mid and lower zone opacities, which are diffuse, and both alveolar and interstitial Nodules, which may cavitate CT: diffuse, ill-defined perivascular opacities DDX cavitary lesion Infection: bacterial abscess Neoplasm: squamous cell, hematogenous metastasis Vasculitis: Wegener’s granulomatosis Granulomatosis: TB, sarcoidosis Septic pulmonary emboli “CAVITY” Carcinoma-SCC Abscess-fungal/bacterial/TB Vascular-septic emboli Inflammatory-rheumatoid nodule, Wegener’s Trauma-resolving contusion Young-bronchogenic cyst Hematogenous metastasis |
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Pulmonary alveolar proteinosis
CXR: Bilateral symmetric opacity in a "bat wing" distribution May be areas of course reticulation Treatment: bronchoalveolar lavage CT: crazy paving Smoothly thickened interlobular septa within areas of GGO Panlobular distribution of increased alveolar density with superimposed reticular pattern DDX CXR batwing opacities: Pulmonary edema PCP, DIP Bronchioloalveolar carcinoma Hypersensitivity pneumonitis DDX crazy paving: Alveolar proteinosis Pulmonary hemorrhage LC chronic eosinophilic pneumonia, BOOP (LL) Lipoid pneumonia |
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Desquamative interstitial pneumonia (DIP)
Case findings: CXR: MC LL GGO CT: patchy GGO in middle and lower lung Alveolar macrophage pneumonia 90% are smokers Respond better to steroids than UIP Bilateral patchy GGO: LL and subpleural predominance DDX: Acute hypersensitivity pneumonitis (HP) RB, RB-ILD Alveolar hemorrhage |
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Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Case findings: Subacute: MC fine reticular or reticulonodular pattern involving both lungs, centrilobular GG nodules CT: numerous centrilobular, peribronchiolar, indistinct nodular opacities with peribronchiolar thickening GGO in a panlobular distribution Example: farmer’s lung, bird fancier’s lung Case findings: Subacute: MC fine reticular or reticulonodular pattern involving both lungs, centrilobular GG nodules CT: numerous centrilobular, peribronchiolar, indistinct nodular opacities with peribronchiolar thickening GGO in a panlobular distribution Example: farmer’s lung, bird fancier’s lung Subacute HP: patchy and nodular centrilobular GG nodules |
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Acute eosinophilic pneumonia (Hamman-Rich syndrome)
CXR: Acute progression of diffuse opacities involving both lungs Kerley's lines and pleural effusions are frequently present CT: Diffuse alveolar opacities with associated thickening of bronchovascular bundles and interlobular septa, simulating pulmonary edema Mediastinal lymphadenopathy and bilateral pleural effusions are common findings DDX: Pulmonary edema BOOP Lymphangitic carcinomatosis Hypersensitivity pneumonitis DDX: Pulmonary edema BOOP Lymphangitic carcinomatosis Hypersensitivity pneumonitis Diffuse alveolar damage (DAD): injury to the alveolar lining and endothelial cells chronic fibrotic phase follows Findings similar to ARDS/pulmonary edema Reticular opacities with Kerley B lines progress to interstitial infiltrates and airspace consolidations Extensive bilateral GGO, airspace consolidation, architectural distortion Diagnosis of exclusion: may be an idiopathic form of ARDS CXR: Bilateral, patchy airspace opacification, spares CP angles With progression, lungs become diffusely consolidated CT: Similar to ARDS with bilateral, patchy ground glass opacities, consolidation Traction bronchiectasis Cryptogenic eosinophilic pneumonia Umbrella term for several conditions: Loffler’s syndrome: Migrating pulmonary consolidation Acute eosinophilic pneumonia: Rapidly progressing illness of several days duration with fever, severe hypoxemia Diffuse lung consolidation mimicking ARDS Chronic eosinophilic pneumonia: Peripheral consolidation Prompt response to steroids Churg Strauss syndrome: Allergic angiitis and granulomatosis Lung nodules, which unlike Wegener’s granulomatosis, do NOT cavitate Peripheral areas of consolidation similar to eosinophilic pneumonia Hypereosinophilic syndrome: Idiopathic eosinophilic syndrome |
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Chronic eosinophilic pneumonia
Case findings: CXR: photographic negative of pulmonary edema peripheral infiltrate (in the outer 2/3 of the lung) Peripheral infiltrates are MC in UL and occur bilaterally. About 20% patients present migratory infiltrates Mediastinal adenopathy in 50% DDX: Bronchiolitis obliterans with organizing pneumonia (BOOP) Sarcoidosis TB PCP Bilateral, peripheral patchy areas of air-space consolidation |
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Bronchiolitis obliterans organizing pneumonia (BOOP)
Case findings: Patchy consolidation may be fleeting and migratory GGO is associated with the presence of alveolitis Consolidations are MC in subpleural regions DDX: Chronic eosinophilic pneumonia Pulmonary hemorrhage Multifocal infection Diffuse alveolar damage, acute eosinophilic pneumonia BOOP: cryptogenic organizing pneumonia MC idiopathic, respond well to steroids BOOP-like reaction seen with: pulmonary infection, drugs, CVD, Wegner’s, toxic fume inhalation Findings: Patchy consolidation or GGO, with a subpleural and/or peribronchial distribution Peripheral consolidation (DDX: chronic eosinophilic pneumonia) Irregular nodules of peribronchial consolidation Crazy paving (MC LL) Bilateral patchy areas of air-space consolidation in bases Patchy areas of air-space consolidation with air bronchogram |
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Septic pulmonary emboli
CXR: Multiple ill-defined, round or wedge-shaped opacities in the periphery of the lung Cavitation with air fluid levels CT: Peripheral nodules Feeding vessel sign Cavitation Wedge shaped lesions abutting the pleura Air bronchogram within nodules DDX cavitary lesion Infection Neoplasm: squamous cell, hematogenous metastasis Vasculitis: Wegener’s granulomatosis Granulomatosis: TB, sarcoidosis Septic pulmonary emboli |
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Langerhans' cell histiocytosis
Case findings CXR: ill-defined nodules (2-10mm), reticulonodular opacities, cysts MC in UL CT: combination of cysts and nodules Male smokers Upper lobe, irregular variable cysts with nodules (may undergo cavitation), spares costophrenic sulci Early peribronchiole nodules, later replaced by cysts Cystic interstitial lung disease Lymphangioleiomyomatosis Regular and uniform thin-walled cysts and normal intervening lung, diffuse distribution, young females Complication of pneumothorax and chylous effusions Abnormal proliferation of smooth muscle cells Langerhans' cell histiocytosis Male smokers Upper lobe, irregular variable cysts with nodules (may undergo cavitation), spares costophrenic sulci Early peribronchiole nodules later replaced by cysts PCP HIV with CD4 < 200, UL cystic disease of varying size and wall thickness Cystic emphysema Fine nodular shadowing in both lungs |
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Ankylosing spondylitis
Apical pulmonary fibrosis, cavitation and pleural thickening DDX UL interstitial markings (CASSET-P): Cystic fibrosis Ankylosing spondylitis Sarcoid, silicosis EG (Langerhans' cell histiocytosis) Tuberculosis Pneumoconiosis |
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Rounded atelectasis
Case findings: Comet-tail sign: juxtapleural mass with associated pleural thickening and distorsion of adjacent vessels and bronchi producing a "comet tail" appearance as they lead towards the mass Focal area of pulmonary collapse adjacent to thickened pleura Associated with: Asbestos-related pleural disease Chronic pleural thickening High association between asbestos-related pleural disease and bronchogenic carcinoma |
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Aortic aneurysm
Pseudoaneurysm: MC saccular Etiology: infectious (mycotic), traumatic Tertiary syphilis: Infectious aortitis of vasa vasorum Asymmetric saccular sinus involvement Tree bark calcifications Dissections rare Mycotic: Saccular aneurysm with perianeurysmal inflammation MC ascending aorta or isthmus Cystic medial necrosis: Degenerative process of aortic muscular layer, involves aortic sinuses and sinotubular junction Symmetric sinus involvement (tulip bulb appearance of aortic root) MC ascending aorta Disssection frequent complication Rare calcifications Etiology: Hypertension Marfan’s disease Ehlers-Danlos Homocystinuria (structural collagen diseases) Etiology: MC atherosclerosis Connective tissue disease: Marfan’s, Ehlers-Danlos Homocystinuria Tertiary syphilis, posttraumatic, mycotic Takayasu’s arteritis, giant cell arteritis Ascending aorta: Syphilis, cystic medial necrosis (Marfan’s, Ehlers-Danlos), homocystinuria Descending aorta: Atherosclerosis, posttraumatic, mycotic |
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Pulmonary carcinoid
Classic findings: central mass (80%) Endobronchial small nodule or obstructing lesion Associated with bronchiectasis, atelectasis, obstructive pneumonitis, air trapping, mucoid impaction Bulk of tumor is extraluminal with a smaller endoluminal component iceberg tumor Calcification, homogeneous enhancement Well-defined hilar or perihilar masses LC located peripherally (smaller than central lesions) DDX: Bronchogenic carcinoma Endobronchial metastasis Hamartoma Castleman’s disease (angiofollicular lymph node hyperplasia, giant lymph node hyperplasia) Plasma cell type: slight enhancement Hyaline vascular type: marked enhancement (almost equivalent to aorta) |
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Kaposi’s sarcoma
Case findings: CXR: central air-space opacities involving the left middle and bilateral lower lung zones CT: bilateral peri-bronchovascular bundle opacities radiating from the hila with a nodular component DDX: Kaposi’s sarcoma PCP Bronchoalveolar carcinoma Lymphoma Sarcoidosis CXR: nodular and linear infiltrates with a perihilar and basal distribution CT: multiple, bilateral flame-shaped or nodular lesions with ill-defined margins distributed along bronchovascular bundles with bronchocentric distribution Coarse reticular pattern or widespread poorly defined nodules with mediastinal and/or hilar adenopathy Airspace consolidation is associated with parenchymal hemorrhage from tumor Perilymphatic “A SKILL” Amyliodosis Silicosis/Sarcoidosis Karposis Infection Lymphangitic spread of tumor Lymphoma |
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Varicella pneumonia
Case findings: CXR: reticulonodular pattern CT: multiple small nodules each with GG halos, worse in upper lobes DDX: Varicella pneumonia Disseminated fungal infection Tuberculosis Metastasis Hypersensitivity pneumonitis Acute phase: multiple, bilateral 5 – 10 mm nodular opacities that coalesce into diffuse patchy air space disease Opacities usually resolve completely, however, in less than 2% of patients they involute and calcify to form innumerable small calcified nodules Pleural effusions are rare |
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Tracheal adenoid cystic carcinoma
Case findings: Oval polypoid mass attached to the anterior left sidewall of the trachea by a thin stalk DDX tracheal mass Benign: Squamous cell papilloma Papillomatosis Pleomorphic adenoma Malignant: MC squamous cell carcinoma (SCC) Adenoid cystic carcinoma Metastasis LC mucoid epidermoid tumor, carcinoid |
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Thoracic aortic aneurysm
CXR: Large mass in region of aortic arch CT: Large saccular thoracic aortic aneurysm Large left pleural effusion Hematocrit level noted in pleural fluid Large abdominal aortic aneurysm Etiology: MC atherosclerosis Connective tissue disease: Marfan’s, Ehler-Danlos Homocystinuria Tertiary syphilis Post-traumatic, post-surgical Mycotic aneurysm Aortitis: Takayasu’s arteritis, giant cell arteritis |
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Anterior mediastinal mass
Tumors of thymic origin: Thymus; thymoma, thymic cyst, thymolipoma Lymphoma Germ cell tumor: Teratoma, seminoma, choriocarcinoma Thyroid: goiter, thyroid tumor Mediastinal hematoma Mesenchymal tumor: Lipoma, leiomyoma, liposarcoma |
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Wegener's granulomatosis
Case findings: Large conglomerate mass in RML 2 thick walled cavitary lesions in the left mid lung and LLL CT: multiple large thick-walled cavitary lesions throughout the lungs bilaterally, some contain air-fluid levels Multiple large, thick-walled nodules, often with cavitation Diffuse opacities common due to atelectasis, confluence on nodules/masses, pulmonary hemorrhage, and superimposed infection DDX multiple cavitary lesions Metastasis: Newly treated or fast-growing carcinoma Wegener’s granulomatosis Septic emboli Multiple abscesses (e.g., aspiration) Multifocal necrotizing pneumonia with infarction Fungal infection: MC in immunocompromised Rheumatoid nodules |
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Thymolipoma
Case findings: CXR: Large well-defined right anterior inferior mediastinal mass that conforms to the shape of the adjacent mediastinum CT: Mass containing fat and soft tissue Little mass on mediastinum, despite large size DDX: Lipoma Liposarcoma Omental herniation Large asymptomatic tumor (lack of mass effect) Soft encapsulated tumor MC anterior inferior mediastinal mass Conforms to shape of mediastinum Mimics cardiomegaly on CXR MC thymoma (encapsulated MC, invasive) Thymic hyperplasia Thymolipoma Thymic cyst Thymic carcinoma Thymic carcinoid Invasive thymoma: local extension Extent of the tumor within the pleura may be so great as to mimic a mesothelioma Thymic carcinoma: hematogenous metastasis Thymolipoma Predominantly fatty thymolipoma DDX: lipoma |
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Scimitar syndrome
CXR: Hypoplasia of right lung with shift of the mediastinum from left to right Cardiac dextroposition Elevation of the right hemidiaphragm CT: Hypoplasia of the right lung and right pulmonary artery, with shift of the mediastinal contents to the right RLL lung obtains its vascular supply from an anomalous systemic vessel arising from the intra-abdominal descending aorta Venous drainage of the RLL is into an anomalous vessel that enters the junction of the IVC and right atrium Also called: Hypogenetic lung syndrome Congenital pulmonary venolobar syndrome (CPVS) Halasz’s syndrome PAPVR: curvilinear density along the right heart border (scimitar vein) Partial agenesis or hypoplasia of the right lung Hypoplasia or agenesis of the RPA Cardiac dextroposition Congenital cardiac malformations Abnormal systemic blood supply to at least part of the right lung (MC posterior basal segment of LL) |
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Amiodarone toxicity
Case findings: CXR: mild cardiomegaly CT: diffuse homogeneously increased hepatic parenchymal attenuation Complication of amiodarone: Pulmonary fibrosis Increased liver density without change in splenic attenuation due to accumulation of the drug, which contains iodine, within the hepatocytes |
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Left SVC and accessory azygos fissure and lobe
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Mycetoma
CXR: Hyperinflation Bilateral bullae Left upper and mid lung scarring Opacity projecting over left heart border CT: Cavitary lesion in LLL with a mass lying in the cavity Adjacent posterior pleural thickening Mild compressive atelectasis or inflammatory changes anteriorly DDX thick-walled, debris-containing lung cavity: Necrotic SCC with abscess Residual lung tissue in an intrapulmonary abscess Mycetoma in a prior cavity (TB, AS, pulmonary fibrosis) Cavitating infarct Hydatid cyst Silicosis with fibrosis |
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Mycetoma
DDX thick-walled, debris-containing lung cavity: Necrotic SCC with abscess Residual lung tissue in an intrapulmonary abscess Mycetoma in a prior cavity (TB, AS, pulmonary fibrosis) Cavitating infarct Hydatid cyst Silicosis with fibrosis Sarcoidosis staging Stage 0: No demonstrable abnormality Stage 1: Hilar and mediastinal lymph node enlargement without associated pulmonary abnormality Stage 2: Hilar and mediastinal adenopathy associated with pulmonary abnormality Stage 3: Diffuse pulmonary disease without associated nodal enlargement Stage 4: Pulmonary fibrosis |
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Candidiasis
CT chest: Several ill-defined pulmonary nodules scattered bilaterally RLL shows an angiocentric nodule CT abdomen: Multiple low-density lesions with high attenuation centers throughout the liver Irregular low density splenic lesion DDX: Disseminated bacterial infections Staphylococcus aureus Enterobacteria Disseminated fungal infections Candida Aspergillus Hematogenous metastasis |
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Kartagener's syndrome (ciliary dyskinesia syndrome, immotile cilia syndrome)
Kartagener's syndrome (ciliary dyskinesia syndrome, immotile cilia syndrome) |
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Relapsing polychondritis
Case findings: Tracheal walls are thickened and contain calcifications Lumen of the trachea is irregular, deformed and narrowed Recurrent inflammatory episodes that affect cartilages of the ears, nose, larynx, trachea and joints Result is fragmentation of the cartilages which are replaced by fibrosis Diffuse thickening of tracheobronchial wall with diffuse smooth narrowing of trachea and main bronchi |
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Pulmonary hamartoma
Case findings: Round smooth well-defined nodule containing popcorn calcification and collection of fat Classic: popcorn calcifications 3rd MC solitary pulmonary nodule (SPN) Solitary pulmonary nodule: Well-circumscribed round or oval-shaped lesion, < 3 cm Almost always benign < 30 years old Benign calcification: Diffuse, central nidus, laminated, popcorn Malignant calcification: Stippled, eccentric |
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Thymic cyst
Case findings: Large deformable cystic mass interposed between the anterior chest wall and the vascular mediastinal structures Congenital: Remnants of the thymopharyngeal duct MC unilocular and may occur anywhere along the course of the embryogenic thymus gland from the mandible to the manubrium Acquired: MC multilocular and are induced by thymic inflammation Found within thymomas or thymic germ cell neoplasm May be associated with Hodgkin's disease involving the thymus May develop after irradiation of the mediastinum MC thymoma (encapsulated MC, invasive) Thymic hyperplasia Thymolipoma Thymic cyst Thymic carcinoma Thymic carcinoid Invasive thymoma: local extension Extent of the tumor within the pleura may be so great as to mimic a mesothelioma Thymic carcinoma: hematogenous metastasis CXR: thymic cysts are indistinguishable from other nonlobulated thymic masses (DDX: thymoma) CT demonstrates fluid attenuation Appearance may vary if hemorrhage or infection complicate the cyst Curvilinear calcification of the cyst wall may occur |
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Tracheobronchial amyloidosis
Case findings: Diffuse bronchial wall thickening leading to an occlusion of segmental bronchi in RLL and segmental atelectasis Calcific deposits are seen in the thickened bronchial wall Small centrilobular nodules visible in the RML and lower lobes reflect inflammatory bronchiolitis Features: Multiple concentric or eccentric strictures and mural nodulation Calcific deposits are frequently present Tracheobronchopathia osteochondroplastica (TPO) Tracheal cartilages are thickened and contain irregular calcifications Formation of multiple submucosal osteocartilaginous growths in anterior and lateral walls (posterior aspect is spared) Involves long segment of trachea Extension to main stem bronchi may be present PERILYMPHATIC “A SKILL” Amyloid Sarcoid Kaposi’s Infection (PCP) Lymphoma Lymphang carcinomatosis |
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Congenital absence of left pericardium
Case findings: Shift of the mediastinum toward the left side Appearance of the heart is somewhat unusual as there are three large convexities (aortic arch, main pulmonary artery, LV segment) at the elongated left cardiac border Hyperlucent area between the aortic arch and the main pulmonary artery, due to interposition of lung tissue at this level (arrow) MR: Heart is rotated clockwise (horizontal position of the interventricular septum) Absence of a hypointense line within the epicardial fat along the left cardiac border Premature atrophy of left cardiac vein (left duct of Cuvier) Leads to a loss of blood supply to the left pleuropericardial membrane (normally persists and forms the left pericardium) Features: Abrupt termination of the right pericardium or total absence of pericardium Cardiac rotation Shift to the left hemithorax Interposition of lung between the aortic arch and MPA Associated with other congenital cardiopulmonary abnormalities in 1/3rd of cases: Atrial or ventricular septal defects Persistent ductus arteriosus Aortic valve anomalies Tetralogy of Fallot Bronchopulmonary sequestration |
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Alveolar sarcoidosis
Case findings: CXR: Bilateral pulmonary nodules Hilar lymphadenopathy CT: Subcarinal and hilar lymphadenopathy Spiculated lung nodules (some with air bronchograms) DDX: Metastatic disease Septic emboli Tuberculosis Histoplasmosis Lymphoma Alveolar Sarcoidosis Wegener’s granulomatosis Rarely nodules grow to form large well-defined masses containing air bronchograms Airspaces are compressed and obliterated by granulomas in the interstitium Cavitation is extremely rare |
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Pulmonary carcinoid
Case findings: Polypoid lesion in the bronchus intermedius DDX: Carcinoid Bronchogenic carcinoma Endobronchial metastasis Adenoid cystic carcinoma (cylindroma) Mucoepidermoid carcinoma Benign tumor (papilloma) Classic findings: central mass (80%) May be entirely within the bronchus or have an intra and extraluminal component Associated with bronchiectasis, atelectasis, obstructive pneumonitis, air trapping, mucoid impaction Bulk of tumor is extraluminal with a smaller endoluminal component iceberg tumor Calcification, homogeneous enhancement Well-defined hilar or perihilar masses LC located peripherally (smaller than central lesions) Carcinoid syndrome is rare |
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Mediastinal lipomatosis
Case findings: CXR: mediastinum is widened CT: Interval development of a right pleural effusion Large amount of fat within the mediastinum and in the epicardial fat pads Associated with: Obesity Steroids: exogenous or endogenous (Cushing’s Chronic renal disease DDX fat-containing mediastinal lesions: Mediastinal lipomatosis Hernia: Morgagni, Bochdalek, periesophageal fat herniation Lipoma, liposarcoma Thymolipoma Germ cell tumor: teratoma |
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Double aortic arch
Case findings: Right-sided aortic arch 1st arch to come off the ascending aorta is on the left side More superiorly, right side comes off Right and left arches both encircle the trachea and esophagus and rejoin into the descending aorta posteriorly Apex of the right-sided arch is more superior than left MC right arch is dominant (75%) No associated cardiovascular anomalies |
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Pseudocoarctation of aorta
Case findings: CTA: Aneurysmal dilatation of ascending aorta Aorta has a kink with narrowed lumen where the posterior transverse aorta joins proximal descending aorta Descending aortic dilatation is seen just distal to this kinking Kinking of aorta without true obstruction Asymptomatic May have post-kinking aortic dilatation which may require intervention if progresses Associated anomalies: same as those for true coarctation |
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Semi-invasive aspergillosis (chronic necrotizing aspergillosis)
Case findings: CXR: irregular nodular opacity in posterior RUL CT: irregular spiculated cavitary RUL mass DDX: Primary lung cancer Metastasis: sarcoma, melanoma, cervical Wegener's granulomatosis Septic embolus TB Fungal: coccidioidomycosis, nocardia, cryptococcus, aspergillosis Impairment of normal defenses due to immunosuppression, cavitary lung disease, or cystic fibrosis can result in infection Manifestations of aspergillus: Allergic bronchopulmonary aspergillosis (ABPA) Mycetoma (aspergilloma) Semi-invasive aspergillosis Invasive aspergillosis |
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Pulmonary alveolar proteinosis
Case findings: CXR: Bilateral, diffuse and symmetrical reticular pattern with diffuse hazy air space opacities predominately in the perihilar and central lung regions CT: GGO with smooth to slightly nodular septal thickening giving the appearance of crazy paving Treatment: bronchoalveolar lavage DDX diffuse airspace opacities: Pulmonary edema Pneumonia PCP Pulmonary hemorrhage TB Hypersensitivity pneumonitis DDX Chronic air space opacity: Lymphoma Bronchoalveolar carcinoma Pulmonary alveolar proteinosis lymphangitic carcinomatosis CXR: Bilateral symmetric opacity in a "bat wing" distribution May be areas of course reticulation CT: crazy paving Smoothly thickened interlobular septa within areas of GGO Panlobular distribution of increased alveolar density with superimposed reticular pattern DDX CXR batwing opacities: Pulmonary edema PCP, DIP Bronchioloalveolar carcinoma Hypersensitivity pneumonitis DDX crazy paving: Alveolar proteinosis Pulmonary hemorrhage LC chronic eosinophilic pneumonia, BOOP (LL) Lipoid pneumonia |
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Miliary tuberculosis
Case findings: Diffuse 1-2 mm nodules DDX miliary nodules: Diffuse and random distribution Infectious: miliary TB (hematogenous spread), fungal Non-infectious: sarcoidosis, LCH, pneumoconiosis (silicosis) Metastasis: thyroid, melanoma |
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Scleroderma (progressive systemic sclerosis)
Case findings: CXR: Low lung volumes with bilateral coarse reticular markings, esophagus is dilated XR hands: ST calcifications, resorption of distal phalangeal tufts (acro-osteolysis) Interstitial fibrosis with basal, posterior and peripheral predominance Esophageal dilatation ST calcifications DDX interstitial fibrosis (basilar and subpleural distribution): usual interstitial pneumonia (UIP) IPF Collagen vascular disease: RA, scleroderma, SLE Drug toxicity: bleomycin Asbestosis |
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Invasive thymoma
Case findings: CXR: Large lobular left anterior mediastinal mass CT: Large left anterior mediastinal mass with coarse central calcification Irregular superior margin with infiltration into the mediastinal fat DDX: Thymoma (invasive) Thymic carcinoid Lymphoma Thymic carcinoma Teratoma Thymoma MC benign Invasive thymoma histologically identical to encapsulated thymoma MC affects 5th and 6th decades Associated with parathymic syndrome: Myasthenia gravis 85% of patients with MG have thymic hyperplasia, 15% have thymoma 50% of patients with thymoma have MG Pure red cell aplasia Hypogammaglobulinemia Calcification MC peripheral along capsular margin MC thymoma (encapsulated MC, invasive) Thymic hyperplasia Thymolipoma Thymic cyst Thymic carcinoma Thymic carcinoid Invasive thymoma: local extension Extent of the tumor within the pleura may be so great as to mimic a mesothelioma Thymic carcinoma: hematogenous metastasis Diagnosis: invasive thymoma DDX: Diffuse malignant mesothelioma Pleural metastasis (bronchogenic carcinoma, extra-thoracic malignancy) Lymphoma |
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Lipoid pneumonia
Case findings: Bilateral areas of consolidation of fatty density within the posterolateral segment of RML and lingula Results from aspiration of mineral, vegetable or animal oil |
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Pulmonary tuberculosis
Case findings: CXR: biapical opacities suggesting scarring, no pulmonary nodules or lymphadenopathy CT: biapical cavitary lesions with scarring DDX cavitary apical disease: Tuberculosis Fungal Infection Cavitary neoplasm Sarcoidosis, silicosis Radiation induced changes |
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Silicosis (with progressive massive fibrosis)
Case findings: CXR: progressive massive fibrosis, masses surrounded by emphysematous lung CT: Bilateral masses of fibrosis Small nodules are present in the superior segment of the left lower lobe, and irregular emphysematous spaces lateral to the left fibrotic mass Nodular calcification is seen in the right hilum (arrow) Early findings: small (1-2 mm) nodules are seen predominantly in the posterior portions of the upper and middle lung Nodes with eggshell-type calcifications Progressive massive fibrosis Complication of coal worker's pneumoconiosis (CWP) Occurs only after long-term exposure to coal dust Coal dust alone can cause PMF, but the role of silica in the production of PMF remains uncertain PMF starts as bilateral masses near the periphery of the lung, but these masses can be completely or predominantly unilateral |
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Histoplasmosis with broncholithiasis
Case findings: CXR: Scattered nodules with focal calcification in the right hilar area Fullness of the hila on the lateral view CT: Scattered calcified nodules bilaterally with slight hypodensity in the right middle lobe Soft tissue mass with dense central calcification located in the middle mediastinum (calcified nodes) Caused by Histoplasma capsulatum Acute phase: Single or multiple areas of consolidation Associated hilar or mediastinal adenopathy Resolves without treatment within weeks to months Epidemic form: Multiple discrete nodules throughout both lungs Hilar adenopathy, which become calcified when they heal Histoplasmoma (solitary granuloma): Well-defined necrotic focus of infection surrounded by an inflammatory reaction, MC in lower lobes Complications from calcified lymph nodes Fibrosing mediastinitis: from large calcified lymph nodes and surrounding fibrotic reaction that constrict and encase mediastinal structures Broncholithiasis: calcified nodes erode into a bronchus DDX broncholithiasis: Histoplasmosis, tuberculosis Actinomycosis Coccidiodomycosis, cryptococcosis Silicosis |
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Solitary fibrous tumors of the pleura (SFTP)
Case findings: CXR: complete opacification of the right hemithorax with shift of the mediastinum to the left CT: large, heterogeneous mass occupying the right hemithorax without significant enhancement Coronal T2: large, well-encapsulated, heterogeneous (suggests necrosis) low-signal mass in the right hemithorax with surrounding pleural effusion MC low T1 and T2: indicative of fibrosis High T2: represent areas of necrosis or hemorrhage Other names: benign or localized mesothelioma, benign fibrous mesothelioma, subpleural fibroma Slow growing, not histologically related to mesothelioma Most (> 80%) SFTP are benign, but still excised because of their growth Rare, < 5% of all tumors involving the pleura Well-demarcated, solitary, enhancing masses that form obtuse angles with the chest wall or mediastinum MC in middle and lower chest Calcifications (~5%) and pleural effusions (~8-17%) are uncommon |
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Tracheobronchopathia osteochondroplastica (TPO)
Case findings: Irregular narrowing of the airway with calcification of the lateral walls Idiopathic benign disease of the trachea and major bronchi characterized by multiple submucosal osteocartilaginous nodules Posterior membranous trachea spared DDX: tracheobronchial amyloidosis |
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Tracheobronchial amyloidosis
Case findings: Nodular and irregular narrowing of the tracheal lumen Affects posterior membranous wall Multiple concentric or eccentric strictures and mural nodulation Calcific deposits are frequently present DDX: Tracheobronchopathia osteochondroplastica (does not affect posterior membranous tracheal wall) |
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Pericardial cyst
Case findings: CXR: sharply defined area of increased opacity in the right cardiophrenic angle (arrow) CT: thin walled water attenuation cyst (arrow) Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration: Thymomas Hodgkin’s disease Germ cell tumors Mediastinal carcinomas Metastases to lymph nodes Nerve root tumors |
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Bronchogenic cyst
Case findings: CXR: Round mass (arrow) that displaces the right primary bronchus superiorly RML pneumonia and pleural effusion CT: Cyst with uniform fluid attenuation and an imperceptible wall Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration |
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Lateral thoracic meningocele
Case findings: CT: low-attenuation mass protruding from the enlarged left intervertebral foramen Intrathoracic meningocele is an anomalous herniation of the leptomeninges through an intervertebral foramen or a defect in the vertebral body Associated with neurofibromatosis Features: Sharply defined round, smooth, or lobulated paraspinal masses Enlargement of intervertebral foramina and associated vertebral and rib anomalies or scoliosis Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration |
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Thymic cyst
Case findings: CT: thin-walled water-attenuation cyst (arrow) Sagittal T1: low SI cyst (arrow) in a thymic location Uncommon and represent 1% of all mediastinal masses May be unilocular or multilocular Congenital thymic cysts: Rare and derive from a patent thymopharyngeal duct Acquired thymic cysts: Occur in patients after radiation therapy for Hodgkin’s disease Association with thymic tumor Status post thoracotomy Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration |
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Mature cystic teratoma
Case findings: CXR: large, well-defined mediastinal mass (arrow) CT: heterogeneous anterior mediastinal mass with areas of fat (long arrow), calcification (short arrow), fluid attenuation, and thin soft-tissue septa MRI T1 and T2: mass with a high SI area of fat (arrow), low SI calcification, and a high SI multilocular cyst Cystic mediastinal masses Congenital benign cyst: Bronchogenic cyst Esophageal duplication cyst Neurenteric cyst Pericardial cyst Thymic cyst Meningocele Mature cystic teratoma Lymphangioma Tumors with cystic degeneration |
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Lymphangioma
Case findings: CXR: large mediastinal mass CT: low-attenuation mass (arrow) that extends to all mediastinal compartments Coronal T2: high SI cystic mass with multiple septa (arrows) MC discovered during the first 2 years of life MC in neck and axilla (10% extend into mediastinum) Types of lymphangioma: Simple (capillary) Cavernous Cystic (hygroma), MC type |
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Poland syndrome
Case findings: CXR: hyperlucent left hemithorax CT: aplasia of pectoralis muscle Partial or total absence of greater pectoralis muscle Ipsilateral syndactyly DDX unilateral hyperlucent hemithorax: Swyer-James-MacLeod's syndrome Pneumothorax Poland syndrome Bullous emphysema Endobronchial foreign body Congenital lobar emphysema Pulmonary artery hypoplasia/occlusion (no air trapping evident on expiratory images) Compensatory hyperinflation |
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Empyema necessitans
Case findings: CXR: destruction and fracture of ribs CT: well-defined fluid-filled mass with rim enhancement Spontaneous discharge of an empyema that has burrowed through the parietal pleura to form a subcutaneous abscess Etiology: Tuberculosis Actinomycosis |
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Left upper lobe collapse
LUL collapses forwards Presents no sharp margins on the frontal film, unlike that due to the horizontal fissure on the right Casts a veil like opacity over the left hemithorax, normally more dense towards the apex |
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Aspergilloma (mycetoma)
Case findings: Thin-walled cavity in the left upper zone Homogeneous mass in cavity Air crescent sign: Rim of air in the periphery of a rounded area of consolidation or pulmonary nodule or mass DDX: Aspergilloma Rupture of hydatid cyst Necrotizing pneumonia (invasive pulmonary aspergillosis, pulmonary gangrene) Manifestations of aspergillus: Allergic bronchopulmonary aspergillosis (ABPA) Mycetoma (aspergilloma) Semi-invasive aspergillosis Invasive aspergillosis |
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Hydatid disease
Case findings: Ruptured hydatid cyst in the left lower lobe in the airways and giving rise to the water lily sign (arrows) Parasitic infection: Echinococcus granulosus Echinococcus multilocularis (alveolaris) Air crescent sign: Rim of air in the periphery of a rounded area of consolidation or pulmonary nodule or mass DDX: Rupture of hydatid cyst Aspergilloma Necrotizing pneumonia (invasive pulmonary aspergillosis, pulmonary gangrene) Meniscus or air crescent sign: Communication develops between the cyst and the bronchial tree Air enters between fibrotic lung forming the pericyst and the exocyst, producing appearance of a crescent of air at the periphery of the cyst Water lily sign: Cyst ruptures resulting in an air-fluid level Floating ruptured membrane floats in the residual fluid |
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Bronchopleural fistula
Case findings: Left image shows an air-fluid level normal for the 5th POD Right image taken two weeks later shows a drop in the height of the fluid level highly suggestive of a bronchopleural fistula Connection between the bronchial tree and the pleural space Presence of air in the pleural cavity with an air-fluid level May occur following: Classically after a lung abscess Pulmonary resection Acute bacterial pneumonia Granulomatous infection (tuberculosis or fungal infection) Failure of this ipsilateral shift almost always indicates an abnormality in the postpneumonectomy space, including: Bronchopleural fistula Empyema Hemorrhage Chylothorax Post-pneumonectomy syndrome MC right side, MC in children and adolescents Displacement of trachea and mediastinum towards the side of the pneumonectomy with displacement and herniation of the lung Produces clockwise rotation of heart and great vessels Trachea and left main bronchus are compressed between aorta and pulmonary artery Leads to dyspnea and recurrent left-sided pneumonia |
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Pneumothorax
Case findings: Lucency at left costophrenic angle Deep sulcus sign: presence of a pneumothorax on a supine radiograph of the chest Etiology: Spontaneous pneumothorax: MC rupture of subpleural blebs Catamenial pneumothorax LCH Lymphangioleiomyomatosis (LAM) Emphysema |
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Plombage therapy
Early treatment of TB Collapsing lung by introducing air into the pleural space Extrapleural insertion of a “plombe” to collapse the lung Fat, oleothorax (oil in pleural cavity) Solid paraffin wax Lucite spheres Plastic ping pong balls (1940s) Sponges of inert plastic material Thoracoplasty: anther procedure to collapse lung Several upper ribs were removed Chest cage was pushed toward the mediastinum, collapsing the upper lobe |
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Thymoma
Case findings: Lobulated mass located in prevascular space Mass is of soft tissue attenuation and contains irregular calcifications Arises from thymic epithelium MC cause of a thymic mass Cystic changes are common 30% aggressive invasion through fibrous capsule May have multiple discrete pleural masses (drop metastases) Extent of tumor in pleura may be so great as to mimic a mesothelioma Associated with myasthenia gravis: 15% of patients with MG have thymoma 50% of patients with thymoma have MG |
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Fibrosing mediastinitis
Diagnosis: post-tuberculous chronic mediastinitis Case findings: Right hilar mass containing a large calcification Mass obstructs lumen of RUL bronchus by extrinsic compression induce atelectasis Stenosis of SVC with abnormal opacification of azygos vein (collateral venous circulation) Absence of opacification of anterior trunk of RPA (compressed by mass) Bibrachial venography: stenosis of distal part of SVC Chronic inflammation of the mediastinum which may progress to diffuse fibrosis Histoplasmosis: May be cause of fibrosing mediastinitis Can lead to obstruction of pulmonary vessels, bronchi or constrictive pericarditis Etiologies: Granulomatosis processes MC Histoplasmosis TB, sarcoidosis, Coccidioidomycosis Association with other sites of fibrosis Retroperitoneal fibrosis, Riedel's thyroiditis Orbital pseudotumour Association with immunological disorders SLE, RA, Raynaud's phenomenon Drug-induced Methysergide |
