Anwser,s6

Anwser,s
Dr :ANAS SAHLE
1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
4. MRCP exam.
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Saturday, December 15, 2012

chest xr cases
Dr :anas sahle
http://www.facebook.com/dranas224

Cxr-18

Diagnosis is:??

Cxr-18

Diagnosis is:??

S Curve of Golden
When there is a mass adjacent to a fissure, the fissure takes the shape of an "S".
The proximal convexity is due to a mass, and the distal concavity is due to atelectasis.
Note the shape of the left oblique fissure in the lateral view below.
This example represents a LUL mass with atelectasis.

Cxr-19
SIGN NAME IS:…

Cxr-19
SIGN NAME IS:…
Wedge Shaped
This case Density
represents a
pulmonary infarct.

Wedge Shaped Density
The wedge's base is pleural and the apex is towards the hilum, giving a triangular shape.
You can encounter either of the following:
Vascular wedges:
Infarct
Invasive aspergillosis
Bronchial wedges:
Consolidation
Atelectasis

Cxr-20
Acinar or interstitial nodules?
Name DDX:…….

Cxr-20
Acinar Nodules
DDX:
1. ALVEOLAR CELL CARCINOMA
2. PULMONARY EDEMA
3. ALVEOLAR PROTEINOSIS

Cxr-22

this sign name is:….

Cxr-22

this sign name is: Inverted Comma
This is an example of an azygous lobe

Cxr-23

Mass density is seen in the lateral view, but not in the PA view .
This finding suggests a chest wall or external problem.
In the film below, an amputated shoulder is projecting as a mass.

Cxr-24

DDX:…
1. Dilated esophagus
2. Paravertebral
nodes
3. Osteophytes
This example is due to
paravertebral nodes.

CXR-25

Name which anatomic lobe affect when silhoutte sign obscured :
ABCDEF

CXR-25
Silhouette Adjacent Lobe/Segment
Right diaphragm RLL/Basal segments
Right heart margin RML/Medial segment
Ascending aorta RUL/Anterior segment
Aortic knob LUL/Posterior segment
Left heart margin Lingula/Inferior segment
LLL/Superior and medial
A: Ascending aorta Descending aorta
segments
B: Left heart margin Left diaphragm LLL/Basal segments
C: Left diaphragm
D: Aortic knob
E: Right heart margin
F: Right diaphragm

chest clinical cases
A 27-Year-Old With a Non-
Resolving Cavitary Lung
Lesion
Submitted by
Lokesh Venkateshaiah, MD
Fellow
Division of Pulmonary, Critical Care and Sleep Medicine
Case Western Reserve University
Cleveland, Ohio
J. Daryl Thornton, MD MPH
Assistant Professor
Division of Pulmonary, Critical Care and Sleep Medicine
Case Western Reserve University
Cleveland, Ohio

History
• A 27-year-old man presented to the pulmonary clinic for evaluation of a non-resolving lung
cavity.
• Four months earlier, he had been diagnosed with pulmonary tuberculosis and was started on
four-drug anti-tuberculous directly observed therapy.
• A PPD placed at that time measured 22 mm of induration.
• During the pulmonary clinic visit, the patient stated that over the last year and a half he had a
cough occasionally productive of minimal blood-streaked sputum.
• He had denied other symptoms including nocturnal diaphoresis, anorexia, weight loss, or fevers.
• The patient’s past medical history was remarkable for an abnormal chest radiogram that was
noted one and a half years ago and one episode of malaria.
• Other than his recent antituberculous therapy he took no regular medications.
• He smoked one-half pack daily for the past 12 years.
• He occasionally snorted cocaine but did not use alcohol or other recreational drugs.
• He emigrated from Malaysia to the United States 8 months ago.
• He was originally from Burma but was a refugee in Malaysia.
• It was in Malaysia that he was noted to have an abnormal chest radiogram.
• He underwent additional investigations while there but was not given a diagnosis nor treatment.


Physical Exam
• The patient appeared comfortable and was in no acute
distress.
• Vital signs were unremarkable.
• The cardiac exam demonstrated regular rate and rhythm, a
normal S1 and S2, and no murmur, gallop or rub.
• Breath sounds were equal bilaterally and absent of
adventitious sounds.
• The abdomen was soft and without organomegaly.
• The patient’s extremities were without clubbing or edema.
• There was a scar on the left upper arm from a prior BCG
injection.
• No other skin lesions were noted.


Lab
• White blood cell count was 10,000 per mm3 with
66% Neutrophils, 14% Lymphocytes and 12%
eosinophils
• Hematocrit 49%
• Platelet count was 309,000 per mm3
• Urea nitrogen was 12 mg /dl, and serum
creatinine was 0.7 mg/dl
• Liver function tests were within normal limits
• Stools and sputum for ova and parasites were
negative
• Sputum for AFB times five was negative

Chest computed tomography
4 months prior to current presentation


at presentation
(4 months following initiation of antituberculous therapy)


Question 1
• What is the diagnosis?
• A. Pulmonary tuberculosis
• B. Acute Bronchitis
• C. Paragonimiasis
• D. Schistosomiasis


• Cysts for Paragonimus were identified on BAL and transbronchial biopsy.
• Paragonimiasis is caused by lung flukes of the genus Paragonimus.
• There are 43 species of Paragonimus, 12 of which infect humans.
• Paragonimus westermani is the most prevalent, especially in eastern and Southeast Asia.
• Infection with these organisms occurs worldwide but predominantly in several parts of Central
and South America, West Africa, and Asia (1).
• In the United States, the disease is diagnosed most commonly in immigrants from endemic
countries (2).
• Endogenous infections do occur and usually are caused by Paragonimus kellicot mainly in the
midwestern and eastern United States (3-6).
• Pulmonary tuberculosis is less likely given several negative sputum AFB stains and cultures.
• Alveolar lavage by bronchoscopy elso exhibited negative AFB stain and culture.
• In addition, the cavitation worsened on computed tomography despite receiving multidrug direct
observed therapy.
• Acute bronchitis is not a common cause of pulmonary cavitation.
• Pulmonary manifestations of chronic schistosomiasis are generally found in patients with a heavy
infectious burden and significant clinical symptoms.
• Schistozome eggs may embolize from the liver to the pulmonary circulation where they may lead
to granulomatous endarteritis, pulmonary hypertension, and cor pulmonale.


Question 2
• How do humans acquire Paragonimiasis?
• A. Inhalation
• B. Ingestion
• C. Innoculation
• D. Inconclusive


life cycle


Question 3
• What is the drug of choice in the treatment
of Paragonimus westermani?
• A. Peptobismol
• B. Cipro
• C. Praziquantel
• D. Albendazole


Treatment
• Praziquantel is the drug of choice to treat
paragonimiasis.
• The recommended dosage of 75 mg/kg per day
orally, divided into 3 doses over 2 days has
proven to eliminate P. westermani in adults and
children .
• Praziquantel should be taken with liquids during a
meal.
• Patients with chronic empyema due to
paragonimiasis may require decortication in
addition to anthelmintic treatment .

chest ct cases-5
Dr :anas sahle
http://www.facebook.com/dranas224

HRCT-1
• What is the major abnormality in this case?
• a) Linear opacities
• b) Nodules
• c) Consolidation
• d) Ground-glass opacity
• 2. Which lung is involved?
• a) Left
• b) Right
• c) Both

HRCT-1

• What is the distribution of the lesions?
• a) Bronchovascular interstitium
• b) Interlobular septa
• c) Centrilobular region
• d) Pleura

HRCT-1

• Find multiple, connected, thickened
interlobular septa in the right lung.
• Find an example of thickened bronchovascular
interstitium in the right lung.
• Find 2 examples of polygonal lobules with
centrilobular nodules in the right lung.

HRCT-2

• Find the thickened fissural pleura in the right
lung.
• Find 2 lobules with thickened interlobular
septa and centrilobular nodules in the right
lung.
• Find an example of thickened bronchovascular
interstitium in the right lung.

Differential diagnosis

• Differential diagnosis of thickened
bronchovascular, interlobular septal, and
pleural interstitium on HRCT:……..

Differential diagnosis
• Differential diagnosis of thickened
bronchovascular, interlobular septal, and
pleural interstitium on HRCT:
• Lymphangitic tumor,
• Lymphoma.
• Kaposi's sarcoma.
• edema.
• The uni-laterality would be very unusual for
Kaposi's sarcoma or edema.

Diagnosis

Lymphangitic tumor

Summary
Summary of diagnostic features of lymphangitic tumor on
HRCT:
• Thickening of
• bronchovascular,
• interlobular septal,
• centrilobular, and
• pleural interstitium
• Smooth or nodular thickening
• Lack of architectural distortion
Comment:
• Unilateral lymphangitic tumor is most commonly seen in
cases of primary pulmonary adenocarcinoma, as in this
case.

MRCP EXAM
Respiratory

12/15/2012

Q1
• Regarding community acquired pneumonia
in infancy:
A -Streptococcus pneumoniae is the most
common pathogen.
B- It may be caused by Staphylococcus aureus.
C- Ciprofloxacin is an appropriate treatment if
blood cultures are negative.
D- Bordatella pertussis infection is usually mild.
E- It may be caused by mycoplasma urealiticum.

12/15/2012

A1
• Regarding community acquired pneumonia
in infancy:
A -Streptococcus pneumoniae is the most common
pathogen. (False)
B- It may be caused by Staphylococcus aureus.
(True)
C- Ciprofloxacin is an appropriate treatment if blood
cultures are negative. (False)
D- Bordatella pertussis infection is usually mild. (False)
E- It may be caused by mycoplasma urealiticum.
(True)
12/15/2012

Q2
• The following are true of cystic fibrosis:
A -Infertility in men is a result of testicular atrophy.
B- In children under one year of age the commonest
cause of pneumonia is Staphylococcus.
C -10% of patients will not require pancreatic enzyme
supplementation.
D -In neonates 10 - 10% present with meconium
ileus.
E -In the school age child, it usually presents with
hepatic fibrosis.


A2
• The following are true of cystic fibrosis:
A -Infertility in men is a result of testicular atrophy. (False)
B- In children under one year of age the commonest
cause of pneumonia is Staphylococcus. (False)
C -10% of patients will not require pancreatic enzyme
supplementation. (True)
D -In neonates 10 - 10% present with meconium
ileus. (True)
E -In the school age child, it usually presents with hepatic
fibrosis. (False)


Q3
• The following are recognised complications
of foreign body inhalation:
A- Pulmonary abscess
B- Asthma
C- Angioneurotic oedema
D- Hyperinflation of the affected lung
E- Hyperinflation of the opposite lung


A3
• The following are recognised complications
of foreign body inhalation:
A- Pulmonary abscess (True)
B- Asthma (False)
C- Angioneurotic oedema (False)
D- Hyperinflation of the affected lung
(True)
E- Hyperinflation of the opposite lung
(True)

Q4
• Which of the following statements are true of
childhood asthma.
A- over 90% of patients show exercise-induced
bronchoconstriction
B- hypercapnia is the first physiological
disturbance in status asthmaticus
C- infants are unresponsive to bronchodilators
D- spontaneous cure occurs before adolescence
E- cough may be the only symptom


A4
• Which of the following statements are true of
childhood asthma.
A- over 90% of patients show exercise-induced
bronchoconstriction (True)
B- hypercapnia is the first physiological disturbance
in status asthmaticus (False)
C- infants are unresponsive to bronchodilators
(True)
D- spontaneous cure occurs before adolescence
(False)
E- cough may be the only symptom (True)


Q5
• Regarding inhaler devices:
A- Metered dose inhalers can usually be used
from the age of about 7 years.
B- The Spinhaler requires co-ordination of device
actuation with inhalation.
C- The Turbohaler can usually be used from
about 3 years of age.
D- Salbutamol can be used with the Nebuhaler.
E- A face mask can be attached to a spacer, so
that it can be used in infants.


A5
• Regarding inhaler devices:
A- Metered dose inhalers can usually be used from
the age of about 7 years. (False)
B- The Spinhaler requires co-ordination of device
actuation with inhalation. (False)
C- The Turbohaler can usually be used from
about 3 years of age. (True)
D- Salbutamol can be used with the Nebuhaler.
(False)
E- A face mask can be attached to a spacer, so
that it can be used in infants. (True)


Q6
• Concerning Cystic Fibrosis:
A- There is a carrier frequency of 1/220 in the
general population.
B- A sibling of an affected individual has a 2/3
chance of being a carrier.
C- It can usually be diagnosed antenatally in a
family with a surviving affected member.
D- Linkage disequilibrium probes may be useful
in epidemiological studies.
E- In suspected cases, the sweat test is the most
appropriate first investigation.


A6
• Concerning Cystic Fibrosis:
A- There is a carrier frequency of 1/220 in the
general population. (False)
B- A sibling of an affected individual has a 2/3
chance of being a carrier. (False)
C- It can usually be diagnosed antenatally in a
family with a surviving affected member. (True)
D- Linkage disequilibrium probes may be useful
in epidemiological studies. (True)
E- In suspected cases, the sweat test is the most
appropriate first investigation. (True)


Q7
• Hypoxaemic respiratory failure (Type I):
A- Can be caused by respiratory muscle
weakness and fatigue.
B- Is found in mountain sickness.
C- Can lead to pulmonary hypertension.
D- Can lead to CO retention if treated with
2

100% oxygen.
E- Can lead to ventricular failure.

A7
• Hypoxaemic respiratory failure (Type I):
A- Can be caused by respiratory muscle
weakness and fatigue. (False)
B- Is found in mountain sickness. (True)
C- Can lead to pulmonary hypertension.
(True)
D- Can lead to CO retention if treated with
2

100% oxygen. (False)
E- Can lead to ventricular failure. (True)


Q8
• Regarding idiopathic primary pulmonary
haemosiderosis:
A- It is inherited as an autosomal recessive.
B- The absence of digital clubbing is usual.
C- Fever is generally absent.
D- Patients usually have associated
polycythaemia.
E- There is often immunoglobulin of
complement deposition in the histology of
lung biopsies.


A8
• Regarding idiopathic primary pulmonary
haemosiderosis:
A- It is inherited as an autosomal recessive. (False)
B- The absence of digital clubbing is usual. (False)
C- Fever is generally absent. (False)
D- Patients usually have associated polycythaemia.
(False)
E- There is often immunoglobulin of complement
deposition in the histology of lung biopsies. (False)


Q9
• Which of the following may cause
pulmonary hypertension?
• A- coarctation of the aorta
• B- pulmonary stenosis
• C- patent ductus arteriosus
• D- kyphoscoliosis
• E- schistosomiasis


A9
• Which of the following may cause
pulmonary hypertension?
• A- coarctation of the aorta (False)
• B- pulmonary stenosis (False)
• C- patent ductus arteriosus (True)
• D- kyphoscoliosis (True)
• E- schistosomiasis (True)


Q10
• Frequent episodic asthma:
• A- Is suffered by 42% of all children with
asthma.
• B- Is defined as an attack rate of ever 2-4
months.
• C- Should be treated with inhaled regular
prophylactic therapy, such as inhaled steroids.
• D- Is characterised by normal growth rate.
• E- Usually requires a burst of oral steroids to
bring under control.


A10
• Frequent episodic asthma:
• A- Is suffered by 42% of all children with asthma.
(False)
• B- Is defined as an attack rate of ever 2-4 months.
(False)
• C- Should be treated with inhaled regular
prophylactic therapy, such as inhaled steroids.
(True)
• D- Is characterised by normal growth rate.
(True)
• E- Usually requires a burst of oral steroids to bring
under control. (False)

Comments:
• Types of chronic asthma include:
• Infrequent episodic asthma: affects 75% of asthmatic children, with
fewer than 4 episodes per
• year. Intermittent bronchodilators are given.
• Frequent episodic asthma: 20%, symptoms 2-4 weekly. Low dose
inhaled prophylactic therapy
• plus intermittent bronchodilator.
• Persistent asthma: 5%, high dose inhaled prophylaxis plus
intermittent bronchodilators ± longacting
• bronchodilators such as salmeterol. These children need regular
monitoring in an asthma
• clinic and recording of growth and asthma diary.
• Exercise-induced: pre-exercise bronchodilator. The British Asthma
Society Guidelines have
• recently been updated (1997), and you are strongly advised to
familiarise yourself with the step
• up and step down approach.


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