Anwser,s 12

Anwser,s
Dr :ANAS SAHLE

1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
:http://www.facebook.com/dranas224

Monday, February 04, 2013

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

CXR61

Croup.

Child present with coughtachypneafever

Croup.
• also called acute laryngotracheobronchitis is
due to viral infection of the upper airway by
parainfluenza virus or respiratory syncytial
virus (RSV)


is a sign of
pneumomediastinum CXR62a
seen on neonatal chest
radiographs. It refers to
the thymus being
outlined by air with
each lobe displaced
laterally and appearing
like spinnaker sails.

Sign name is: The spinnaker sign
(also known as the angel wing sign)

CXR63

Sign name is: bulging fissure sign

bulging fissure sign
• The bulging fissure sign refers to lobar
consolidation where the affected portion of the
lung is expanded.
• It is now rarely seen due to the widespread use of
antibiotics.
• The most common infective causative agents are
– Klebsiella pneumoniae
– Streptococcus pneumoniae
– Pseudomonas aeruginosa
– Staphylococcus aureus

CXR64

Name is: paraspinal lines

CXR65

Name is:
Azygous vein

CXR67
Name is: paratracheal "stripe"

CXR68b

Diagnosis is:Allergic bronchopulmonary aspergillosis
(ABPA)

CXR69

Name is: pleural plaques

CXR70

Cardiac patient take anti-arrythmatic drug:
Amiodarone lung

chest clinical cases
A 60-Year-Old Man with
Acute Respiratory Failure
Submitted by and Mental Status Changes
Lokesh Venkateshaiah, MD
Fellow
Division of Pulmonary, Critical Care and Sleep Medicine
The MetroHealth System, Case Western Reserve University
Cleveland, Ohio
Bruce Arthur, MD
Fellow
Division of Pulmonary, Critical Care and Sleep Medicine
Cleveland, Ohio
J. Daryl Thornton, MD, MPH
Assistant Professor
Division of Pulmonary, Critical Care and Sleep Medicine, Center for Reducing Health Disparities
Cleveland, Ohio

History
• A 60-year-old man presented to the emergency department complaining of persistent
right-sided chest pain and cough.
• The chest pain was pleuritic in nature and had been present for the last month.
• The associated cough was productive of yellow sputum without hemoptysis.
• He had unintentionally lost approximately 30 pounds over the last 6 months and had
nightly sweats.
• He had denied fevers, chills, myalgias or vomiting.
• He also denied sick contacts or a recent travel history.
• He recalled childhood exposures to persons afflicted with tuberculosis.
• The patient smoked one pack of cigarettes daily for the past 50 years and denied
recreational drug use.
• He reported ingesting twelve beers daily and had had delirium tremens, remote right-sided
rib fractures and a wrist fracture as a result of alcohol consumption.
• He had worked in the steel mills but had discontinued a few years previously.
• He collected coins and cleaned them with mercury.
• The patient’s past medical history was remarkable for chronic “shakes” of the upper
extremities for which he had not sought medical attention.
• Other than daily multivitamin tablets, he took no regular medications.

Hospital course
• He was initially admitted to the general medical floor for
treatment of community-acquired pneumonia (see Figure 1) and
for the prevention of delirium tremens.
• He was initiated on ceftriaxone, azithromycin, thiamine and folic
acid.
• Diazepam was initiated and titrated using the Clinical Institute
Withdrawal Assessment for Alcohol Scale (CIWAS-Ar), a measure
of withdrawal severity .
• By hospital day 5, his respiratory status continued to
worsen, requiring transfer to the intensive care unit (ICU) for
hypoxemic respiratory failure.
• His neurologic status had also significantly deteriorated with
worsening confusion, memory loss, drowsiness, visual
hallucinations (patient started seeing worms) and worsening
upper extremity tremors without generalized tremulousness
despite receiving increased doses of benzodiazepines.

Physical Exam
• On arrival at the medical ICU, the patient appeared cachectic and dyspneic.
• He was unable to complete sentences.
• His blood pressure was 125/71 mm Hg, heart rate of 122/min, temperature
100 °F, respiratory rate 33/min, and oxygen saturation 77% on room air and
92% on 40% venti-mask.
• At the time of presentation to the hospital he had oxygen saturation of 92%
on room air.
• The heart exam revealed tachycardia but regular rhythm, a normal S1 and S2
and no murmurs, gallops or rubs.
• On auscultation of the lung fields, breath sounds were diminished on the
right side in the upper zone without the presence of adventitious sounds.
The abdomen was benign without organomegaly.
• The patient’s extremities were normal with absence of clubbing or edema.
• He was oriented only to person, and had an inability to pay attention or
remember immediate events.
• He was moving all four extremities with slightly brisk deep tendon reflexes.
• Neck was supple and the pupils were brisk in reacting to light.


Lab
• White blood cell count was 11,000/mm3 with 38% neutrophils, 8% lymphocytes, 18 % monocytes and
35% bands
• Hematocrit 33%
• Platelet count was 187,000/mm3
• Serum sodium was 125 mmol/L, potassium 3 mmol/L, chloride 91 mmol/L, bicarbonate 21 mmol/L,
• blood urea nitrogen 14 mg /dl, serum creatinine 0.6 mg/dl and anion gap of 14.
• Urine sodium <10 mmol/L, urine osmolality 630 mosm/kg
• Liver function tests revealed albumin 2.1 with total protein 4.6, normal total bilirubin, aspartate
transaminase (AST) 49, Alanine transaminase (ALT) 19 and alkaline phosphatase 47.
• Three sputum samples were negative for acid-fast bacilli (AFB).
• Bronchoalveolar lavage (BAL) white blood cell count 28 cells/µl, red blood cell count 51 cells/µl, negative
for AFB and negative Legionella culture.
• BAL gram stain was without organisms or polymorphonuclear leukocytes.
• Blood cultures were negative for growth.
• Sputum cultures showed moderate growth of Pasteurella multocida.
• 2D transthoracic ECHO of the heart showed normal valves and an ejection fraction of 65% with a normal
left ventricular end-diastolic pressure and normal left atrial size. No vegetations were noted.
• Purified protein derivative (PPD) administered via Mantoux testing was 8 mm in size at 72 hr after
placement.
• Human immunodeficiency virus (HIV) serology was negative.
• Arterial blood gas (ABG) analysis performed on room air on presentation to the ICU: pH 7.49, PaCO2 29
mm Hg, PaO2 49 mm Hg.


cxr

Figure 1.2.
(Figure 1.1) Monday, February 04, 2013

Question 1
• As this patient’s acute respiratory failure
worsens, what is the appropriate means to
provide ventilatory support?
• A. Pressure support ventilation
• B. Volume assist-control ventilation with tidal
volumes of 6 ml/kg predicted body weight
• C. Volume assist-control ventilation with tidal
volumes of 12 ml/kg predicted body weight
• D. Noninvasive positive pressure ventilation


discussion
• After admission to the ICU, the patient was noted to be in acute lung injury (ALI), a subset
of acute respiratory distress syndrome (ARDS).
• The diagnosis of ALI requires all three of the following: (a) bilateral pulmonary
infiltrates, (b) a PaO2:FiO2 ratio of ≤ 300 and (c) echocardiographic evidence of normal left
atrial pressure or pulmonary-artery wedge pressure of ≤ 18 mm Hg.
• Low tidal volume ventilation (LTVV), also known as lung protective ventilation, has been
demonstrated to significantly improve mortality in patients with ALI and ARDS .
• In a study conducted by the ARDS Network comparing LTVV to traditional tidal
volumes, patients were placed either on tidal volumes of 12 ml/kg predicted body weight
or 6 ml/kg predicted body weight within 4 hr following randomization.
• Tidal volumes in the 12 ml/kg group were reduced to as low as 4 ml/kg while keeping the
plateau pressure ≤ 50 cm H2O, and tidal volumes in the 6 ml/kg group were reduced to as
low as 4ml/kg while keeping the plateau pressure ≤ 30 cm H2O.
• The trial was discontinued early because of the mortality difference between the two
groups (31% in the 6 ml/kg group versus 40% in the 12 ml/kg group, p = 0.007).
• Ventilator-free days were also significantly higher in the LTVV group.
• While patients with ALI and ARDS can be maintained with pressure-limited or volume-
limited modes of ventilation, only volume assist-control ventilation was utilized in the
ARDS Network multicenter randomized controlled trial that demonstrated a mortality
benefit.
• Noninvasive ventilation has not been demonstrated to be superior to endotracheal
intubation in the treatment of ARDS or ALI and is not currently recommended .

Question 2
• What is the most likely explanation for
his altered mental status?
• A. Alcoholic hallucinosis
• B. Pneumonia and sepsis
• C. Heavy metal poisoning
• D. Frontal lobe stroke


discussion
• This is a case of heavy metal poisoning with mercury.
• The patient used mercury to clean coins.
• Family members who had visited his house while he was hospitalized found several jars of mercury
throughout his home.
• The Environmental Protection Agency (EPA) was notified and visited the home.
• They found aerosolized mercury levels of > 50,000 PPM and had the home immediately demolished.
• Alcoholic hallucinosis is a rare disorder occurring in 0.4 - 0.7% of alcohol-dependent inpatients (5).
• Affected persons experience predominantly auditory but occasionally visual hallucinations.
• Delusions of persecution may also occur.
• However, in contrast to alcohol delirium, other alcohol withdrawal symptoms are not present and the
sensorium is generally unaffected.
• Delerium tremens (DT) occurs in approximately 5% of patients who withdraw from alcohol and is
associated with a 5% mortality rate.
• DT typically occurs between 48 and 96 hr following the last drink and lasts 1-5 days.
• DT is manifested by generalized alteration of the sensorium with vital sign abnormalities.
• Death often results from arrhythmias, pneumonia, pancreatitis or failure to identify another underlying
problem .
• While DT certainly could have coexisted in this patient, an important initial step in the management of
DT is to identify and treat alternative diagnoses.
• Delirium is frequent among older patients in the ICU (7), and may be complicated by pneumonia and
sepsis.
• However, pneumonia and sepsis as causes for delirium are diagnoses of exclusion and should only be
attributed after other possibilities have been ruled out.


Contin-
• Frontal lobe stroke is unlikely, given the absence of other findings in the history or
physical examination present to suggest an acute cerebrovascular event.
• In 1818, Dr. John Pearson coined the term erethism for the characteristic personality
changes attributed to mercury poisoning .
• Erethism is classically the first symptom in chronic mercury poisoning .
• It is a peculiar form of timidity most evident in the presence of strangers and closely
resembles an induced paranoid state.
• In the past, when mercury was used in making top hats, the term “mad as a hatter”
was used to describe the psychiatric manifestations of mercury intoxication.
• Other neurologic manifestations include tremors, especially in patients with a history
of alcoholism, memory loss, drowsiness and lethargy.
• All of these were present in this patient.
• Acute respiratory failure (ALI/ARDS) can occur following exposure to inhalation of
mercury fumes
• Mercury poisoning has also been associated with acute kidney injury .
• Although all of the options mentioned above could possibly contribute to the
development of delirium, only mercury poisoning would explain the constellation of
findings of confusion, upper extremity tremors, visual hallucinations, somnolence and
acute respiratory failure (ALI/ARDS).


Question 3
• The most likely form of mercury intoxication
that could explain this patient’s clinical
picture would be:
• A. Inorganic mercury
• B. Elemental mercury
• C.Organic mercury
• D. Methylmercury


discussion
• Knowledge of the form of mercury absorbed is helpful in the management of such patients, as
each has its own distinct characteristics and toxicity.
• There are three types of mercury: elemental, organic and inorganic.
• This patient had exposure to elemental mercury from broken thermometers.
• Elemental mercury is one of only two known metals that are liquid at room temperature and has
been referred to as quicksilver (.
• It is commonly found in thermometers, sphygmomanometers, barometers, electronics, latex
paint, light bulbs and batteries .
• Although exposure can occur transcutaneously or by ingestion, inhalation is the major route of
toxicity.
• Ingested elemental mercury is poorly absorbed and typically leaves the body unchanged without
consequence (bioavailability 0.01% [13]).
• However, inhaled fumes are rapidly absorbed through the pulmonary circulation allowing
distribution throughout the major organ systems.
• Clinical manifestations vary based on the chronicity of the exposure .
• Mercury readily crosses the blood-brain barrier and concentrates in the neuronal lysosomal
dense bodies.
• This interferes with major cell processes such as protein and nucleic acid synthesis, calcium
homeostasis and protein phosphorylation.
• Acute exposure symptoms manifest within hours as gastrointestinal upset, chills, weakness,
cough and dyspnea.


Contin-
• Inorganic mercury salts are earthly-appearing, red ore found historically in cosmetics and
skin treatments.
• Currently, most exposures in the United States occur from exposure through germicides or
pesticides .
• In contrast to elemental mercury, inorganic mercury is readily absorbed through multiple
routes including the gastrointestinal tract.
• It is severely corrosive to gastrointestinal mucosa (.
• Signs and symptoms include profuse vomiting and often-bloody diarrhea, followed by
hypovolemic shock, oliguric renal failure and possibly death .
• Organic mercury, of which methylmercury is an example, has garnered significant attention
recently following several large outbreaks as a result of environmental contamination in
Japan in 1956 (17) and grain contamination in Iraq in 1972 .
• Organic mercury is well absorbed in the GI tract and collects in the brain, reaching three to
six times the blood concentration .
• Symptoms may manifest up to a month after exposure as bilateral visual field
constriction, paresthesias of the extremities and mouth, ataxia, tremor and auditory
impairments .
• Organic mercury is also present in a teratogenic agent leading to development of a
syndrome similar to cerebral palsy termed "congenital Minamata disease" . February 04, 2013
Monday,

Question 4
• The best way to diagnose mercury toxicity in
this patient is to:
• A. Sample hair for levels of mercury
• B. Measure blood levels of mercury
• C. Measure 24-hr urine levels of mercury
• D. Measure spot urine levels of mercury


discussion
• The appropriate test depends upon the type of mercury to which a patient has
been exposed.
• After exposure to elemental or inorganic mercury, the gold standard test is a 24-
hr urine specimen for mercury.
• Spot urine samples are unreliable.
• Urine concentrations of greater than 50 μg in a 24-hr period are abnormal (21).
• This patient’s 24-hr urine level was noted to be 90 μg.
• Elemental and inorganic mercury have a very short half-life in the blood.
• Exposure to organic mercury requires testing hair or whole blood.
• In the blood, 90% of methyl mercury is bound to hemoglobin within the RBCs.
• Normal values of whole blood organic mercury are typically < 6 μg/L. This
patient’s whole blood level was noted to be 26 μg/L.
• This likely reflects the large concentration of elemental mercury the patient
inhaled and the substantial amount that subsequently entered the blood.
• Mercury levels can be reduced with chelating agents such as
succimer, dimercaprol (also known as British anti-Lewisite (BAL)) and D-
penicillamine, but their effect on long-term outcomes is unclear (22-25).


chest ct cases-11
Dr :anas sahle
http://www.facebook.com/dranas224

HRCT-1

• Give the distribution and pattern of the
nodules in the right lower lobe?
• Centrilobular nodules with tree-in-bud
pattern

• Find the collapsed right middle lobe.
• Find the collapsed lingula.

• Find a row of 3 centrilobular nodules in the
right lung.
• Find 2 examples of tree-in-bud pattern in the
right lung.
• Find a thickened bronchus, consistent with
bronchitis in the right lung.

• This lung from a young child with cystic fibrosis shows the
volume loss and atelectasis (red areas) associated with
bronchiectasis.
• The paler, aerated lung bulges above the areas of collapse.
• This lung did not collapse when it was removed postmortem
as a normal lung would.
• Why would the aerated portions of lung
remain expanded?
• The widespread bronchitis and bronchiolitis
produce variable obstruction of small airways
with mucus and exudate, which trap air.

• Here, the posterior mid lung shows extensive varicose
bronchiectasis, which is similar to that seen in the HRCT
image in the right middle lobe.
• The term varicose denotes dilation as seen in venous
varices.
• When greater dilation occurs, it is referred to
descriptively as cystic bronchiectasis
• Note the loss of parenchyma between the crowded
airways, and the large caliber of the lumen near the
pleural surface, compared to airways in the lower lung.
• Find a bronchiectatic airway.
• Find a normal airway in the lower lung.

• This is a subsegmental bronchus from a patient
with bronchiectasis.
• Describe the structures in the wall.
• Fibrous tissue and inflammation. The cartilage and smooth muscle have
been destroyed.
• Describe the contents of the lumen.
• Purulent exudate
• How does alveolar parenchymal loss occur?
• Chronic peribronchial inflammation gradually replaces alveoli with scar.
• How does airway obstruction occur?
– 1) Mucus and exudate in large airways and
– 2) stenosing mural fibrosis and luminal inflammation of small airways.

Differential diagnosis

• Differential diagnosis of bronchiectasis,
bronchitis, and bronchiolitis on HRCT:
– chronic bacterial or mycobacterial infections,
– cystic fibrosis,
– allergic bronchopulmonary aspergillosis,
– middle lobe syndrome,
– chronic bronchiolitis.
– proximal bronchial obstruction by tumor or
foreign body.

Histologic differential diagnosis:

• chronic bacterial or mycobacterial infections.
• cystic fibrosis.
• allergic bronchopulmonary aspergillosis.
• middle lobe syndrome.
• chronic bronchiolitis.
• proximal bronchial obstruction by tumor or
foreign body.

Diagnosis:

Bronchiectasis with associated adjacent
bronchitis and bronchiolitis.

Diagnostic features

• Diagnostic features of
bronchiectasis, bronchitis, and bronchiolitis
on HRCT:
– Bronchial dilation and wall thickening
– Tree-in-bud pattern
– Centrilobular nodules
– Mosaic perfusion of air trapping (more
later).

Anwser,s 12

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