The most likely diagnosis is C. Silicone pulmonary microembolism

Anwser,s
Dr :ANAS SAHLE
1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
4. Collicum exam.
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Saturday, December 08, 2012

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

Cxr-11

Diagnosis is:??

Cxr-11

Diagnosis is:
PANCOST
TUMOR

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-13
This sign name is:?

Cxr-13
This 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)

Cxr-14
This sign name is:?
DDX:…….

Cxr-14
This sign name is:?
Crossing Mid-line
When 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. Cavities
2. Pleural space: Hydropneumothorax
3. Bowel: Hiatal hernia
4. Esophagus: Obstruction
5. Mediastinum: Abscess
6. Chest wall
7. Normal stomach
8. Dilated biliary tract
9. Sub diaphragmatic abscess

Cxr-16
Differential diagnosis for
this sign is:……..

Cxr-16
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 Extrapleural Sign
5. Equal length and width in early stages

Cxr-16
DDX:
Chest wall lesions Rib
Mets
Callous
Hematoma
Plasmacytoma
Parietal pleura
Mesothelioma
Metastatic masses
Extrapleural Sign
Intercostal 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 disease
Posterior mediastinal masses
Hiatal hernia
Left lower lobe disease
Descending aorta
This is an example of an aorta aneurysm.

chest clinical cases
A Trans-sexual with Acute
Dyspnea and Diffuse
Infiltrates
Submitted by
Misbah Baqir, MD
Senior Fellow
Mayo Clinic
Rochester, MN
Alvaro Velasquez, MD
Staff Physician
Divison of Pulmonary, Allergy and Critical Care Medicine
Emory University School of Medicine
Atlanta, GA
Octavian C. Ioachimescu, MD, PhD
Staff Physician
Division of Pulmonary, Allergy and Critical Care Medicine
Emory University School of Medicine, Atlanta VA Medical Center
Atlanta, 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


DISCUSSION
This 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-4
Dr :anas sahle
http://www.facebook.com/dranas224

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

• Find 2 centrilobular nodules.
• Find an area of partially confluent, lobular
consolidation.
• Find an area of homogeneous, mass-like*
consolidation.

HRCT-3

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

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-2

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

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

Collicum EXAM
Respiratory

12/8/2012

A1
-A
-B
pseudobulbar palsy -C
bronchoscopy -D
recumbent position -E

A2

A

B
Intravenous fluids C
Tracheal suction D
Antibiotic E

A3
•

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

A4
Amoxicillin and clavulanate potassium

Moxifloxacin -A
O -B
O -C
-D
-E

A5

-A
-B
BMI -C
FEV1 -.D
-E

A6

TNF

COPD .A
.B
.C
HANTAVIRUS .D
SARS .E

A7
:sputum Gram stains
and cultures
.A
.B

.C
ICU .D
.
.E
39

A8
•
mycoplasma
.A
azithromycin .B
.C
.D
.E

A9
P. Aeruginosa
.A
.B
COPD .C

.D
Tazobactam and Piperacillin sodium : .E
.

A10
:Loeffler's syndrome •
.A
eosinophilic pneumonitis .B
.C
.D
. Hepatomegaly .E

A11
: •
Multiple .A
myeloma
.B
.C
.D
.E

The most likely diagnosis is C. Silicone pulmonary microembolism

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The most likely diagnosis is C. Silicone pulmonary microembolism