Granuloma or not?

This is a 47 year old healthy male who had a chest radiograph for a chest injury.  A nodule was seen in the LUL, and a CT was done.  He does not smoke, nor had any exposure history.  The CT images are shown.  Does this require biopsy or is this a granuloma?  It was not present on a CXR 5 years ago.

Treatment for a giant lung bulla

This is a 22 year old female with no prior respiratory complaints.  She devloped a bronchitis in February and May, 2008 and had a CXR that suggested bullous disease in the RUL.  PFT’s showed normal spirometry and the diffusion capacity was 89% predicted.  She had no respiratory illness as an infant.

Her CT scan showed the following

Which of the following would you recommend?

1) Leave the bulla alone, no Rx recommended, inform to go to ED with SOB or pain

2) Recommend Scuba diving lessons to utilize hyperbaric conditions to shrink the bulla

3) Refer for an experimental endobronchial valve to deflate the bulla

4) Refer to thoracic surgery for surgical bullectomy

5) Insert a Heimlich valve to permit deflation of the bulla through chest wall

I include a reference regarding 1 way valves:valve

SOB and increasing infiltrates in a 49 year old

This 49 year old male had been healthy but presented with increasing SOB. Below are the radiographs in the first 6 days in the hospital

A CT was done.  Two representative images are below

The CT shows a sinus of valsalva aneurysm that is nearly completing obliterating the LA cavity approximately 4 cm, causing a pulmonary venous obstruction. See the enclosed echo report from SMH and a brief reference.  echo-report-s-of-v  s-of-v-cardiolgy

While I could find reports of S of V aneurysm causing Ra-RV inflow obstruction, I could not find a similar case of a LA obstruction as in this presentation.  There are 3 sinuses of Valsalva, so it likely is that one is more susceptible to aneurysm formation but that is my own speculation. 

34 year old female with SOB and abnormal CT

This 34 year old female presented for evaluation with 2 months of increasing shortness of breath, chest tightness and cough.  There was minimal sputum production, but she is uncomfortable at night and had to sleep with 2 pillows.  Wheezing had been present but she did not respond to steroids, albuterol or Symbicort. Her lab data was normal except for a positive mono test.  She was not exposed to any aerosols.  She is a non-smoking, non-drug using female with 2 children living in a rural enviroment.

The CT images are shown:

What are possible diagnoses and how would proceed at this time

Hypoxia in a 50 year old female

This patient arrives with hypoxia despite supplemental oxygen and this radiograph.  Why do you think the film is abnormal and what is the diagnosis?

Ground glass infiltrates

clinical-practice-essay

 

 

 

The ground glass infilitrates were caused by alveolarseptal amyloidosis.  The CT showed a uniformity of ground glass infiltrates, without a mosaic pattern.  The pathology images above include H&E, congo red and crystal violet stains which are typically used to confirm the diagnosis.  The fibrils were also  birefringent but this could not be photographed.  These were samples obtained by transbronchial biopsy.

 This case was used as a clinical vignette for the 2nd year medical students.  Above is the paper written by Nicholas Braus (click on the clinical-practice-essay icon) which is an excellent review of the pathophysiology of this disorder.  I invite you to read it.

Air in the pleural space

 

 

 

This patient is a 67 year old female who had a chronic right pleural effusion.  A thoracentesis in March did not reveal a cause.  She presented in May to HH with a pain in her left chest and increased sputum production for 2 weeks. A CT scan was done.  What do you think was responsible for the air in the pleural space?

Diffuse Ground glass infiltrates

This is a 57 year old black female who had been a smoker but stopped 1 yr ago . She complained of increasing shortness of breath over 1 year.  She had undergone PFT’s that showed reduced FVC (59%) predicted and FEV1 (72% predicted).  Her total lung capacity was 71 % predicted.  She was unable to do a diffusion capacity.  The intial chest radiograph was read as normal.  Representative images from her CT scan are above

Do you think this is an abnormal scan? Would you perform a diagnositic procedure? If abnormal, suggest a diagnosis compatible with the CT scan.

 

Holes in the lung

 

This is a 55 year old female who has sustained 2 pneumothoracies and had bilateral pleurodesis.  Otherwise she is mildly short of breath.  PFT’s show an FEV1 of 69% predicted an FEV1/FVC ratio of .50.  Her DlCO is 79% of predicted.  She has not smoked and the alpha-1 level is normal

Please offer a differential diagnosis

 

Nodules that bleed

The prior benign nodule case was nodular amyloidosis.  Please read about the risk of bleeding and nodular amyloidosis under the case comments.  One of the DDx was an AVM  I include a recent patient with an AVM that was diagnosed many years ago and embolized recently.  The patient had some TIA’s which is a risk as is brain abscess.

Can one of the fellows write a brief review of sclerosing hemangiomas and find an image for me to publish? That was another popular dx.  LL had nodular amyloidosis in her DDx.