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.

Diffuse infiltrates in an EMT

This is a 35 year old EMT who presented to HH with severe SOB and hypoxia.  He was feeling well, but the day before admission applied waterproofing aerosol to his boots outside in a well ventilated area for 20 minutes.  The next day he was SOB and came to the emergency room.  He was a smoker but did no elicit drugs.  He revovered over the next 24 hours.  He has no known systemic disorder

What is the cause of the lung injury?

Benign lung nodule

This 67 year old female had severe COPD.  She was found to have lung nodules on her chest CT scan. There was low grade uptake on PET scan.  She underwent a needle biopsy that was negative for malignancy, but sustained severe bleeding and this required transfer to SMH .  Because of severe lung disease, no open biopsy was done.  Approximately 1 year later, she had an open lung biopsy in California and a benign abnormality was discovered. 

Please contribute to the differential diagnosis of these abnormalities.

Hypoxia in an elderly male

  

Recently, there was a chest conference pertaining to the CT in Langerhan’s cell histiocytosis. 

This 81 year old male presented to the emergency room with severe hypoxia.  He had been a long-time smoker, and had been short of breath over the last year.  A CT scan was done and images are below. 

Do you think the CT scan is most compatible with 1) emphysema 2) idiopathic pulmonary fibrosis 3)pulmonary fibrosis with emphysema 4) end-stage langerhan’s cell histiocytosis 5) end stage sarcoidosis?

Chest Conference 3/5

This case was presented Wed 3/5 at chest conference.  This was a 70 year old female who presented with 3 months of progressive wheezing and shortness of breath.  PFT’s showed a typical upper airway obstruction pattern.  Examples of CT and bronchoscopy are above (click on image to enlarge)

Laryngealtracheal papillomatosis can involve either trachea or more commonly the larynx.  There is a bimodal age distribution and  can occur in childhood (<5 y/o) or adulthood (typically 20-30 years. They are closely associated with HPV 6 & 11 virus, which can be acquired during birth or later in life with oral contact .  HPV proteins are expressed exclusively in squamous epithelial cells.  Squamous papillomatosis can become malignant, but rarely.  Removal often results in recurrence, the resection removes the active infection but not the latent virus DNA.  This patient was treated with Heliox and laser removal with good results.

The abnormality can occur in the lung parenchyma with cavitation,and this has a poor prognosis.