Payal Kohli, HMS IIIGillian Lieberman, MD

Mr. M: A Case Study of Pulmonary Pathology

Payal Kohli, Harvard Medical School Year IIIGillian Lieberman, MD

September 2004

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Payal Kohli, HMS IIIGillian Lieberman, MD

LateralPACS, BIDMCPAPACS, BIDMC

Mr. M: 33 yo Kenyan M with cough and SOB

Lymphadenopathy

Lymphadenopathy

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Payal Kohli, HMS IIIGillian Lieberman, MD

Mediastinal Lymph nodes

http://www.bartleby.com/107/illus621.html http://rad.usuhs.mil/medpix/medpix.html?mode=tsearch2#top

Patient 2: Lymphadenopathy

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Payal Kohli, HMS IIIGillian Lieberman, MD

Differential Diagnosis for “Hilar Lymphadenopathy”

• Lymphadenitis, infectious

• Lymphoma, lymphosarcoma

• Mets (esp. undifferentiated or small cell ca of lung)

• Sarcoidosis

http://rad.usuhs.mil/medpix/medpix.html?mode=defaultPara-bronchial nodes

Sub-carinal nodes Pre-carinal

PACS, BIDMC

Mr. M: Chest CT with contrast

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Payal Kohli, HMS IIIGillian Lieberman, MD

Sarcoidosis• Multi-system granulomatous

disease• Unknown etiology• Peaks in third decade; F>M• Can also get pleural effusions,

cor pulmonale, mycetoma, infection and pneumothorax

• Clinical, pathological and radiological diagnosis

Stage I: Stage I: LymphadenopathyLymphadenopathy

Stage II: Stage II: LymphadenopathyLymphadenopathy + + parenchymalparenchymal opacityopacity

Stage III: Stage III: ParenchymalParenchymal opacity opacity alonealone

Stage IV:Stage IV:Pulmonary fibrosisPulmonary fibrosis

http://rad.usuhs.mil/medpix/medpix.html?mode=default

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Payal Kohli, HMS IIIGillian Lieberman, MD

Menu of tests for imaging lung in Sarcoidosis

• Plain Film and CT: Staging– hilar lymphadenopathy– parenchymal opacities/fibrotic changes

• MR: mediastinal fat and nodes• Gallium-67 scanning

– direct relationship between number of macrophages in lung during alveolitis and uptake of Gallium-67

– Non-specific, low neg. predictive value, difficult to interpret

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Payal Kohli, HMS IIIGillian Lieberman, MD

Mr. M’s chest CTs with lung windows

3 months after steroid Rx:(Stage II Sarcoid)

traction bronchiectasis, ground glass lungs, consolidation with bubbly

cystic change

traction bronch. consol., cystic change

gr. glass

PACS, BIDMC

6 months later with hemoptysis:Thick-walled cavitary lesion in LUL, internal dependent debris,

adjacent pleural thickening

PACS, BIDMC

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Payal Kohli, HMS IIIGillian Lieberman, MD

• Infection or abscess (bacteria, mycobacteria, fungi, parasites)

• Neoplasms (bronchogenic cancer, lymphoma, mets)

• Pulmonary infarct• Septic embolism• Vasculitidies (Wegener’s granulomatosis)

DDX of cavitary lung lesion

Ryu and Swenson. Mayo Clinic Proc. 2003;78:744-752

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Payal Kohli, HMS IIIGillian Lieberman, MD

Mr. M’s diagnosis: Aspergilloma

• Dependent conglomeration of intertwined fungal hyphae admixed with mucus and cellular debris within a cavity or ectatic bronchus

• Air crescent sign aka Monod’s sign• Pleural thickening

Supine

Franquet et al. RadioGraphics. 200; 21:825-37.

PACS, BIDMC

PronePACS, BIDMC

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Payal Kohli, HMS IIIGillian Lieberman, MD

Saprophytic Aspergillosis

Patient 3: Plain Film Patient 4: Linear Tomogram

Surgical Specimen

Dependent debris

Franquet et al. RadioGraphics. 200; 21:825-37.

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Payal Kohli, HMS IIIGillian Lieberman, MD

Other types of Aspergilloses

Allergic bronchopulmonary(Asthmatics)

Semi-invasive/ Chronic necrotizing(Diabetics, Alcoholics, COPD)

Airway invasive(Immunocompromised/AIDS)

Angioinvasive(Neutropenic)

Franquet et al. RadioGraphics. 200; 21:825-37.

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Payal Kohli, HMS IIIGillian Lieberman, MD

Treatment of Aspergilloma

• Primary: Surgical intervention• Secondary:

– anti-fungal therapy• Systemic Itraconazole• Topical Amphoterecin B (CT-guided)• Limited efficacy

– Bronchial artery embolization for hemoptysis

Sugar, A. “Aspergilloma”. UptoDate. 2004.

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Payal Kohli, HMS IIIGillian Lieberman, MD

Back to Mr. M…

• Presented with cough, SOB sarcoidosis• Developed left upper lobe aspergilloma

left upper lobectomy• Developed right upper lobe aspergilloma

right main bronchial artery embolization• Right upper lobectomy

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Payal Kohli, HMS IIIGillian Lieberman, MD

Mr. M: Another complication…

Pneumothorax with pleural effusion

PA Plain Film

tracheal deviation

blunted costophrenic

angle

Pleural outline

PACS, BIDMC CT w/o contrast PACS, BIDMCpleural efffusion

pneumothorax

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Payal Kohli, HMS IIIGillian Lieberman, MD

Mr. M: other complications…

CT-guided decompression of

pneumothorax

Air embolism to right

posterotemporal lobe

CT DW-MRI

Signal abnormalities in

temporo- occipital region

due to stroke

All images: PACS, BIDMC

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Payal Kohli, HMS IIIGillian Lieberman, MD

Radiological care of Mr. M, a patient with sarcoidosis

Screened and followed with …– Doppler U/S of carotids and femorals to detect for

thrombus formation– MRA of Circle of Willis to detect embolic events– CT of maxillofacial sinuses to evaluate for infection– Routine (monthly) chest CTs and plain films for

staging of sarcoidosis and screening for infections

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Payal Kohli, HMS IIIGillian Lieberman, MD

References

• Franquet T, Muller N, Gimenez A, Guembe P, de la Torre J, Bague S. Spectrum of Pulmonary

Aspergillosis: Histologic, Clinical, and Radiologic Findings. RadioGarphics. 2001; 21: 825-837.

• http://www.bartleby.com/107/illus621.html

• http://rad.usuhs.mil/medpix/medpix.html?mode=tsearch2#top

• Reeder, M. Reader’s & Felson’s Gamuts in Radiology, 4th ed. New York: Springer-Verlag,

2003.

• Ryu and Swenson. Mayo Clinic Proc. 2003;78:744-752.

• Sugar, A. “Aspergilloma”. UptoDate. 2004.

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Payal Kohli, HMS IIIGillian Lieberman, MD

Acknowledgements

Many thanks to…• Damon Soeiro, MD• Erik Stien, MD• Mizuki Nishino, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras, our Webmaster