apid review - society of radiological technologists 2007-...

APID REVIEW

SHAHID HUSSAIN

SHERIF A. A . LATIF

ADR IAN D. HALL

Rapid Review of

Radiology

Shahid Hussain MA, MB, BChir, MRCP, FRCR

Consultant Radiologist Heart of England NHS Foundation Trust, Birmingham) UK

Sherif Aaron Abdel Latif MB , ChB, MRCS, FRCR Consul tant 1~1d iologist

Dudley Group of Hospitals NHS Foundation Trust, West Midlands, UK

Adrian David Hall MB , ChB , MRCP, FRCR Consultant Radiologist

Dudley Group of H ospitals NHS Foundation Trust, West Midlands, UK

MANSON PUB LISHING ----------

Dedications

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Contents

!'rdJ.cc

Contri butors

,\bb,n; .I;o",

G,'nnJI Imrodllcl ion

Ch'l'tcr I - ChC51 1"'.ginS

CI,.ptcr 2 - ,\bdomin.1 I""sing

Ch'l'tcr 3 - Centr.] :-l"<ry"". Sr.t""" He,d .10<1 Ncc~ I Ill.g; 11\;

ell'plcr'; - " lll " \ll",kdct~ 1 Inug;nll

CII'I"'-' 5 - I"cd; .,,;,· Imag;ng

GII.!,"-' 6 - 1I,.,.j, l",agi"l1 b.y /~"frSllJr /trill l .. ,/",n,

Furth,',lk.ding

I min of ])illl:,,,,,,i.1 ]); ')\"""'$

Gener.1 ]n,kx

5

o , II

71

Ii' 205

2H9

331

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•

Preface

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Contributors

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Abbreviations ,~

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d~'h,-It"."'i .m i", 1'"'""_"""' "oJ

Abbreviations

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"·U in'",',", ," ' "m" .... SAH ,",,,, .. -f>,.,OJ hKn"..,tuj\<

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~ 11U:; P "'.g""" "''''''>oX, TIPS """i"I"'" ;"""""'r"" f"""'~I"" "' '' ,f>o~ .. ,~, "" '" """",' "'~')' oJo",,,

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0.' ,.",,,,,,h ,;,~ '·HL " .. H .. "d-u"d.o" 'l,oJroon< OK" "<"""''ll,n" ~"""")" ' ·SI' ' . n'ri<ul . .... r"l J.r."

,

GENERAL INTRODUCTION

This book has been written primarily for senior radiology ITJinces preparing for final radiology exams and in particular fo r trainees studying for the Fellowship of [he Royal College of R3diology. With Ihis in mind, the cases presented herewith have been presented in the exact manner that the cases are presented in the Ro}'al College of Radiology FRCR 2B exam. In the exam, long cases and viva cases are presented with a very minimal bur highly relevant history and the required response is expected to be presented in a particular way. This format of reporting' involves giving a Description/ Interpretation of the images; Diagnosis; Differential Diagnosis; and advice on Furrhcr Management. We have laid Ollt the answers here in exactly this manner and have included a Discussion [Q give in depth further information about each condition which wi ll enable the sntdent to answer any qucstions directed to him or her in the viva situation, By tollowing the RCR exam formal , thc candidate should be ideally prepared for t his e.l:am and for [he future as a Consultant Radiologist.

FILM TECHNIQUE Whatever the imaging modality, the radiologist interprets images using all the infonnation and clues available, to prod uce a differential diagnosis and/or advise on further investigation and management. Above all else, this mUSt be done in a SAFE manner, and this often requires one [Q be systematic in approach. Secondly, this process must be done in a SENSIBLE manner - it is easy to quote endless lists of differential diagnoses but if these are not refined for each individual case, the r.:tdiologisr's input is of little value.1l1e following discussion concentrates in particular on performing these tasks in the examination viva scenario. However, much of the advice is applicable to everyday practice [Qo, in particular the emphasis on a safe and sensible approach.

TYPES OF FILM The rypes of film one may enCounter in an exam/viva arc as fo llows:

The ' Aunt Minnie' There arc certain disorders that have a characteristic appearance on imaging that allows one to make an instant 'Spot diagnosis'. It \\~Il be assumed the candidate has come across it before, and thus t he best preparation here is

exposure to as many ofthese cases as Ix>ssible. Radiological atlases and film libraries provide ready access ro many of these classic cases, which can then be committed to memory. You can prepare a ready-made description of these cases for rhe viva. Ifro\! arc sure of the diagnosis, dispatch the film promptly with your preprepared 'speech' so that you can progress to the next case as soon as possible. Of course there may be 'Aunt Minnie' cases that yOll haven't secn and rhis may present a problem, Such cases arc often not amenable to working out the diagnosis - you either know it or you don' t . The only thing ro do is be methodical in your analysis and description of the findings so that at the very least you can suggest whether you feci an abnormali ty is li kely 10 be lo ngstanding and benign or orhenvise, and make appropriate suggestions on how you would proceed.

The 'test of observation' Here, there is an abnormality prescnt that once seen, may wclllcad to an easy d iagnosis. The abnormality is subtle or hidden however, such that it tests the candidate's perception and approach [Q a case. Perceptual abi lity, however, is variable, not only between people bur also in the same obscn'er on diflcrcllt days (this is particularly [rue in examinat:ions where anxiety levels arc high). You must therefore be systematic in analysing each film if there is no ob\'ious abnormality [ 0 sec on firsr inspection. There arc mallY diflerent s}'srcmatic approaches and it is beyond [he scope of this discussion to be morc prescriptive. Howcver, make sure you haye a system and usc it. Moreover, describe the process you are going through aloud in the viva so that the examiner knows that you arc practising safe radiology.

The 'jigsaw puzzle' This type of case presents several findings that once identified and considered together, lead to a specific or differential diagnosis. This nOt only tCSts perceptual skill and systematic approach, but also the abili ty ro mentally 'cross-reference' se\'eral diflcrential diagnosis lis ts for the various abnormalities identified , to find thc 'best fit' diagnosis. Whenever producing a differential diagnosis in an examination or real life, it is \'ital to produce a sensible list, not just a recital oflong lists learnt from books. To do this, you must use all clues available from the clinical histOry and film, and combine this information with knowledge of the incidence of each possibility in a given patient population.

•

Generalln1roduetion

Th. ' di.<1.1. '""", "" m,nr .~",."", I ,><I.~".i<,1

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AN ALYSING THE CASE A, ,1, .. Jy 'mph,,",d. h,,~ . 'p" " of ,,,>l)'l~"" . 11 ')1"" uf r~m, MOl< .... ,." ><I, ;,:, on f""~~k '<'r""""'" ~'I I>< ~i""., '''nl><, '"'r'" "fi>.l"".",~

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PRESENTING THE CASE W",," r"""""'s "")' , .. 1""1"" '~m in ,n.,,,,,, ,-..,,' "'r"n ",h,,~-.I p<><lk,. ,I>< 'W"»<h "",".1 I>< ,"" .,,'" '1'" Ito)'>l <:oI"u orkoJ,>I"I'r 10" W''''' ~u...J_, "" 'h< "'" 0"'''' '''''''' ,h .. "'r"~' In ' I>< ~ '"" ,',.. ,I' ~'. '" ,,"~I .. " .00 ' hD n .. ~., h,,~ I"",,"t<d II" ... n " "'n hooL ~~" b'~lly "" ..... S .. ' h' r~n', 1""""" '"'' D. ,c';pl;on R,h.n, ..... i',,·, '0.1 ",,<li,', ,l<.! .... "I'''>l ""d.,f' i". 'I"" .... " mOIl,,,,,. ,,'mm"" ."g ,I>< ".01.'>1' " ,I>< ,,~, ,,( ,I>< ,x...,'irtion.

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A.k.,S q'''" .... of th< "~nin<, to I><lp '""~"'" ,h< Iitm ~ "",.Jly "'''r"bIt, 00' Oftly .Ii" T"" ~.w m..x. '''o,iJ,,,,J ."'_" '"' •• ',l" f~", ,"J h", ,;,h" "O<"J """' , ....... r,i>I>"' ",oJ.: ;. 'k" tit., "'" ..... ", ... 1), ><dilf fo.d " .• ,;'""""' ,~'. r. " k"l" 1~~,iI,ili'r '''" om;n ",inJ , A.k;',. q"'''''''' <"I), "'. I", f,w< 1'''' ~.w "'''''' • 'I'~' m"~' ' n .I)~~ of ' ", ""', hH~"'''. <>"11' 1" ;"" ,,, J,~"",,,,,, .

Th< lind ms, of ,uu<,,; ns 1i"1",,' inm';t" .... "' "'"'"'1\'"''''''' '''~ '" UI''',''inll "'" T"" or<. u k ..... ,·.Iu."" r'>ct~""", If )'0" I.". OJ,n,i,,,J • hf. · th",,,,.m~ ' "'<~'"'t' "" , rol" ., '"''m''''' ""It .. 'I ~"" IJ ,on',," ", 1<""n n6 d""o, imm,d;,,")"' '" "".,n,;'1 Fi",nr •• 'h," , •• "iJ,,;"~ ~ I",II , ,, ,"","« '''n'l~''.", >houIJ oc ,"",<" , .1, , .... m,,' ""n ,.,,, ,I." ' h< """;'" ,1".oJ~ h ... , ,~ '" ".oJ)' ,,, Jk,.' I'"

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If)''''1< un,,,,,", .1",,, ~'hol ,I>< I~., ,"",,,, i< "n b< """,, Jit""~" H""·,,·,, .• ' "'" It,,< "",,<0.1 ~, '''I ...... .n,l <0'''''' f"<>,«d " r lion"",. "",ion< ",ihhk ind",k r ",,,,.'inj! , ",mm,t)' "f l''' '' ' ,,1<..."'''"'"' ' '"~S"'"'S ii""" in,,"'11"""'. " k .. S .... mo", .,fmm,,,,,,,. "c. 101.'" , k." ,;,,~ .. ,I" .. ,," ""'- 1.

Ge neral Introduction

GENERAL VIVA CONSIDERATIONS r.xtk. mol... pm.. •. ''''''1<' ..... """ .. !Jl' ..... ~."' ''' )"0 ' ,t'" 'n "" "I. ,'''"' .... 01" 0"" "'''H " .,,,1 " . r'~ ... " I " I ,. "",1,,1 ""' l"" '''"' I"," m"h '""" ,h<~ ''''''' ~,d <0<.''''''_ A, .~II .. '"" ins 1'''"' , .. , ... , ..... , •• ~' •• ,,0. """- " f .... " .. ~ f'<"""~ ".";,, ,h .. ,nt~h' h< OC''', ",""h",J OC,;,... )"'" "'., ."min .... " (. ~ '.I."in~ ) , r,,K';'" 1""' .1< .. , ;,.",., ,.>< ,w.;., n ...... )r< .''''', '" ,I", )' " , .. d....,,,h ,h,,,, <N' q"~ I I " ~> "'"' Uh' ...... _ ' ,~t;. ,'nl!",' " I""" ~' ;II ~u '" "'" '",M· k.I~, I»« "f d-,,,,, ,um-'lr< ''''''. MM .. '"'" ,!"n, 10."""1\ " .nJI"" ,,,,,)>1.),' . IUJ", _ onI)' f<>M,,, .. "' ... ' .. ~ _"""' I'''''' k,. bo, ~ ill oI~, '""' "I' r"hoIo~r..".j boiIJ "r rum ,n", '" J,,,"_ "I ......... >1 · I' r' .. ·· "",,·

D> .. 't ~i'" "1" A",k.y h, l. "" "ioh du"'> ,,,," io,,,,,, ... 1 ""> bl ,,, • .,h", , m ",. H'M"". " " ',, ,",, ''''' ,h ... r' """ I" <I'" h" 8"''' '" "..Jty 'h" D"'~ L f,llk", ~ ..... ,,,,,, • . ll>< " .'" no ,10.", m",,), ,.oo;'h,,, ~-"" "n. ,UbI •• ".m, ",,' OC"",", ~fth< '''sI< "" ,n. )' """'~h' "")' h.J ':'' 'd. ~u ' 1><, ...... of"" ''''.

SUMMARY

,n.r r."'d 'h",,,",, I .... " .. ,,f , h ~ r""u ", f"'" ,00 .I ... ",J m'n'~ <tot,. f,'~'Y "'. ~ • "'~. "rl"""'"")' ,,, <I.m''''''',,',' """ .t>i l ;' ~ ', "'''F''''"~'' ,,' '"~, _ .. 11y , to. P"""""'<1" ".,"'_

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n" "'" ..... ''''-'''''''.''''''a ... ....,.;"",. ,""".;",,~ ~I,h ... " t'''' ,"'.,~ h ,,",,ti,~.,, ""'" " ... ,,'",,' ...J r'''""'''' ....... ~,",n Y'"' " .. ~ "ok.! 10 """'Of "'Y <>IlK, """""">Ii". II< .. r., M,~, .~ .• 11 . ,," ,. d" , )'" "" .... r, ... ><1 .. ,,,1hl," )' "'' '''''' ,.,',

Relerence I "', )>l t;.",s, ,-,( R ... .,.'!;)' (;u"',,'" "" ">t,",,, ,~ .

ikl"'''''~ s. ..... n K.I"'''' "" FKCK 1'", l~; http'/ln"·.",."_"'/ 'on"',,,. " r" ~ .~, 11>. 7 I l

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DESCRIPTION G~. )"'" OI\SEKV.nl0S~ '" ,ho fUm. '''IuJ''~ ",10,." ".,w,. ~><Iin ... ,

DIAGNOSIS \;~, 'h, ."", f.' ""6"'_ Iv.- ,Iw im.~. fond;">~

DIFFERENTIAL DIAGNOSIS G,,, .1 ... ;.,-.1 """,I", ,,j'I'..,l-.k J'II<",.,'" Juto~"" b ,I .. Un,!!" rutJ.'P'

FURTHER MANAGEMENT \;~< '"U""""" b ",,,,',,,, n."",, """'5""'"' , "d ;",m,,"", m"'u""'nt wh~" n"d to oc unJo "" k.",

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CTTHORAX I"" " '"" ,I" r l.;" ,..l.W '1'0, , .. < "'." ')~'" ",bUr .. >l"", "".,,', "".ii." ...... , ,>lev", I>on<>, ,'<'.~"''' ' ~>Ii t ...... ,. ", I" ,H"s ~'.;' ~ "f mu,"" in , f'-"~" ... "II;" .ok , .... " , ",,"' ,,>.11 " "8 '~;",j,,~, ,f ... il,hk. M ,~, • ."0< (">[ ~'k""" IV,,,",,,,, , ,, "'," ~, .. ", Lungs F",", 1<..,", ' ~'l' ,,~ II I>< obo.iou. bo, J o,,', fo,S" to , h, d . IQ, m,,,. ,"h,l, , _ .... lit i" . I.ool. .. "fuDy '0. .""",,,'-'1 ''',~o,''. k" I");.."mkuiil .... ",;, .. ' v 'or " I",," '" , .. ><".-1><)" ""I"""..". lo~uK, h 'h, ",,,' ll I ",,~ J'"'"r .. "'''~ ...J h."""S' '''''"'' I'"" ".~,;, .... , " ill <.0"'." ... , f>< ,,,a1 ,"' .. .,., .. '"'" ."<",, ..... , ~"' ~ I~ '" "OJ,", "r . , ~-"" "" _·"t of , .. f'-,.«rio~ ~>l l ,,( , I>< "",h ... 1)0,,', ""~,, '" ,h,,·~ ,I>< , ...... )' o.-.h I"g" ,"d ,,,,.11 ,1\",I"n moll OJ,,,,,,,, t:r .. on. ~, '><e'''"' ,,,,,~",,i.-.-. " f t'" ~"""'."I)' ... " ",,,,'" ~ h'" II' ..,.,,,,,, 6 ~"n _ "",,k to. ,mhol"

M. di .. llnum Ch<" ~~ ""," ,1 r ' ''''')' .n<! ."" ,,"' )' <of g''' ' ",,,,,1., ,,<I.J",~ .n'.'l"". oJ;'><<I"" fl 'r>. <lC . .\",'" ro. .""',"'", ')"''''''"'",,,,,, hy_ A",~ I",,, Ii" ,1,-", " "><rI"~',,;,. ,,,,,,,,,1 ",,,,,,,,d;., ,,,II,, .. ,,,",,,,. " " ;"~ ,i,"'''' ,t<. ~!<"l,m ,-r ,.co,,, "non ,I,""",,,,,,, ,., )'Mim. ' ''''''''''l' ""'K ' <"" ","~,,,,, ..,..,' j,,, "~'i,,, t "i"t "'~"''i"'" , >oo"~,, ,,, k)l1o~' , II< ," ... ,;,,. """i;, >t; , . ", in!" , ~< I"~-,, . " . onJ ,,,,,,,,,."" " ,,, ",-,,,,

PI .... S, ,,III'i<UI" ",.J"b.M '~"1"" """" • ."a), ",;""J if ,,, •• "<<if~"~- ,,·"".,,oJ_ r""UI ... " ...... '" m'r ~dl , .. 0/ '" ""I,", '''' Ioog ~ ;"""" ,

Bon os "-,,,,,, ~."" ~,~., '" ....... "'ioI, M " korl .... ",hmu' m .. l, r<""'01< or m"It.I<,,,,,,, C"l' "'"""" ... k< .""""'"' of ,'" ' r "",,..I.-;o,, ","'h , .. ~, ,h'n " i,I im' S'" ""M_

Soh l i .. uu . nd 'he 'p oriphry' '"" '" ~'~h , '" , "'" ,aJ"u.ph. ,h"l ,I>< >oft , .".,,, of til< ,,"' .. ~~ I , ........ "'''). , ~, ;n", ..... , .. "r>r<' "-'-loot," 0" ,'" Io~n' "..,,, '"" hOJokn '-" ..,OJ""., '''t ......... r.

CASE 1

History ~ ,\< .)." . ...!J c .. ~.~'" md. ["", .. ",,1 '0 h .. CP ~·.h • J')' "'''~ " ••

... """',,' ,,( h«,," "" .1 ""'" ' "'. H • • · .. otI.. ... · .. fit anJ 0<11

CASE 2 Histo ry .... 1l· ,.' ...... >1<1 ~,i." ",:ok r,...."".J , 'j,h rmJoc';'~ <",,&h, ,0000o", of """h ...... n;ght .nm

Chest Imaging Cases \, 2

Answer 1 Chest Ima ging

ANSW ER 1

Observ"io ns llli 'I'll" <1\", ,oJ"W'ph ,1\",,, ,"1 .. ",1 ,..,", ,,1,,,,,,,1..10, oh,Jow;"g r«domin.",ly .ft' <! ing ,t.. ..... nd 0P!'" ,,-.,., "';'h 'I"';"g ,,(,h •• ...,~"" 'r~"" 1 .... ","ok • .....-", .. .11, . 1 .... mm in <li,m<w • ..,.1 'pp<M ill ok'''''<I, ....J hm <"ndo,", ';"po<, """"'" «"".i" 11K", ~ hw <nI"l"''''''' moO"" '*" ...... on th< , if h, . ...J .ho ~i.k"lo,~ of 'h' IWI' p",,,,,h,,1 .... ,' ,i".... <1.,< ,,, Ifmrh~"''I'''lIf_ Gil,,, II>< d'.~-.1 ",,,ii>, ... ",001.,," " ,I>< '"'~, I"'I~' ,1~""K~_

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, , •

Answer 2 Chest Imaging

C<>mp4",>!""" .>!'n in.;I",I<: • I'''W<'''~~ rri .. u,,' TR _ d..., ",. f • •• J in" nu,,,,

"'!""'''' ~ it~ w""'qu<"t d"" tiC ~"""""",". • M~i,'l' T~ _ m"~' ·. ~ .. m"''S' "''". Jiw<min"""

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HRCf "" t... . ... fi~ .~ ",,,I><, " '.k.,,,,,,, ond T ~ ~~"'" ~'"h .,.-,.jul<. ;" , « .. , ,aoo.,l,, d .. "i"",ion du, to mdoI>ron<hi>l ' r"'oJ . 1'h~ p.~, • '"", ;" OOJ' '!'I""'~"'" Th< JoIk,,"t;.[ J~ "" ""trilobuI,, oOOul<> ",,!oJ<, n .... " "I>,,-,"d ,"1 OK"~""'. oIk"", Ioron<hopulmonuy

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Funhor mlnlglment K"~~,, .. '), "k",' ~ ; d •• '.;''' ... ,'f'U'"", ')'''~'irl lo"_~ 'u >1<",;1'r In' ,,;J 'N Io.o<;IIi.

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{lOOO I, Tu""".""" /rom ""~ '" ."". iIM(;.(;,.,h;', 20, ~~~ .... 70.

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;;~;:;;~~;;~~~~~:; .no loft fomo,.1 h •• d with . nkv!o. i. 01 .... hip joint. M.,~.d limb .hon.""" i. " '" ,on •• ~""""o ,

CASE3

History ~ ~;;."..".,~" m.l, P'''''"'''' "~~ r"'!l"'''~~ J"p""'" • ..J n",o' lou

CASE 4 History .\ M·,~,,",~J m.l, P""'"t<J " ~h

h""~"",·""

Chest Imaging Cases 3, 4

"

Answer 3 Chest Imllging

ANSWER 3

ObH ,...llions l311 er 'm'~' of 'h, ,h." .. '~'." ,li'Yo,,, . ;''''."1,, .... ! nOOul" p',",,1 ' h"un"'g io "', Io n h"",,,ho,,,_ '11, ;. m'''O". 0r~" "" "II '''' .. '""'n," ",J .,., ;",-"h',. m,J ... ,.,,') pku,,_ So "",) "'''''I'''''n,")m') pol,,,,,,,,,,}' ",,,,,,,,"or" K'<n on ,h .. , ,.,.; , ...... . __._ ,,,tio,p ..... '",,,, .. no .',ih/, m,J""in,1 m ... , T.u" '~"h" .. ith ,I\< ",,;.:.1 h;" " t)', 'h, " " " ,,. ", , ... ~ "i,," . ,of ,", ... I\<!,." •. 'h"",," .. ",,',," ""',.,, '" ",,"okJ W;'h ""iI"" '0 ,'>< (,m,,,. ,,,,, 'N or,,,, cr •• :on ,", .. ~, "', " .... ""'J Ii" k ",,"" • of ... ",,,. K'",U. "I rk" ,,) .1 " '''''' ..,.1 """"M ~"."''''r'' .... ' ' h~""." ""~'M , I,,, '" "I." OiI9no_l_ .\I')i~"'n' m,,,,,h,6<,,,, ,

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ANSWER 5

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Answer 7 Chest Imaging Case 8

ANSWER 7

Obs. ",.l ions (7) Th .... ;. ~'N!"r"' ''' '~ .. ,..m,1 ... " .. "",1 "r";')' <I"""ghout Ooth lung. ~-;,h "" " .. ,) 1'",00-""",,,,,_ "l h~ ;. r"' ...... ' .. ,, ')· ,.(' "',. "'"'"'" .,," ~,"'" ""~"t.,",,, _ l'oo.l,.,kHa".j low' bonk,...J I><mo.l"rhnsm. "'J ... " .ubpku,,1 "'",h,",,,,,' . llK,,, M. IUf" ,....,, 1)· J<f""J , on ...... """ ...... , in both ul' I'''' ""',," .·ith .. "" .. nd· ... ~ l i""'~ <h."~,,. TIl<>< ""'i"5' ,,< .. ~"pio'g • ;,b P"'3,.",i,~ m,"''' r.oo"~;,, '1"';" " .·i," U "J.rif;"~ P"'U",,,,,,,,;~~.

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ANSWER 8

Obso",. Uo nsl80) Th,,,, m ",,.,01 . ', 11 ,,, ,;",,1 ~,fi ,~~ .. ,Im, i,l' _ 1.,1" """"~ hoth lung' .'ith no ..... ,1 rKdorn.,,,,,,,,_ 'II>< noh' ~"_"" ~ ",," un ' " ' "'g. <~. , .. (,, '" .oJ ;, IDo"""",", in "I~",.,mc< .ith n_kd ","""".kn>l<y and .pr .... n' p",;"",,1 ,"'".",. ," .. he, ... ~in~ of .. ;. ",~";",J lou' 'ho , o 'P" "" f,,,m , h;, folrn mu" b< of. "",,,"I< of '"" ,~, h" ",,"" ~ i,h ,,,,,,,;,,,J PU~"""'I)m" ..... ""_ Ollgnosls ''''"8 ",«"'"" "'ak ...,..,.rlrv" """~'''''''"'' . om. , ontll l dilgnosis Fm mul' .... Iu"S ,-".JuJ .. ,

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Answer 9 Chest Imllging

ANSWER 9

0 1a.",.lIo no I9 •. 9bl I'~ ,hoc" ,~'"w-""" 1'10) .. h" .. ". ~<II ,10&....1 ~~;. ... ;" , .... ' I"~rk<'l' of tho 'w>' luns ........ ;,,~ on """"'" ' . Sic ~' ; ,h "'" 'h'" .'.11, 1'1,;' ~ .. ''''''~''"' ~.h ........ lIy b .... -,I k .... ,_ Th< , ;"gk nUl "'''t.< -. , cr , ......... ,m!fl ' ,o," (9b) """', • Iu<.nt k ..... of,:" .s.n~ty '0"" ""nJ. thru.r,h t"' ,h,,. w.tl '0 • ",bpi,. ,,, "" " ..... , Diagno. i. 0>< .. , . '0" '""",,0,

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Di .... . . lo n Im •• .,~ lie"" ..... ., • rI ';" ""I;."., ..... "" "~,~Iy h< .",,1 ~"h • good ""5'" '" <oo'Ok",,< ~, J.ft;,,,",~,, pi,",,, ~,.,,, "'"" .1"_" ...-",",'m->l ,~;,'".

I ml""~" J iIk" nri".,~ .-. "" "" th.tt f"'"" ,~ • pi< w-~

""".", OK"""" • O~'''''' ~,~k ~ ith '"' d",,, ~ .. l

s.-.",~h "1"''''" <J~" 1'<,,,,,,, .. 1 ~,,"."'

P,a"Uc_1 Up. Wh< " • rlt",,] ~ ... ,~,., "".,' ;, .I<m;""' . "",!\t,~ , 10,,'1 ' h, r'.Im h' "'rr<"'''s .,';'1<"" "" ~""'i<" ," ", 1 "' .. 'Il".....,..-~n ynd<~.;" f rib iC" ,,,« 1"'''''' 10 • "'bpi< ,,>1 h..,m"""" US , an to. IK il'1i, I ~';' " tit, Jin<" ", .. ,"", ..,. .s.",," ;,, ; ,,~ ~h< '''', ,." I'k",~ I" • • , ~ tl.", ," ~~;'1.

Fun" .. man_lIomont )<" ",~ h " '«"m,n' "q,,;"J Ow ,h~ to.n~ ..... ~."

, . A. OoI CT i"'"'Y_ .I'>ow • • "b· b ... d I.,ion «u,mg ,om plo' o do.tro01ion 0' 'h. """ .. 00, ti ght 8th rib,

CASE 10

History ~ 7~ ·l"'''·'~'' m.l, p,,,.n,,,1 ~it~ , .... I"'"

CASE 11

History A 61 · r<i,·~ I~ n,,]c ,.,.. .. n"J wi,h .h<x1",,, ",.",.. "h.


"

"


ANSWER 10

ObH rv. llo ns llOal 'ri>~ AP "",,, ,,,,I.OW"'" <1<",,,,,,,,,,,,, , 1,'1<' "",d,,,,,, ;".1 m .... "" ,Il, l<il . T'" .... h of Ih, ..,.., • ....J pm,.,,,1 """', oJi,," .. ",. ," , .... ,.,," "pm" ("' .. 'h" m'''. ~hkh .. Jb,,, ,h,. il .... "" fNn> , h, posI"k" ""J",. " .. m . 1'1"", ;, 'u ~il'.,., ,·okilk".,., in t'" 1.,,,.1 """'" of,i>" m"" _ ~'hkh ~""'J "'l!I;"t 'h" "" biuo, ";,, f .. , • oJ,,,,,t '",,"1),",,1 , ...... ,,~ ""' •. <.Aom""", .. • i," ,>1.\ fj"" ",,,,I.l "" " ",';' 1 ",."'" ' "1 d .. n",.

Ol~g nolll

Th""",,,, '"'''' '0' "1)''''.

Oiff. ,U l ;11 dil ina l is Of 1""" ,;",- ""t<;n •• "h~'." , ",", '. l""t""",u~.n •.

• ,\r;">I.\>o.<",· • ~ .• ".m,oJ"II"l' h .. ,"""I"';'-"" Of •• 1<';"'- ....I i ... ;" .. m .. "

Thy"''''"'', • T ... "'"n,

ThY''';.! ,.I"SI 'rt"" ~~" """~",,,.I '''''" ..... • L,mrhom· _

O f miJJ" ,"<d,,~in~ m"~ I.f"'rh ","",

• " """""'"~-I·I"~i<"iuot ,\" . ""'nd iot _'" ""''''1,,", c.""""", ,.,. """" hu'l ,,-" ho • .

Oi..:u .. ion "" ..,;,1 CT ""~ ( lObi of , ... , h,,' ~·;,h IV <0.'"'' """'. (h" <1<"""".,,. ~ .""' ~"'...,'" '- 1')1'''.1 , ...... "''''"--.1 "1'1"""""<> '"' of" "",.!lut;"" ,~ ... _ ,ho; ~;.Io ,""""." . ,,"" • i,h f'<,0pI",,,1 <",,""' .. ~.okit"'''''', N,,,, •• I cr " .. " ,'''''"''''", r." , IK ,h",,," "~,, ... d . .1 ,,,' d~"",,, f<~ to< "''''J"'jj ""''' .0.1 <1 .,\ ,m ,." ,I>< Ih."""" .""","ding ~ ., .. 5"r,~.' r.-p';, ~ ,,,,,, •• ,,,,,t "'~I" ,om, In Ih, .. ul< ,~u""" , ~'''''' "" old illm, ",. .. ~~, hl< • • 1i 11<","",,"" ""'I" . n •• M< ".~" ,Ii""·",,,,, "'''Y .... "''''''')'. In "'" "' """''' diM<rnon , . "" ''''' h< ~'i.k.;,,~ .of "", """;',,;n""','" ;"'K"'" f."r .rl" .... ",. w 'h' ..,..,", 00 ,1 ... .on" Ji'rt...""", " f "Id[',,,;oo . ·;'h .;JJ i,".,,1 ~,ol.,,"ph, ;" ~"k, <0 .. ,"'" .. 'h' .IiIT"'" ' .... di""'~;,, • p,~"n.-.- "'"I ~";",,'" ~ ,h. ,p ......... '~''' n ,h.

1""",;",- "f'<" oft .. ho;, rt mJ Ih. ' h"' .. ."r .... ,,..! "",,,;n' """', .... ;"g "'~" '."'trIo'KY" ")'5" " ' "in • • oJ ,1-.0.-,,", J ... , . M;.!.lk "" .I~";".I......,, """"." "",,,, ,,~ 11"''' " ... h.

An",." ... J"";,,.I ' r>« ~ from ,''' .n"""' ...... " ,,,-,,,", "'X' t<t ,h. '''mum . . ... 1 ...... . ." ,h""", ,.o! !)mrh noJ"

Mow;"g 'h, """""" of ,,,-h "1"" ",..! 'rpl) inB ,h, ,""""<II< ~V' ,,]10». 1<-, .... tI" ;o<n'"'''''''' uf ~ hoi • 0.00; ............. ""I' "'- F", ""mrk,;" Fipn-< l <k d"", ~ • I.v~< •• <11 """,>«1 . ........w ."d""io.l .",. «1 .. «1 ,~ ' l>< I<f< "''''' '",J.L TI .. H, .... rt I.""", " n ho; ,I<.rlr ""n. '''''I<~'I< t h, """ ,-'0"'" I-< ~·i<h" ,ho; m~I"I' o",J".,I, um. Altl""~h 'hsh"~ dilr""I, , ... ,,'" ,h, "1\"" "'h"'! ,ho; " .... "" "'" ",,'''''K,O "'" ho; ,n .. t, I-<'~'''n t h, " '" n,i<J 1<, . .. ""'t , ho; .1",,, .. lin~ .. "t>. "'M",;"g ' h" Ih< 1<0 .. , ... 1""",;",- "".1;","", ..... , Th;'" <0.1;,""" br 'l>< 1" ",1 fi l ... ( I Od) ;" t" ...... . Pit"," , ",J '''' k ..... ",u f'N"J '0 '" • ",ulOf.o""",.

P .. olic. 'tip ' !,,",,) til,", "" t.. ,~ry "",f,,1 "' ho;"" io<.Ii'''~ ,"";~,,;, ... m""",.

Fu rth . , m~ugemenl

If,,,,,, ~ <1,"",1 """.,.," ,",0 <:T ;, """"y 'Il< .," in,~";S"""'" oi ,oc.;.. ,

A nswers 10, 11 Chest ImO!lging

,0<. 'c~ AP and 'ate,oI ches' ,odi"llroph • • haw 0 po". rio, "'toin,inol m ....

ANSWER 11

Ob •• .., o, io ns (" . ) Th~ r.-l , .... ,><lioy'rh .m~' •• ,y,)" .. U ""1in«I • ,m ",I, 'i .... J<o, ;,,' ,.,"", ,n 'h' ' ;gh, ",OJ 'un< , in ,h, Kp... or,,,, 00.;.0"",' &. ..... Tho h .. rt .. ,"",~<d ~"h ,u.l." I."...,;'; ,or", "II.,~ •. Tk<'" ~ uri"" "' • .., "",," ' 'U"~"' "'" .. ,J , >l;~h' ;,,,"'''' ... "",,;'w ",<"d' f l1><>< ,,'1"''''-' ''' ''''' in .. """,, ~ilh k* "'ur f",,,, om , I" .;,.h, ,OkJ '_~f « .. IJ ,'><"'"-'« .>d.,,,, Io.~-,~"d r""'" ftuo.l in tho ""''-1''< ji,,,, ... <;om,..,. .... "'h '"I' ",..,"' ',I"" "'. _,,,,",,,,',1,. , ~'M'", " "p (,1", ,~" "","",n' , ....... IJ ,on"'" """""'"'" "itt.. "1'"''')''

010g80lis 1'k",,1 r"' ..... ""' ... ",·

Oiff" rontial d iagnolis '''' ><>I;,,,,}, lun~ ' ..... ''' / .. .,,'

:-;"'1'1",;'" • ~hl""n' - p,"''''' b" .. "~nk ""'""'"".

""ir,,)" m<t"'''~' • ~' "¥n - h"",,' .. m,. " jm<"" •• ,~.,;,,,',", .. ,

m.l!i>rm>t .... 1A V~I ). Ink«,,,,,,

G,,,,ulorn . _ TK. h",op"''''",;"

"><'"""-I .. n')"R~. <') rr''''''''''.-Ib",,,~ s<",., ,n,\'NAu"

N.-.n· ;"1'<"."", • \\"Y""" ~....,1om>t0';',

Ilh<"",,,,,"-I .~h";';' ( U )

• ,"f"" . S",,"-I .-100) 1001,

C,"' ~'".,', • ~~""",*,n;'"·!,, . • ~,,<>t"t""" f., "' ~" ,,,,,,,, '')' • PIn .. , m ... / l ukl, · ~;" """,..-/',,'''' '

SU"'"'''''''''. k ...... hoc"," .~'t~,

OiSCUSlion Th~ ~ ix,' ", .... "w;.,,, oftlui.! ;" ,'" ,,,, <lob .. """,. ."<1 .. iJ<'H."" "" ,I>< ..... " r .... "".~ .. ""';,,~ "'I)' ~d ""f""J i" "'rio, 1>0.-""", l1><" ", <>Ii", ," I"" 1'<""",, of """ .. 1 ftu", r!.nh<<<. '" '''''u .... ", ;"J"'" b.o.;k,,,,,, orJ r"h,,"'I!!' ~"" .......... f,il"", 'h" h" I<,j , ,, ""'ur>! ~,,", .."",nul_ ..... n, m,in ""rort"". cf ",eh , «.00" .... K 'h" ,h<<< ~ ",~,", i'l ,,, mi';n",!",,' i< " • ~,," I ru"""""I" ....ruk/m ....

(I .. ,.)

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", ! · 'i· '. . · - -" j~n

l·Bt- ~ -l!'" ~.s.!: ~ ;~~ .. '~E~ 0' ~_u - " "::Z • • '" i!. ~ .1.-,--;; "' .~ ~ ... , .... ~ ~-';! '.i~':~ '," ,",~-~1: <! ,. . ~ . ." ",.~. q.;;,d ~!i ~ 1,' .d ""'''1'

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, , : " .:. ,,~ " - -. •. 5 ~<J! . • E~:)4 .~ , ~!ti~~J-.~II~ ., ~:t.n~{~~·,~ ';'5B~ ~V~~~ , 1" .. ' .. ..3ll..,· E'~' ··~ " ~·[·, _ ' ," _,..,1 i:t .• ~.~ e-" ' ~:E~1"'-~ '~f·E '·..e · • E ~l" ". ::l .!:':-~ " ';~:]' ... _ • _ ,;.. _ . 0 _ ~ ..

1:. '" _.~B_ " ~.~,,,,~~~_a~~if1's-~ •• - ... 0.. ... '.~ · ~"·>' ~l-· ·· ,.-"i ~.ij ~ t ~ ~ !-~~~'~E ~ ,~~ ",,~~j ~ i ~ ~ .• I!. ~ '" 01- ~ J! - '- . .. "J< • ~ 11 ... :;; ~ .• ,J ~ n c"" - "' ~"~E _ ../:-" u" .. ,.,·,=~ .. _ ., . - " _.>,,1

• •

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L i I! -~~~ ~ - ; ',-, - . • • 5d' . g, :: :: ¥

•

CASE 12

Hi$.o'Y A .~ !~ ... ,>IJ ..... _, .... ~;,h

;.,"..,"'''' !It ... J .... _. ,........,d .. ·010 """" .. ,n, I N'"''' ' " .. , ,..., ! ... l ~

Chlst Imaging Case 12

"

Answe,12 Chest Imaging

ANSWER 12

Obso""lIo no 112., 12b) 'IlK "',n ""I., .nI",«1 ... , .. ,h;" ~ on AI' , ... I.'\l' 'f'h. ;, ~ oot r"";t,k t,,'" ,u ... , 'n,,,<;". d.ffu ... b~,,<,,1 """, ... ", «'''"'...- ;n" ..... ... "!"< ;'y . 'oh ~.ri'l" K 1;.",

"' 'h< 'W>' I""" , ,,.., "'" .," " 00 ,'" '""" " P 112»), Th, k& k ....... ,nWp-J . ..J ttK" .. . puImonM)" 00.1,,., in ' h< k & "1'1"" .on< "'''''''~ ' PI',,-,, u""'iy 1.5 ,m_ '" ,;nl" 1<& ..... " , .. ",.".,., ... 1>0 ... «J.

Tho ""'" Hl'~'<>"".n" ..... ,to" ,'" ~,,;'"t h... , I<ft ,, ~('< , k*,< "n" .,u, ~ ; , h i<~ "~" ><i< ....... "hy .,><1 Ilmrh ," ~.~ ,-"'..,."", ,.... . H "~,,..,, ~;". o , '" " ~''''' ' ~r"'.n d;"'.", .. ", , '" , .. "" '" "r«'<"~ , .... , ... ~'S'~ .. ,' ~ ... ",;N, 'h" '" ".,M ",,', ~'"~ "n'" .m! ,'''',''' .. s kit k . ... fool" " . A " I""" fi lm ,ft" ' ",,,m.m fi .. "'. " t"",, m;p,t h<lr d,,;~ '. l>u ' h< ;'Iil..ly '" "",d ... ~;"S of 'h< '.'f"" .. d ' u .. o., ~';," CT .n)",'" • • " J ,h;, ""T .... ~ff tb< ~ " " ..... ,

Oil gno.i. 1 ~1i "1'1'<' k"" t",n<),,, ~ hh I)"'rk.n~'~ <", ..... ,""-', OlHete nlil l dllgnosls fo, 'U"""'" ''"'''s 'l""'fOh""Si';, <."." ... ~ .. Iy r.. ... top don)'

I.."P'" Th)TOOJ. B"",,_ S"'''"" •. r .. "" .. ~ •. c.,, ;,

fo.«P''' (I« 'ky R) ie""" Pu'''''. ''')' '~no .. , h)I"""'''''''

• L)''''rh."~~~.

M",,)' " , 1>< .. -.,00;,;"", <,,, ...... w "'1"0] 1"", . ""'"~ th< ,~" " x.J ..... ,b.,,.., .. " l f., .boY< ,it,,,,_ h , n'I'1<. ""I.d" ... , ..... . . nf 'h ,,,,,", f,b,,-";n ~ lun~ <unci;';':'n. I) m I,h~w<",, ~, ~ "rh ,n t ' '~)""utu,;" 1ym!,1~ ......... ' ... PO,""'""';" F~, ,ul.,-.I<",,' """u"" • Sum;.! . • L,'mr h'"g.;,<,"' ..... ,,""",

Sih'n,. I·, .... r b. ... •

Dj.cu .. io" c." . .. 'umo" " .ho ... . r"""n.;')' ,,, ;n,'><I, ,I", I" ,,~

in"",i,"'m. """ f1>< ,....,n«!i« I""" ... ! rl>< ~.,.,,,,,,,.~, L,'n'l,h" ",, I" ,'""" d~l<.-..k<l!>y ,1'1< 'Urn"'" ;''''I f . • ,,.. ,!", "',,">< of ,on" " . ,n ""u l",!; In ... ,u""",. ,,"~ .",".,", S, mp!n"" o.:lu,1< ""r"o" " J ,,",~,

[1. in til", ''I\"' ... of """ • ...d """,ul..-;",,",ulo_ ", ... 1 .. ;n"" ,;,;.1 ",""'0'1\', K.'''''), A .... ' 1«,l<y ~ 10.:" cr ,00..-, "",,~ut.. 'hk"',,"~ of ,I>< ""_ I,, "r'''. "'.'g ,,., "" .... I,n...., ..... , ... 'ul., ..... k~ ..... ,,",....,",,1

th;';"'n"g, In ,J,!;, .... 'k", ' " ,m.1( ('<,~"I ' " " _ r k"," ""J " k., H"rt f. il"" "",!"", ~m H .. ' rr<''''''''' "" [>I ';" ,11.-0 " .. cr. '!>.,mpo f1>< m~k<","~ ~ """" I"'!y ' " '" ....... ~ .... , Iw", ~';U ,.~ .. ,,., ........... ,,1 1\"' rI>'" . nor"h), ,hot ;, oft,,, 1''''''0 ' .. Ipnplo",IY' ;" Uk< 1><", r. , u". I)mrh ... ~." ",,,,] 1 .. ' roW""'" b;1 .. " .. <h,"f-'~

P •• "'ic.l lipo W"' " I)", .... ,"'~~ ~ J~""J. ~"". ~"of"",op., ,>['m."&""" ........ ! ....... ~obl< im*" l.<. ~o>g ro<to., .... ', roo, "'i"~.,.

cr 'o" .... S (;,~, .. g, of' " '''r'<u''' ",,"'I<. , ,, " ",, ~ " I ,,;' .. ",'"" ""rlo"~ .. ""1".1 'hK"'n~ "" ,'" "'" J"""""~ "'nn~' , H",,',w. ir~ "' .. ,;" ""r<"'*'" to J;rl, ,,,n' ;", ;",,00b.1.v "rto[ ,hH.o; ,S of 1>< .. , f.illw< &,,'" Iym r h'"f~;' Oft cr ,,~,",,~, " ... ,,' .... ~"'s «h<" ,oJ •••• , ... , " ... , .. m' r' f" l1<", ·up CTI of", ,,,","<,,' h h<.., f" "'" ""Y "..:>Iv< ,h,""".

Funhi. m.nlgem. nl 0""'[',;",,1 ""'~'n<n' ~ "''''''''1'. If .k<m<J ",;'01'" ~"

' "'""""''' ~l", • "",h '" , .... p<""'y "''''''''' ;,. ' r r "'!'" '" ;r oo' , 1,,><Iy 'rr, ,,,nt .. in ,h~ " ", CT ."",,i"~ of , '" ' ""'''. ,b.lom," ,"J ('<his " " " ,,, ,""""on~- "" J,rtrn".

Funh . , .. din g ('.,.""01,- If •• F~,~.". I) . I'",. f.F (19'J"J I_ Tho"",.,

m"ifo,,,",",, ,-,fb«.~ , . ,,"""" " _''''''"' dh< ... , oJ " ...... k""'"' <~- ""'t""'n'- Cli."oIltw1 ...... , 5oI( a ): Ul-H~.

12b ~ .. 1.1 B "PIOI Hne.

CASE 13

History ~ ,l6 _ )~.~r.I.I "m"" ",,,,,.';'" Ii, .oJ .d.I"""""" .ioh .,"" J)'f"'''''' ....t 1« , ,"",.' .'",," r';" ,

CASE 14

History A ;;_)~"-<M J ,~'" r""'"t<J ~·"h Jp'ph.p.,

• ~",.3" >: ."~~ ,, .~ 5- ""~ 0.r-' O

~ F!"I"t~f~<-~l ir; s-

"

" ~ Ii -.'" , '. _.~ ~':iH:~P~~~ ~ ... f"~" 5' ",: ";0 .f.,:r .. -- :. ~ ".;r", = ~.' 0 ",a of. " 0 ," ._3. --""" ~ ~ ,. " ;;:~.; §3l ~. ~~ ~.~ -;,~f~ ; ,..."", . ""S· ~ "r"' '- -;: ~ ;. ~ ~_ ~~i~H'~ ~~ ii ! ',"g tq~; ~ 1-,;" r i ,_ . ..,' _~ _ ~ :r, .. ... "";. .... ' -"~- . ' ,3 = ",-. 5". ;>-i 0 ~;;::-or ,.",. ~, .... '-' _~~~ ,-1h --<j':·"I"' - ."~~' --.~ « • :;,,-~ .• ,,-,3. :r;/.' ' ~.~< .. , _ .::.,. T.'!;!-"~"~l"" . - , iH;-!~" g-,' ~~~':l

~li'~~%:' - ~~~;; ~ _ g_.;,.i"~; ..... ,-" ._,~~_~ " or : .• ;.:~~,ii~ ,-:;~~ . . - .'. ~.~ o

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A nswer 14 Chest Imaging

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CASE 15

ory 68-year-old male presented with

progrcssi\'c dyspnoca.

CASE 16

ory --H)-year-old male presented with a g progrcssi\'c history of dyspnoca

_more reecn! onset cyallosis.


37

38


ANSWER 15

Observations (15al This chest TJdiograph demonstrates bilateral lower zone imerstirial rcricular opacity with evidence of basal volume loss demonstrated b~' descent of bath hila. The interstitial opacit), gives the heart an irregular 'shaggy' border. These. appearances arc in keeping with basal fibrosi6. There is a calcified pleural plaque rcbred to the right hemidiaphragm. The combination of basal tibrosis with pleural disease would suggest asbestos exposure with pulmonal)' asbestosis and pleural plaques.

Diagnosis PulmonarY;lsbcstosis.

Discussion Pulmonary asbestosis is a chronic progressive fibrotic condition secondary to chronic asbestos exposure. eroeidol itc (blue ) asbestos fibres arc mOst commonly associated with malignant disease and pleural disease. Radiological features are of a fibrosing alveolitis that predominantly affects the bases and is indistinguishable from other causes. Fibrosis can progress to result in progressive massive fibrosis, but this again predominates at the lung bases. Pulmon:u), asbestosis has a latency period of -40 years and therdore pleural changes are usually seen prior to lung parenchymal changes.

Othcr features of asbestos exposure include: Pleural efli.tsion - this is the earliest pleural abnormality, with a latency of - 10 years. Focal pleural plaques - have a btenc}' of 20-40 years. DitTuse pleural thickening Pleural calcification. Rounded atelectasis - this is also known as folded lung and :uises due to infolding of thickened plcurtl. with associated subscgmental atelectasis.oMost commonly seen in the lower lobes, it has the appearance of a rounded subpleural mass abutting

15b CT image of the chest demonstrating a large intra parenchymal lung lesion that is abutting thickened pleura. Vessels appear to be radiating towards the lesion as though pulled towards it.

thickened pleura, with linear bands extending from the mass into the lung (craw's feet ) ( I Sb ). Malignant mesothelioma - - 90% arc related to previous asbestos exposure Lung carcinoma - there is a brency of -30 years and occurrence is related to the dose of asbestos exposure and to cigarette smoking - which can increase risk by 100-fold.

Practical tips Multiple pleur.l.l plaques arc characteristic tor previous asbestos exposure ( I Sc). Look for signs of m:llignancy in patiems with asbestos exposure - remember the increased risk of pleural and pulmonary malignancy. Pulmonary masses should be investigated with CT - ch:lfacteristic findings may permit a confident diagnosis of folded lung in some cases. Asbestosis is the 'odd one out' among the inorganic dusts causing pulmonary fibrosis. Thl: other fibrogenic dusts cause upper ZQlle fibr06is.

Further management • Systemic sympwms, e.g. weight loss, shou ld be

carditlly investigated to exclude mesothelioma or bronchogenic carcinoma, for which these patients are at increased risk. In cases where there is still clinical concern abom an area of possible tolded lung despitl: imaging, percutaneous biopsy may be requ ired to exclude a malignancy.

Further reading Akira M, Yamamoto S, Yokoyama K, etal. (1990 ).

Asbeswsis: high -resolution CT-pathologic correlation. Radiolog'l 176: 389- 394.

15c Axial image shows a right anterior calcified pleural 'plaque consistent with previous asbestos exposure. There is also subpleural reticulation representing fitirosis and appearances would be of asbestosis.


ANSWER 16

Observations (16) This frontal chest rJdiograph shows extreme cardiomcgal~' .

There is marked dilatation of the central and main plll .anary arteries with 'pmning' of peripheral pulmonary merics. No diffuse lung abnormality is seen

T he findings arc indicative ofpuhnonary hypertension. Gj,.-cn the gross cardiomegaly, a kft to right shunt is the alIOS! likely cause. Howe\'er, cyanosis should not occur and lIS presence suggests the shunt has rc\-crscd, that is, the p;1[ienr has developed Eisenmenger's syndrome.

Diagnosis Pulmonary arterial hypertension from an undiagnosed ,"cntricular septal defect (VSD ) progressing to Eisenmenger's syndrome,

Discussion Pulmonary arterial hypertension is dilgnoscd by a sustained mean pressure >20 mml-lg (systolic >30 ITlITlHg, diasTOlic >1 5 ITlmHg ). Radiological fe:Hllfes on a plain chest r.td iograph that suggest the diagnosis arc: • Increase in size orthe main pulmonary artery. • Reduction in size of peripheral pulmonary arteries

known as 'peripheral pruning'. • Right heart enlargement • Calcification ofthe central pulmonary arteries - a late

but characteristk sign. • Parenchymal mosaic attenuation pattern seen on

HRCT.

Primary pulmonary hypertension is idiopathic. The condition can also arise secondary to pulmon:lTY disease or

CASE 17

History .. \ 50-year-old female presented with progressi,'e dyspnoea and intermittelH cyanosis of the fingcl1l.

cardiovascular disease, either from an increase in overall pulmonary arterial resistance or from :In increase in the o ' ·erall circulatory ' ·olume going through the pulmonary circulation.

Increased resistance - pulmonary veno-occlusil"e dise:lse, chronic pulmonal)' thrombocmbolism, any chronic I'emil:ltory disorder leading to chronic hypoxi:l and resulting vasoconstriction in the puJmonal)' arteri:ll bed Increased flow - left to right shunts, i.e. ASO (atrial septal defect), VSO (vemricubr septJ.J defect), rOA (patent ductusarreriosus).

In Eisenmenger's syndrome the pulmonary arterial pressure climbs until it c,"elltually exceeds the pressure in the left heart and the shunt re'·crscs. It is seen in those with pulmonary hypertension from :I left to right shunt.

Practical tips • On a pl:lin chest radiograph, hilar l}'mphadenopath~'

can mimic pulmonar), aTlerial hypertension. Clinical history here is vital and cr should be subsequentl)' undertaken in the right clinical sening. The diameter of the m:lin pulmonal)' artery should bo less than that of the ascending thoracic aorta. Rcvcrsal of this ratio is a sign of pulmonary hypertension.

Further management Primary pulmonary hypertension has 110 cure :md a dism:ll prognosis. It is a diagnosis of exclusion so all underlying causes of secondal)' pulmonary hypertension m ust be investigated. Cardiology referral with a I'icw to echocardiography would be required initially.

39

40


ANSWER 17

Observations (17a) This frontal chest film shows abnormal rcticuhr interstitial op:Kiry at both lung bases, though there arc no features to indicate significant volume loss at the present time. A large area of calcinosis is noted in the soft t issues around the upper right hUlllerus. The combination of find ings and clinical history suggests a diagnosis of systemic sclerosis with lower zone pulmonary fibrosis and Raynaud's phenomenon

Diagnosis Lower zone pulmonary fibrosis due to systemic sclerosis.

Differential diagnosis For lower zone pulmonary fibrosis: • Idiopathic pulmonary fibrosis (I PF) (cryptogenic

fibrosing alvcolitis - CFA). • Connective tissue disorders - systemic sclerosis,

rheumatoid • Asbestosis. • Drugs - especially certain cytotoxic;, e.g.

cyclophosphamide, bleomycin, busulphan, etc.

Discussion This autoimmune d isease has also been known as scleroderma, \\~th a subgroup known as CREST syndrome Current nomenclature is systemic sclerosis wiTh diffuse or limited scleroderma, the latter being The equivalent of CREST syndrome. The condition is three times as common in females and typically presents in the 4th- 5th decades. A variety of autOantibodies may be present including ANA and rheumatoid Factor. Clinical features are many and varied bur include: • Musculoskeletal - thickened skin, soft tissue

calcinosis, Raynaud's, erosi,·e arthritis (sec Case 152). Lungs -loll"er zone pulmonary fibrosis, aspiration. Oesophagus - hypotonia results in dilatation and dysphagia. lncompetence of the gastfo-ocsophageal sphincter results in reflux and consequent peptic stricture, aspiration, etc. Small bowel - dilatation and slow transit result in bacterial overgrowth and malabsorption. Barium studies show 'hidebound' appearance due to fibrosis pulling the vah>ulae closer together. Pscudosacculatiolls and pneumatosis in small and large bowel.

T he CREST syndrome represents Calcinosis, Raynaud's, oEsophageal dysmotility, Sclerodactyly, Telangiectasia.

Practical tips Once lower zone pulmonary fibrosis has been noted on the chest radiograph, examine the film for the following features that may indicaTe a specific diagnosis: • Dilated oesophagus - systemic sclerosis (sec Case

152 ). Erosions of the lateral ends of clavicles -rheumatOid. Pleural plaqucs - asbestOsis.

• Soft tissue calcification - systemic sclerosis. • Signs of malignancy including bony sclerosis from

myeloproliferative disorders - cyTOtoxic induced • Sympathectomy clips - systemic sclerosis ( 17 b ).

Remember which disorders cause upper and lower zone fibrosis ( reler to the differential diagnosis abovc, and also that in Case 18 for npper zone fibrosis ): sarcoid is rhe classical upper zone disease, much as IPF is the classical lower zone disea~. Thereafter, remember that the upper zones arc better aerated and the lower zones better perfused. So, diseases caused by inhaled dust (inorganic or organic, e.g. silicosis

~ and extrinsic allergic akeolitis [EAA] respectively) I ,,'" atlect the upper zones, while the lower zones will be '0"1 afkcted by blood ~orne disorders, i.e. drugs and

autoimmune conditions. Unfortunately, asbestos is an exception and docs not obey this logic. As with many fibrotic lung conditions, theft; is an increased incidence of pulmonary malignancy in systemic sclerosis associated pulmonary fibrosis check for focalnodulcs/masses on the chest radiograph. Alternatively, tOcal airspace opacities may represent aspiration.

Further management H RCT is the imaging choice in diagnosis and follow-up ofinrcrstitiallung disease. cr imaging findings of fibrosis include lung volume reduction, subpleural reticulation, interlobular septal thickening and tJ":."letion bronchiect.1sis.

CASE1S

.... is tory .~3 r.:ar "Id 111J.1c I'n:scn1\:,j \\11h hol.:k

Jnd p"('grc"'I"c d\'~pnoc.1

:;'SE 19

"'11"Jlcprt"SCIllCd"1thkfl~rm


4'

42


ANSWER 18

Observations (18a) Plain radiograph of the chest shows changes of upper zone fibrosis with elevation of both hila and upper zone reticular opacit ies. In addition, there is a cavilY in the left uppe r zone containing a soft tissue density mass with surrounding air crescent. These appearances would be consistent with a mycetoma. The patieTlt also has a marked kyphosis with the head obscuring the lung ::apices. Moreover, on close inspection . there is a hint of syndcsmoph),tc formation along the right lateral aspeCT ofrhOr:lcic spine.

T he combination of findings is consistent \\~th upper zone fibrosis associated \\ith ankylosing spondylitis. There is myceroma formation in the fib rotic C:IVil}, in the left upper zone.

Diagnosis Ankylosing spondylitis.

Differential diagnosis For uplX'r zone fibrosis (mnemonic - 'STRAD'):

Sarcoidosis. TB. R.1diation. Ankylosing spondylitis. Dust inha13tion - inorganic (e.g. silica) and organic (i.e. chronic extrinsic allergic ah·eolitis).

Discussion Ankylosing spondylitis is an autoimmune disease that most commonl~' manifests as a seronegative ;lfthropathy, predominantly affecting the axia l skeleton (ini tially sacroiliac joints then thoracic and lumbar spine). It usually presents in the 2nd-4th decade and more fTcquently affects men (sex mtio of - 5: I ). As well as bone involvement, there arc respiratOry and cardiac m:llliteslations. Respi ralo!)' man itestations arc seen in - I % of cases and features include:

UPlX'r lobe pu lmonary tibrosis. • Relicular/ reticulonodular opacities in lUllg apices.

Apical bullae and cavit"Jtioli . Paraseptal emphysema. Bronchiectasis .

Cardiac fC:ltll res include aorti tif; involving the ascending aona with aortic \·alve insutlicielll'Y.

P13ill radiographic featu res of upper zone fibrosis include:

EIc\':Ition of the hila. Tenting of the hemidiaphragms. Ele\':Ition of the horizontal fissure on the right (a good indicator). Increased lucency of the lower zone due to hyperexpansion. Reticular opacilies ill the upper zones.

Practical tips Clues to help limit the diOercntial d iagnosis for upper zone fibrosis include:

Kyphosi' and 'bamboo spine' indicate ankylosing spondylitis. Egg shell nodal caldficalion suggests silicosis or S:trcoid. Associated calcified grJnulomatn suggest T B.

Al wa~'s look fo r signs of secondary in fection/ mycetoma in fibrot ic cavities ( ISb ). Whcn pulmona!), fi brosis due to ankylosing spondylit is is suspected, look for signs of complications of dmg treatmcnt on the film: • Ihascular necrosis of humeral heads secondary to

steroids. • Atypical dist ribution of fibrosis may be secondary

10 drug treatment.

Further management M ultidiscipl inary management is requ ired in this ll1ult isystem d isease .

18b CT image in the same patient shows a cavitating lesion in the left upper lobe apical segment containing an Aspergillus fungus bait.

ANSWER 19

Observations (19) Two Spot images from an angiogram ;11I<cstigation at the Ie ... el of the aortic arch lre prcscnt'cd. Both images show the left shoulder joinr in an alxlucTcd position. The left hand image shows contn st filling of the aortic arch with filling of the brachioccphalic tru nk and left common CUQ[id m ay. There is filli ng of the; proximal subda\~an artery but them there is a complete occlusion with no filling beyond it. The right hand image shows a slightly delayed film \\;th .:omr:ast seen in the left vcncbral artery (best seen at the k\'d of the C3/ 4 ) providing filling of the distal left wlxb.v;an anery.

Diagnosis Subclavian steal syndrome.

Discussion This is a condition that is usually acquired and caused by ahcrosdcrotic d isc:!$!:. Stenosis of the su\xla,·i3.n artery results in stcaling of blood [Q the arm via rctrogradc flow m the ipsilateral "crlcbral artery. Othcr acquired causcs -:Iudc "asculiti (T akarasu ), cmbolism, aortic disscction, radiation fibrosis and chest trauma. Congenital causes arc ancommon. Clinical features include:

lefT arm is more commonly im'oked than thc right. Reduced BP b~' up to 40 mmHg in the aflccted arm.

• Delayed/wcak pulse in the aflccted arm.

CASE 20

History \ -I4 ' ye:lT-old male having a pre cmplo)'mcnt chest radiograph.

SubcJa"ian insufficicncy - pain, numbness and weakness in the arm that is brought on by cxercising thc limb. Necrosis ofthc fin gertips. Vertebrobasilar insuflicicncy - syncope can be prccipitatcd by exercising the arm due to the stealing of blood. Headaches, ataxia, vertigo, diplopia, homonymous hcmianopi::a ::and hemiparcsis have ::all been reported.

Practical tips Di::agnosis can be m::ade nonin\'asi\"d~' by US by idemif)~ng reversal of Doppler flow in the "cnebral artery.

Further management CT can be useful to identify/characrcrizc c::alcificd atherosclerotic plaque in the subcl:lvian artcry (uncontrasted CT) and also the site/ degree of stenosis (arterial phase CT). Surgical referral is required for treatment wilh either balloon :mgioplast}' (+/ - stem insenion ) or surgical bypass (common carotid to subclavian artery).

Further reading Chung ]W, Park JH , 1m JG, etnl. ( 1996). Spiral CT

angiography ofthc thoracic aort:l. /{adioGmplJiCJ 16: 81 1- 824 .

43

44


ANSWER 20

Observations (20a) This chest radiograph shows multiple fine, sand-like, tillY calcified lesions measuring Jess than I mill in diameter, spread throughout both lungs. Both lungs arc of normal \'olul11(. No olher abnormality is seen.

Diagnosis Ain:ol:lf microlithiasis.

Oifferential diagnosis With pin-poinr high-density nodules, rhe possibilities afC Girl}' limited, as follows: • Inhaled illO%'3nic dusts such as silicosis. Nodules tend

ro be a linle larger and arc predominantly in rhe Illiddle and upper zones. CoaicscclKc \0 torm larger lesions with cavir,uian and fibrosis occurs. Egg shell calcification of nodes. Other inoTbranic inhaled dusts such as tin oxide, limestone and marble.

Slightly larger high -density opacities lead [0 a largcr ditlercntial in addition to the above:

Varicclla pneumonia - pr~\lious inlection can appear radiologically with multiple calcified nodules measuring 1- 2 mm in size. No lymph node calcification isscen. Hist9plasmosis - hcaled inlection Gill also result in multiple tiny calcifications throughom rhe lungs. Associated 'I~rh mediastinal lymph node, liver and spleen calcification. Metasr:.uic calcinosis - focal calcification within the alveolar septae due to elevated senun calcium and phosphate b 'ds in conditions such as h}'PCrparathyroidism, multiple myeloma, sarcoidosis, milk-alkali syndrome or hypervitaminosis D. There is upper zone prcdominancc and disease can progress to

fOrtn airsp;lCc opacities, consolidatil'c appcarances and fibrosis (20b). Pulmonary haemosidcrosis due to mitral vall-e disease. Barium aspiration - hyperdense opacities in the lowcr zoncs morc common on the right (20c).

Discussion This is a rare condition that aflccts adults in the 4th- 6th decades, resulting in calcification within the all'eoli. Usually these paticnts arc asymptomatic, howcI'er thcy can prcsent with dyspnoca on exenion. R.1diological appearances call be quite striking with diffuse tiny calcit1ed nodules < I mm in diamcter spread throughout borh lungs. The middle and lowcr zoncs arc preferentially aHee!ed. Serum GI1cium and phosphatc arc normal. DiAcrentiation from the causes below is usually made by thc normal biochemistry, characteriSlic radiological appearances and the p3.ucity of clinical symptoms rci3.1il'c to the lll3.rked radiological changes.

Practical tips Clinical history is of vital imponance when narro"~ng down 3. list of ditlCrcnt i3.1 diagnoses. Alveolar microlithiasis is 3. good cX:1mple of where markcd r:ldio[ogical changes :1re associatcd with a relative lack of symptoms. A simple

question to the clinician such as 'how unwell is this patient? ' can be most helpful.

Further management No further m;lIlagement is required in this benign condition.

Further reading Brown K, j\'lund OF, Aberle DR, Batra P, tt (I/. ( 1994).

Intrathoracic calcific3.tions; radiographic features and di ffe rential diagnoscs. RadioGraphiu 14; 1247-1261 .

20b Chest radiograph showing bilateral upper zone airspace opacities of metastatic calcinosis.

20c Chest radiograph showing hyperdense airspace opacities in the lower zones predominating on the right in a patient who aspirated during a barium swallow examination .

apid review - society of radiological technologists 2007-...

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