Anwser,s 8

Tuesday, April 11, 2023

Anwser,sDr :ANAS SAHLE

1. Chest xr cases.2. Chest clinical case.

3. Chest ct cases.4. MRCP exam.

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chest xr casesDr :anas sahle

http://www.facebook.com/dranas224

CXR-31

DIAGNOSIS: Aneurysm of Descending Aorta

CXR-32

DIAGNOSIS: Fungous Ball

Crescent sign - semilunar air space above mass density

CXR-33a

AspergillosisSub-acute Invasive Form

CXR-33b

Cavitation with return of white countResembling fungous ball with crescentic air

Non- mobile fungous ball

CXR-33c

Cavitation with return of white countResembling fungous ball with crescentic air

Non- mobile fungous ball

CXR-34

DIAGNOSIS: Blebs

CXR-35a

CXR-35b

DIAGNOSIS: Broncholith

Lingular pneumoniaPost obstructive pneumonia

Lingular pneumoniaPost obstructive pneumonia


DIAGNOSIS: Broncholith

CXR-36DIAGNOSIS: Left Cervical Rib

You identify the rib by the transverse process with which it articulates .

A: Transverse process cervical vertebra: HorizontalB: Transverse process dorsal vertebra: Upward

CXR-37

DIAGNOSIS: Dextrocardia


Note

• Stomach bubble on left• Right diaphragm lower – Position of heart determines which diaphragm is

lower, not liver.• Pectus accounts for increased density on left

CXR-38

DIAGNOSIS: Dextrocardia / Kertagener's Syndrome :


chest clinical casesA 20 Year-Old with a

Mediastinal MassSubmitted byTyler B. Anderson, MDFellowDivision of Pulmonary, Allergy, Critical Care and Sleep MedicineThe Ohio State University Medical CenterColumbus, OhioJonathan P. Parsons, MD, MSc, FCCPAssociate Professor of Internal MedicineDivision of Pulmonary, Allergy, Critical Care and Sleep MedicineThe Ohio State University Medical CenterColumbus, Ohio


History • A 20 year old Caucasian man with no significant past

medical history presented to his primary care physician for chest discomfort and cough.

• Two months prior to presentation, he reported having an unremarkable viral syndrome which resolved with no medical intervention.

• His primary care physician prescribed a short course of antibiotics for empiric treatment of pneumonia with some initial improvement in symptoms.

• His chest discomfort returned and he developed progressive dyspnea on exertion which led to a chest radiography.


Physical Exam• The patient was in no acute distress. • Vital signs were unremarkable. • Cardiac exam demonstrated regular rate and rhythm with no

murmur, gallop or rub. • Lungs were clear to auscultation bilaterally without wheezes or

rales. • Abdomen was soft with no hepato/spleno-megaly. • There was no palpable cervical, supra-clavicular or axillary

lymphadenopathy. • Genitourinary exam was negative for testicular masses.

Neurologic exam showed no focal deficits. • Cranial nerves appeared intact.


Lab• White blood cell count 7.2 K/uL, 56%

Neutrophils, 28% Lymphocytes, 7% Eosinophils• Chemistry and liver function testing was within

normal limits• Human chorionic Gonadotropin (HCG), serum

<0.5 MIU/mL (normal in males <5.0 MIU/ml)• Alpha-fetoprotein (AFP), serum 2.2 NG/mL

(normal 0.0-8.3 NG/ML)


cxr


Ct


• An abnormality was noted in the left mediastinum which prompted his physician to order a computed tomography (CT) of the chest and to refer him to a pulmonary specialist.

• This CT scan revealed a rounded, well-demarcated mass in the superoanterior mediastinal compartment.

• The largest diameter measured 6.8 x 4.8cm.


Question 1• What is the most common cause of an

anterior mediastinal neoplasm?

• A. Germ cell tumor • B. Lymphoma • C. Parathyroid adenoma • D. Thymoma


Discussion • The mediastinum is located in the central portion of the thorax. • The boundaries are the pleural cavities laterally, the thoracic inlet superiorly and the

diaphragm inferiorly. • The anterior compartment refers to the retrosternal space that is anterior to the heart and

great vessels. • It contains the thymus, lymph nodes, adipose and connective tissue. • Approximately one half of mediastinal tumors occur in the anterior mediastinum1. • Thymomas, lymphomas and germ cell tumors are the most frequently diagnosed tumors of

the anterior mediastinum with a relative incidence of 30%, 20% and 18%, respectively 2. • Thymomas are the most common neoplasm of the anterior mediastinum with an incidence

of 0.15 cases per 100,0003. • Interestingly, mass location tends to predict malignancy. • Approximately two thirds of all mediastinal tumors are benign, but masses in the anterior

compartment are more likely to be malignant1.• A retrospective review of 400 patients by Davis et al found that 59% of anterior masses

were malignant, compared to masses in middle mediastinum (29%) and posterior mediastinum (16%)2.


Question 2• What is the most common presenting

symptom in a patient with a mediastinal mass?

• A. Chest pain Systemic • B. Dysphagia • C. Hemoptysis • D. "B" symptoms (fever, weight loss, night

sweats)


Discussion • About two thirds (62%) of patients with mediastinal masses of

any etiology will have symptoms at the time of diagnosis2. • Chest pain is the most frequently reported symptom (30%)

followed by fever and chills (20%)2. • Anterior mediastinal masses produce symptoms at a greater

frequency (75%) than masses from middle or posterior compartments, 45% and 50% respectively2.

• Similar to mass location, presence of symptoms at diagnosis also predicts malignancy.

• Overall, 85% of patients with a malignant neoplasm were symptomatic at presentation, while only 46% of patients with benign neoplasms had symptoms2.


Question 3• What is the most common syndrome

associated with thymoma?• A. Hypogammaglobulinemia • B. Myasthenia gravis • C. Pure red cell aplasia • D. Superior vena cava syndrome


Discussion • Symptoms of myasthenia gravis include generalized weakness and fatigue, along with diplopia, ptosis and

dysphagia. • Myasthenia gravis occurs in 30-50% of patients with thymoma; however, only about 15% of patients with

myasthenia gravis have a thymoma4. • Given this strong association between thymoma and myasthenia gravis, it is recommended that all patients

diagnosed with myasthenia gravis undergo CT or magnetic resonance imaging (MRI) to evaluate the mediastinum for thymoma.

• Conversely, all patients with clinically suspected thymoma should have a serum antiacetylcholine receptor antibody level examined even if they are asymptomatic1.

• Thymectomy gradually alleviates symptoms in approximately 25% of myasthenic patients with thymoma5. • Thymoma has been associated with a number of other paraneoplastic syndromes as well. • Hypogammaglobulinemia is then next most common paraneoplastic syndrome, and is present in approximately

10% of patients with thymoma6. • Pure red cell aplasia and Good syndrome have also been reported to be associated with thymoma in rare cases.• The patient was referred to thoracic surgery for a surgical biopsy as the diagnosis was in question. • A left parasternal mediastinoscopy (Chamberlain approach) was performed. Pathology from this specimen

revealed small fragments of thymic tissue with preservation of normal architecture. • There was no histologic evidence to support malignancy and flow cytometry was negative for lymphoma. • A positron emission tomography (PET) scan revealed diffuse mild activity; the standardized uptake value (SUV)

max was 3.9, consistent with benign thymic tissue. • He was diagnosed with rebound thymic hyperplasia following the viral illness in the weeks prior to presentation .


Question 4• Which condition(s) is/are associated

with Rebound Thymic Hyperplasia (RTH)?

• A. Addison disease • B. Cancer, post chemotherapy • C. Hyperthyroidism • D. Severe burns • E. All of the above


Discussion • Rebound thymic hyperplasia (RTH) is a form of true thymic hyperplasia

which can occur in children and young adults recovering from systemic illness or after treatment of various malignancies.

• It is characterized by generalized hyperplasia with preservation of normal thymic architecture and immunohistologic appearance7.

• RTH has been documented in many clinical conditions including hyperthyroidism, Addison disease, severe burns or after chemotherapy8.

• During stress, the thymus may shrink to 40% of its original volume; then over time usually grows back to its original size within 9 months9.

• In RTH, the thymus can grow 50% larger than its original size9. • This may present a diagnostic challenge as RTH can clinically or

radiologically mimic recurrent or metastatic mediastinal neoplasms.


Question 5• What is the treatment of choice for

RTH?• A. Chemotherapy • B. Observation • C. Radiation therapy • D. Surgical resection


Discussion • The thymus is functionally active in childhood and adolescence

and may be susceptible to fluctuation in corticosteroid levels10. • The reversal of elevated endogenous corticosteroids in many of

the aforementioned conditions is thought to be a causative factor in RTH10.

• Although steroids will shrink a hyperplastic thymus11 this is usually not necessary as the transient overgrowth will resolve over time.

• The patient was observed with follow up CT scans of his chest. • The mass had decreased by greater than 50% of its original size at

3 months. • At 6 months (Figure 5) and 9 months the CT chest continued to

show further decrease in size of the mediastinal mass with no evidence of local invasion or progressive lymphadenopathy.


chest ct cases-7Dr :anas sahle

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images 1 and 2.

Look at images 1 and 2. • This case shows multiple nodules. • Asymmetry of the lungs is due to collapse of

the left upper lobe.• 1. Are the nodules focal or diffuse? • 2. What is the anatomic location of the

nodules? • a) Primarily bronchovascular

b) Primarily centrilobularc) Primarily pleurald) Random

Look at images 1 and 2. • This case shows multiple nodules. • Asymmetry of the lungs is due to collapse of the left

upper lobe.• 1. Are the nodules focal or diffuse?• diffuse • 2. What is the anatomic location of the nodules? • a) Primarily bronchovascular• b) Primarily centrilobular• c) Primarily pleural• d) Random

HRCT-1

HRCT-1

• Find the left upper lobe bronchus leading into the left upper lobe.

• Outline the collapsed left upper lobe.• In the right lung, find 3 pleural nodules.• Find 3 nodules at the end of vessels in the

right lung.• Find 4 or 5 nodules along the fissure (F) in the

right lung.

HRCT-1

HRCT-2

HRCT-2

• Find 2 centrilobular nodules in the right lung.• Find a nodule at the end of a vessel in the

posterior right lung.

HRCT-2

Histology of a Nodule

Q

• This rounded, subpleural structure, about 0.5 cm in diameter, corresponds to the subpleural lesions in the images above.

• In this case, no cellular structures are present except at the edge.

• 1. What are possible causes of this nodule? • 2. What does the homogeneous pink material

in the nodule represent?

Answer

• 1. Possible causes include infection and tumor. – This particular patient had known

metastatic testicular carcinoma. – The necrosis of the tumor may have

resulted from therapy or ischemia or both.• 2. The homogeneous pink material represents

necrosis.

Differential diagnosis of random nodules on HRCT:

• hematogenous metastasis (particularly from thyroid, kidney, and breast)

• Miliary infections. Langerhans' cell histiocytosis, sarcoidosis, and silicosis are common causes of

nodules, but such nodules are rarely diffuse and haphazard.

Histologic differential diagnosis:

• Metastatic tumor. • Infection should be considered.

HRCT diagnosis:

• Metastatic breast cancer with hematogenous spread throughout the lungs and endobronchial metastasis to the left upper lobe, resulting in collapse.

Summary

• diagnostic features of numerous hematogenous metastatic nodules on HRCT• Usually random distribution • Often smooth, well-defined • Varying size common


04/11/202353

MRCP EXAMRespiratory

04/11/202354

Q1A 9 month old child presents with respiratory distress,

worsening over 2 days. Blood gases show a

pH of 7.25, a PCO2 of 7.5kPa, a PO2 of 8.5kPa, and a base excess of -4.

• A -Results are consistent with bronchopulmonary dysplasia.

• B -Blood gases suggest type 1 respiratory failure. • C- Immediate intubation is required. • D -Results are consistent with late severe asthma. • E -Bicarbonate may be necessary to correct the

acidosis.

04/11/202355

A1 A 9 month old child presents with respiratory

distress, worsening over 2 days. Blood gases show a

pH of 7.25, a PCO2 of 7.5kPa, a PO2 of 8.5kPa, and a base excess of -4.

• A -Results are consistent with bronchopulmonary dysplasia. (False)• B -Blood gases suggest type 1 respiratory failure. (False)• C- Immediate intubation is required. (False)

• D -Results are consistent with late severe asthma.(true)

• E -Bicarbonate may be necessary to correct the acidosis. (False)


Q2• Long-acting ß2 agonists:

• A -Can be used to prevent activity-induced symptoms without anti-inflammatory therapy.

• B- Become less effective over time (tolerance). • C- Are beneficial in acute viral croup. • D- Protect against allergen challenge for up to 48

hours. • E -Should not be used in association with

erythromycin.


A2 • Long-acting ß2 agonists:

• A -Can be used to prevent activity-induced symptoms without anti-inflammatory therapy.(true)

• B- Become less effective over time (tolerance). (False) • C- Are beneficial in acute viral croup. (False)• D- Protect against allergen challenge for up to 48 hours.

(False) • E -Should not be used in association with erythromycin.

(False)


Q3The oxygen dissociation curve is shifted to the right by:

A- Decreased haemoglobin concentration

B- Reduced temperature

C- Reduced pH

D- Increased partial pressure of carbon dioxide

E- Increased DPG


A3 The oxygen dissociation curve is shifted to the right by:

A- Decreased haemoglobin concentration (False)B- Reduced temperature (False)C- Reduced pH (True)

D- Increased partial pressure of carbon dioxide (True)

E- Increased DPG (True)


Q4In lung empyema:

A- Strep. pneumoniae is usually isolated from the pleural cavity .B- Installation of urokinase may be helpful .

C- Anti-TB triple therapy is indicated if the fever does not settle within 14 days .D- An underlying malignancy should be excluded .

E- Initial treatment of the pneumonia has been inadequate.


A4 In lung empyema:

A- Strep. pneumoniae is usually isolated from the pleural cavity. (False) B- Installation of urokinase may be helpful. (True)

C- Anti-TB triple therapy is indicated if the fever does not settle within 14 days. (False) D- An underlying malignancy should be excluded. (True)

E- Initial treatment of the pneumonia has been inadequate. (False)


Q5Regarding lung development:

A- The pseudoglandular phase lasts between 16 and 26 weeks .

B- Alveolar capillaries first appear about 20 weeks of gestation .

C- The primitive airways appear as a dorsal outpouching of the foregut epithelium .D- The pulmonary vascularture is derived from endoderm .

E- The peribronchial mesenchyme (spalnchnopleura) plays an essential role in shaping the lungs during embryogenesis.


A5 Regarding lung development:

A- The pseudoglandular phase lasts between 16 and 26 weeks. (False)B- Alveolar capillaries first appear about 20 weeks of gestation. (False)C- The primitive airways appear as a dorsal outpouching of the foregut epithelium. (False)D- The pulmonary vascularture is derived from endoderm. (False)E- The peribronchial mesenchyme (spalnchnopleura) plays an essential role in shaping the lungs during embryogenesis. (True)


Q6Recognised causes of acute upper airway obstruction include:

A- Angio-oedema

B- Asthma

C- Mumps

D- Retro-pharyngeal abscess

E- Laryngomalacia


A6 Recognised causes of acute upper airway obstruction include:

A- Angio-oedema(True)

B- Asthma(False)C- Mumps(False)D- Retro-pharyngeal abscess(True)

E- Laryngomalacia(False)


Q7The following lung function tests are compatible with severe scoliosis:A- An FEV1 of 65% of normal .B- An FEV1/2 of 65% of normal .C- Total lung capacity of 95% of normal .D- Tidal volume of 105% of normal .E- Peak flow of 50% of normal.


A7 The following lung function tests are compatible with severe scoliosis:A- An FEV1 of 65% of normal. (True) B- An FEV1/2 of 65% of normal. (False) C- Total lung capacity of 95% of normal. (False) D- Tidal volume of 105% of normal. (True) E- Peak flow of 50% of normal. (True)


Q8Concerning Tuberculosis:

A- The infection rate is increased in Crohn's Disease .B- Overcrowded living conditions do not significantly affect prevalence .

C- The treatment of lymph node infection is of a greater duration than pulmonary infection.D- The tuberculin skin test is a good indicator of disease activity .

E- In pregnant women treatment should be delayed until after birth.


A8 Concerning Tuberculosis:

A- The infection rate is increased in Crohn's Disease. (False) B- Overcrowded living conditions do not significantly affect prevalence. (False)

C- The treatment of lymph node infection is of a greater duration than pulmonary infection. (False)D- The tuberculin skin test is a good indicator of disease activity. (False)

E- In pregnant women treatment should be delayed until after birth. (False)


Q9The following are signs of severe asthma:

A- A silent chest in a 7 year old girl .B- Inability to feed in a 10 month old child .C- A heart rate of >90 in a 5 year old child .

D- Decreased right-sided breath sounds in a 10 year old girl .E- A respiratory rate of 60 in a 2 year old boy.


A9 The following are signs of severe asthma:

A- A silent chest in a 7 year old girl. (True) B- Inability to feed in a 10 month old child. (True) C- A heart rate of >90 in a 5 year old child. (False)

D- Decreased right-sided breath sounds in a 10 year old girl. (False) E- A respiratory rate of 60 in a 2 year old boy. (True)


Q10Lung biopsy may be useful in the following cases:

A- A 6 month old boy ventilated for adenovirus infection .

B- A 2 year old with leukaemia and possible adreamycin toxicity .

C- A 4 year old child with dense lower zone opacities on chest x-ray .

D- A 3 month old Afro-Caribbean boy with "ground glass" chest x-ray .

E- A 4 month old with severe confirmed RSV positive bronchiolitis.


A10 Lung biopsy may be useful in the following cases:

A- A 6 month old boy ventilated for adenovirus infection. (True)

B- A 2 year old with leukaemia and possible adreamycin toxicity. (False)

C- A 4 year old child with dense lower zone opacities on chest x-ray. (False) D- A 3 month old Afro-Caribbean boy with "ground glass" chest x-ray. (True)

E- A 4 month old with severe confirmed RSV positive bronchiolitis. (False)


Health & Medicine

Anwser,s 8