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1. Anwser,s
Dr :ANAS SAHLE
1. Chest xr cases.
2. Chest clinical case.
3. Chest ct cases.
4. Collicum exam.
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Sunday, January 13, 2013

2. chest xr cases
Dr :anas sahle
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3. CXR-46
DDX:
Lymphoma
Sarcoidosis

4. CXR-47
Sign name is: Cannon Balls - Lung Metastasis

5. CXR-48
Diagnosis is : Cavitating Metastasis

6. CXR-49
Solitary pulmonary metastasis
this patient had Cancer Thyroid

7. CXR-50
Lymphangitic Metastasis
Cancer Breast
•Missing right breast
•Bilateral diffuse interstitial
changes
Old film Diagnosis is:
Lymphangitic Metastasis

8. CXR-51
Bilateral
Air space disease
Vertical (non-segmental) Left Hilar and Mediastinal Radiation
Corresponding to Diagnosis is: Radiation Pneumonitis
radiation port

9. CXR-52
Diagnosis is: Sarcoidosis
Alveolar form
Bilateral symmetrical hilar nodes

10. Sunday, January 13, 2013

11. chest clinical cases
A Case of Recurrent
Pneumothoraces
Submitted by
J. Shaun Smith, DO
Fellow
Pulmonary and Critical Care Medicine
The Ohio State University
Columbus, Ohio
James N. Allen, MD
Professor of Medicine
The Ohio State University
Columbus, Ohio

12. History
• A 41-year-old female presents to pulmonary outpatient clinic with a history of right-sided
pneumothorax, which had resolved.
• She gives a history of several spontaneous pneumothoraces on her right side over the past
6 years.
• She provides a past medical history of endometriosis and is being treated symptomatically
with occasional over-the-counter medications.
• She also has a history of right-sided pleural procedure after the second pneumothorax.
• However, despite this surgical intervention, she continues to have recurrence of the
pneumothorax.
• Of note each pneumothorax resolved without intervention or complication.
• Pulmonary function testing (PFT) was performed demonstrating a FEV1 of 86%
predicted, total lung capacity (TLC) of 112 % predicted and diffusion capacity of 93 %
predicted.
• There was no significant response to bronchodilator challenge.
• Her remaining past medical history is significant for chronic low back pain from an L4-5 disc
herniation, now status-post discectomy, chronic knee pain from osteoarthritis, and
arthroscopic anterior cruciate ligament surgery.
• Her only medications are nonprescription anti-inflammatories and a multivitamin.
• She has never used tobacco or recreational drugs.
• Family history is unremarkable. Sunday, January 13, 2013

13. cxr
Sunday, January 13, 2013

14. Ct
Sunday, January 13, 2013

15. Question 1
• What is the most likely diagnosis?
• A. Catamenial Pneumothorax
• B. Lymphangioleiomyomatosis
• C. Congenital bullous disease
• D. Marfan’s syndrome
Sunday, January 13, 2013

16. Question 2
• Which of the following is NOT associated
with thoracic endometriosis?
• A. Hemoptysis
• B. Neck pain
• C. Pulmonary nodules
• D. Transudative effusion
Sunday, January 13, 2013

17. discussion
• Thoracic endometriosis, which is most likely cause of catamenial
pneumothorax, can present in various other forms.
• Pneumothorax is the most common presentation (73%) followed by
hemothorax (14%), hemoptysis (7%), and lung nodules (6%) (6).
• Interestingly, hemothorax correlated most with the presence of either
pleural or pelvic endometriosis.
• Hemoptysis is caused by endobronchial or parenchymal ectopic
endometrial tissue.
• During bronchoscopy, the lesions appear as purplish-red patches which
bleed easily on contact.
• Cytology will show clusters of small cuboidal cells characteristic of
endometrial tissue .
• Pain is also quite common, and is often due to diaphragmatic
endometrial implants.
• Discomfort may be referred to the ipsilateral neck, shoulder, chest or
arm.
Sunday, January 13, 2013

18. Question 3
• What is the proposed mechanism for catamenial
pneumothorax?
• A. Congenital diaphragmatic fenestrations
• B. Acquired diaphragmatic fenestrations from
endometrial implants
• C. Metastatic spread of endometrial tissue
• D. Release of dinoprost tromethamine during
menstruation
• E. All of the above
Sunday, January 13, 2013

19. discussion
• The mechanism for catamenial pneumothorax is unclear.
• Four possible mechanisms have been proposed.
• The first potential mechanism is congenital diaphragmatic defects providing
an opening between the peritoneal cavity and the atmosphere.
• When the cervical mucus plug is absent, air is allowed to migrate upward
through the peritoneal cavity into the pleural space.
• The second mechanism involves necrotic endometrial implants on the
diaphragmatic surface creating a perforation in the diaphragm.
• Thirdly, catamenial pneumothorax could also be caused by metastatic
spread of endometrial implants through the pelvic veins reaching systemic
circulation.
• This last proposed mechanism involves implants disrupting the pleural
surface during menses.
• The prostaglandin dinoprost tromethamine, which is present in the plasma
of some women during menses, constricts both bronchioles and
vasculature, which may result in pneumothorax when alveolar tissue is
damaged and associated bronchospasm prohibits expiration .
Sunday, January 13, 2013

20. Question 4
• What is the preferred treatment of
catamenial pneumothorax?
• A. Oral Contraceptives
• B. Pleurodesis
• C. Repair of diaphragmatic defects
• D. Combined surgical intervention and
hormonal manipulation
Sunday, January 13, 2013

21. discussion
• There are several therapeutic options to treat catamenial pneumothorax.
• Nonsurgical treatment includes hormonal suppression with medications, such as leuprolide, a
gonadotropin-releasing hormone, and standard oral contraceptives .
• Surgical intervention includes bilateral salpingo-oophorectomy, closure of diaphragmatic defects
and pleurodesis.
• Polyglactin mesh has been used to cover the diaphragm as well in an effort to occlude occult
fenestrations. This also promotes adhesion of the lung to the diaphragm .
• Overall, a combined surgical approach followed by hormonal manipulation has been most
successful in preventing recurrences, with a 50% success rate .
• Video-assisted thoracoscopy is the preferred method for surgical assessment and treatment (9).
• The pleural and diaphragmatic surfaces can be inspected at which time superficial endometrial
implants are vaporized using combination of hydrodissection and carbon dioxide laser.
• Deeper implants, however, require sharp dissection.
• With video-assisted thoracoscopy diaphragmatic defects can be resected and closed with an
endoscopic stapler device.
• Standard thoracotomy may be employed when video-assisted thoracoscopy in not adequate or
prior surgical intervention has failed.
• Talc pleurodesis and pleurectomy should only be considered in cases of treatment failure .
Sunday, January 13, 2013

22. Sunday, January 13, 2013

23. chest ct cases-9
Dr :anas sahle
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24. HRCT-1

25. HRCT-1
• 1. Are the nodules diffuse or patchy?
• Diffuse.
• 2. What is their distribution?
• Random.

26. HRCT-2

27. HRCT-2
• Find nodules along the inter-lobar fissure in
the right lung.
• Find nodules at the peripheral pleura.
• Find centrilobular nodules.
• Find a nodule at the end of a vessel in the in
the left lung

28. HRCT-2

29. Gross Appearance

30. • The lesions in this slice of lung correspond to
those shown above.
• Compare the size of the nodules in the lower
lung to that in the upper lung.
• Are they larger or smaller?
• SMALLER
• Can you give a reason for your answer?

31. Histologic Findings

32. • Compare the amount of cytoplasm in the
rounded collection of cells indicated by the
thin arrows to the amount in the surrounding
cells.
• Which cells have more cytoplasm?
• What types of cells are in the rounded
nodule?
• What type of cell is indicated by the thick
arrow?
• What is the histologic diagnosis?

33. • Which cells have more cytoplasm?
• The cells delimited by arrows
• What types of cells are in the rounded nodule?
• Mostly epithelioid histiocytes (with prominent
cytoplasm), some lymphocytes
• What type of cell is indicated by the thick arrow?
• A multinucleated giant cell
• What is the histologic diagnosis?
• Ill-defined, non-necrotizing granuloma

34. Differential diagnosis of random nodules
on HRCT:
• miliary tuberculous.
• Fungal.
• viral infections.
• hematogenous metastasis (particularly from
thyroid, kidney, and breast).

35. Histologic differential diagnosis:
• infectious granulomas (mycobacterial and
fungal).
• Sarcoidosis.
• hypersensitivity pneumonia.

36. Diagnosis:
Miliary tuberculosis

37. Sunday, January 13, 2013

38. Collicum EXAM
Respiratory
1/13/2013

39. A1
•
Churg-Strauss syndrome .A
.Esophageal perforation .B
Splenic abscess .C
Radiation therapy .D
eosinophilic pneumonitis .E
Sunday, January 13, 2013

40. A2
•
.A
.B
.C
.D
.E
Sunday, January 13, 2013

41. A3
•
PH .A
PH .B
PH .C
transudat .D
.E
anaerobic
Sunday, January 13, 2013

42. A4
. •
FVC 62% •
FEV1 46% •
FEVI/FVC 62% •
TLC 92% •
DLCO 44% •
•
.A
.B
.C
.D
.E
Sunday, January 13, 2013

43. A5
•
Emphysema .A
.B
Asbestos .C
mesothelioma .D
.E
Sunday, January 13, 2013

44. A6
•
FVC 70% •
FEV1 80% •
FEVI/FVC 110% •
TLC 92% •
DLCO 88% •
•
.A
.B
.C
.D
.E
Sunday, January 13, 2013

45. A7
•
Pre Post Ventoline •
FVC 75% 70% •
FEV1 50% 70% •
FEVI/FVC 60% 100% •
TLC 92% 85% •
DLCO 70% 80% •
•
.A
.B
.C
.D
.E
Sunday, January 13, 2013

46. A8
Dynamic . •
Hyperinflation
. Inspiratory .A
Capacity
COPD .B
.C
.D
.E
Sunday, January 13, 2013

47. A9
•
.A
Ipratropium Bromide .B
Inhaled glucocorticoioids . .C
Salbutamol .D
.E
Sunday, January 13, 2013

48. A10
•
.A
Montelukast .B
.C
.D
Ipratropium Bromide .E
Sunday, January 13, 2013

49. Sunday, January 13, 2013