Eva Castañer

CT Diagnosis of Chronic Pulmonary Thromboembolism

Chronic pulmonary thromboembolism is mainly a consequence of incomplete resolution of pulmonary thromboembolism. Increased vascular resistance due to obstruction of the vascular bed leads to pulmonary hypertension. Chronic thromboembolic pulmonary hypertension is clearly more common than previously was thought, and misdiagnosis is common because patients often present with nonspecific symptoms related to pulmonary hypertension. Computed tomography (CT) is a useful alternative to conventional angiography not only for diagnosing chronic pulmonary thromboembolism but also for determining which cases are treatable with surgery and confirming technical success postoperatively. The vascular CT signs include direct pulmonary artery signs (complete obstruction, partial obstruction, eccentric thrombus, calcified thrombus, bands, webs, poststenotic dilatation), signs related to pulmonary hypertension (enlargement of main pulmonary arteries, atherosclerotic calcification, tortuous vessels, right ventricular enlargement, hypertrophy), and signs of systemic collateral supply (enlargement of bronchial and nonbronchial systemic arteries). The parenchymal signs include scars, a mosaic perfusion pattern, focal ground-glass opacities, and bronchial anomalies. The presence of one or more of these radiologic signs arouses suspicion and allows diagnosis of this entity. Early recognition of chronic pulmonary thromboembolism may help improve the outcome, since the condition is potentially curable with pulmonary thromboendarterectomy.

When to Suspect Pulmonary Vasculitis: Radiologic and Clinical Clues

Vasculitis is an inflammatory destructive process affecting blood vessels. Pulmonary vasculitis may be secondary to other conditions or constitute a primary, and in most cases idiopathic, disorder. Underlying conditions in the secondary vasculitides are infectious diseases, connective tissue diseases, malignancies, and hypersensitivity disorders. The most widely used approach to classifying the primary vasculitides is based on the size of the affected vessels (large, medium, small). Thoracic involvement is most commonly seen with primary idiopathic large-vessel vasculitides (Takayasu arteritis, giant cell arteritis, Behçet disease) and primary small-vessel antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (Wegener granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome). The radiologic manifestations of primary pulmonary vasculitis are extremely variable and include vessel wall thickening, nodular or cavitary lesions, ground-glass opacities, and consolidations. Diffuse alveolar hemorrhage is a clinical syndrome that usually results from primary small-vessel vasculitis in the lungs. Although chest radiography is often the first imaging study performed in patients with pulmonary involvement by vasculitis, chest radiographs often fail to show the exact pattern and extent of thoracic involvement and CT is more useful in assessment of the thoracic findings. The pulmonary primary vasculitides are rare disorders, and their diagnoses are among the most demanding challenges in medicine because their signs and symptoms are nonspecific and overlap with those of infections, connective tissue diseases, and malignancies; thus, diagnosis of vasculitis relies on recognition of characteristic combinations of particular clinical, radiologic, laboratory, and histopathologic features.

PRIMARY LYMPHOMA OF THE BREAST: MR IMAGING FEATURES. A CASE REPORT

Primary non-Hodgkins lymphoma (NHL) of the breast are rare and represent less than 0.6% of all mammary malignancies. Secondary involvement of the breast in patients with diffuse disease occurs more frequently. The radiologic features of breast lymphoma are nonspecific, and the diagnosis is based on histologic criteria. We present the MR-imaging features of a case of primary NHL of the breast.

Idiopathic azygos vein aneurysm: a rare cause of mediastinal mass

Venous aneurysm of the azygos arch is a very rare cause of mediastinal mass and is usually an incidental finding on chest radiography. Nowadays the diagnosis is made by non-invasive tests such as thoracic CT scanning and/or magnetic resonance imaging. The case is described of an asymptomatic woman in whom a mediastinal mass due to an azygos vein aneurysm was diagnosed by non-invasive procedures, the aetiology of which, in all probability, was idiopathic.

Pseudomonas aeruginosa isolates in severe chronic obstructive pulmonary disease: characterization and risk factors

BackgroundPatients with severe chronic obstructive pulmonary disease (COPD) are at increased risk of infection by P. aeruginosa. The specific role of bronchiectasis in both infection and chronic colonization by this microorganism in COPD, however, remains ill defined.To evaluate the prevalence and risk factors for P. aeruginosa recovery from sputum in outpatients with severe COPD, characterizing P. aeruginosa isolates by pulsed-field gel electrophoresis (PFGE) and focusing on the influence of bronchiectasis on chronic colonization in these patients.MethodsA case-cohort study of 118 patients with severe COPD attended at a Respiratory Day Unit for an acute infectious exacerbation and followed up over one year. High-resolution CT scans were performed during stability for bronchiectasis assessment and sputum cultures were obtained during exacerbation and stability in all patients. P. aeruginosa isolates were genotyped by PFGE. Determinants of the recovery of P. aeruginosa in sputum and chronic colonization by this microorganism were assessed by multivariate analysis.ResultsP. aeruginosa was isolated from 41 of the 118 patients studied (34.7%). Five of these 41 patients (12.2%) with P. aeruginosa recovery fulfilled criteria for chronic colonization. In the multivariate analysis, the extent of bronchiectasis (OR 9.8, 95% CI: 1.7 to 54.8) and the number of antibiotic courses (OR 1.7, 95% CI: 1.1 to 2.5) were independently associated with an increased risk of P. aeruginosa isolation. Chronic colonization was unrelated to the presence of bronchiectasis (p=0.75). In patients with chronic colonization the isolates of P. aeruginosa retrieved corresponded to the same clones during the follow-up, and most of the multidrug resistant isolates (19/21) were harbored by these patients.ConclusionsThe main risk factors for P. aeruginosa isolation in severe COPD were the extent of bronchiectasis and exposure to antibiotics. Over 10% of these patients fulfilled criteria for chronic colonization by P. aeruginosa and showed clonal persistence, independently of the presence of bronchiectasis.

Enhancement of intramammary lymph nodes with lymphoid hyperplasia: a potential pitfall in breast MRI

Abstract. We present three cases of breast lesions labeled as probable intramammary lymph nodes that showed an increase in size on follow-up mammography. Contrast-enhanced MRI was performed and the three lesions showed strong and rapid uptake of the intravenous contrast. Core needle biopsy established the diagnosis of lymphoid hyperplasia in all three patients. Because intramammary lymph nodes affected by benign processes can present findings similar to malignant lesions, the usefulness of contrast-enhanced MRI in these cases is controversial.

Cellulose granulomatosis of the lungs.

Abstract. Chest radiographs and high-resolution chest CT scans were performed in a 30-year-old man with a history of intravenous drug abuse and diffuse micronodular infiltrates. Transbronchial biopsy gave a diagnosis of cellulose granulomatosis of the lung. Cellulose granulomatosis should be considered in the differential diagnosis of pulmonary interstitial disease, especially in the setting of intravenous drug abuse.

Nodular pattern at lung computed tomography in fat embolism syndrome: a helpful finding.

Abstract: The purpose of this study is to describe the computed tomography (CT) findings in pulmonary fat embolism syndrome (FES). The chest radiographs and CT scans of 5 patients with the diagnosis of FES as determined by the presence of at least 1 major and 4 minor criteria were reviewed. The radiologic features included ground-glass opacities, with different patterns of presentation seen in all patients. Three patients presented with alveolar opacities, and small (<1 cm) ill-defined nodules were seen in 4 of 5 patients. In the context of a patient with previous trauma and the clinical suspicion of FES, the presence of nodules at CT examination may be a helpful finding in the diagnosis of this entity. The chest radiographs and CT scans of 5 patients with the diagnosis of FES as determined by the presence of at least 1 major and 4 minor criteria as defined by Gurd and Wilson were reviewed.

The impact of stereotactic large-core needle biopsy in the treatment of patients with nonpalpable breast lesions: a study of diagnostic accuracy in 510 consecutive cases

Abstract. The objective of this study was to assess the usefulness of stereotactic large-core needle biopsy (LCNB) in the management of nonpalpable breast lesions (NBL) and compare it with stereotactic fine-needle aspiration biopsy (SFNA) performed simultaneously in a significant number of cases. From November 1993 through June 1997, 510 consecutive patients with NBL underwent 14-gauge LCNB with 354 women undergoing simultaneous 21-gauge SFNA in the same lesion. Mammographic findings, lesion size, number of core biopsy specimens, complications and diagnoses of both techniques were analysed. Surgical biopsy, tumorectomy or mastectomy was indicated for malignancy or poor correlation between SFNA or LCNB results and clinical or radiological findings. Values of diagnostic accuracy of both LCNB and SFNA were determined. The ratio benign surgical biopsies/malignant surgical biopsies (BB/CB) of the series was calculated. A total of 171 patients underwent surgical treatment; in 31 (18.1 %) a benign process or atypical ductal hyperplasia was the final diagnosis. The ratio BB/CB was 0.22. Sensitivity and specificity were 93.2 and 100 %, respectively, for LCNB, and 77.2 and 92.3 %, respectively, for SFNA with cytological analysis. Large-core needle biopsy provides more accurate diagnosis than SFNA in the management of nonpalpable breast lesions and obviates a surgical diagnostic procedure in a significant number of cases.

Benign pleural diseases

The pleural space is a potential space under normal physiologic circumstances. It envelops the lung, the mediastinum, the diaphragm and the chest wall. A thin film of pleural fluid provides lubrication for the two pleural layers; only 2-10 ml of pleural fluid is present in healthy people. For the purposes of this review, pleural abnormalities will be divided into pleural effusion, pneumothorax, and pleural calcification.