Adult Chest Disease

KT/V
 Scope
• Pulmonary infections
• Diseases of the airways
• Diffuse lung disease
 Pulmonary infections
• Acute pneumonia
• Pulmonary tuberculosis
• Other myobacterial pulmonary infections
• Branching bacteria
• Fungal infections
 Acute pneumonia
– Bacterial pneumonias
– Mycoplasma pneumonias
– Viral pneumonias
– Chlamydial and rickettsial pneumonias
– Lung abscess
– Aspiration and inhalation
 Streptococcus pneumoniae
• Most common cause
in all age groups
• Lobar consolidation
• Air bronchogram
• May proceed to
pleural effusion and
empyema
 Staphylococcus aureus
• Superinfection in
influenza
• Hematogenous
• Bronchopneumonia
• Multiple patchy
consolidation,
cavitation
 Klebsiella pneumonia
• Lobar
consolidation
• Right, upper lobe
• Increased volume
 bulging of
fissures
• Cavitation
 Klebsiella pneumonia
• Lobar
consolidation
• Right, upper lobe
• Increased volume
 bulging of
fissures
• Cavitation
 Legionnaire’s disease
• Spreading
consolidation
• One lobe 
opposite lung
• Slow resolution
 Pseudomonas and E.coli
• Chronic lung
disease- COPD, CF
• Long term ATB
• Basal
bronchopneumonia
 Melioidosis
• Burkholderia
pseudomellei
• Endemic area
• Disseminate
septicemia
• Consolidation
• Necrotizing pneumonia
 Mycoplasma pneumoniae
• Atypical bacteria
• Young adults
• Fine reticular or
nodular shadows
• consolidation
 Viral pneumonias
• Distal bronchi and bronchioles
• Interstitial process with destruction of
epithelium, edema and lymphocytic
infiltration
• Radiological appearances
– Peribronchial shadowing
– Reticulonodular shadowing
– Patchy or extensive consolidation
• Influenza virus
– Secondary
bacterial
infection
• Varicella zoster
– Adults more
than children
– Acute:
widespread
nodular
shadows
– Recovery:
calcify nodules
 Lung abscess
• Suppuration and
necrosis of pulmonary
tissue
• Causes
• Most common:
aspiration of upper RS
tract
• Air-fluid level:
communication with the
airways
 Aspiration

• Mendelson’s
syndrome
• aspiration of acid
gastric contents:
bronchospasm
edema hypoxia
 Pulmonary tuberculosis

• Primary pulmonary TB
– Most common: lower
lobe, subpleural lines
– Primary complex
• Peripheral consolidation
(Ghon focus)
• Regional lymph nodes
 Post primary infection
• Apex of upper or lower
lobe lordotic view
• Progress to
consolidation, cavities
• Fibrosis and volume
loss: healing
• Cavities, bronchiectasis
• Chronic cavities
colonized by aspergillus
• Miliary TB • Pleural changes
– Hematogenous spread of
infection – Pleural effusion
– Small discrete nodules 1-2 – Pleural thickening
mm in diameter – Pneumothorax
• Tuberculoma • Airway involvement
– Localized granuloma
– Solitary well-defined
nodule up to 5 cm
• Lymphadenopathy
– Hilar and mediastinal:
primary infection
Pulmonary TB
 Nocardiosis
– Nonsegmental
cavitating pneumonia
– Pleural effusion,
empyema
– Immunocompromised
 Fungal infection
• Histoplasmosis
– Calcified hilar or
mediastinal nodes
– Later progression:
fibrosis and
cavitation
– Fibrosing
mediastinitis
 Aspergillosis
• Allergic
bronchopulmonary
aspergillosis (ABPA)
• Aspergilloma
– Ball or mycetoma free
in the cavity
– Mobile ball when
change position
DDx: blood clot,
cavitating tumor, lung
abscess
 Aspergillosis

• Invasive aspergillosis
– Immunocompromised
patient
– Bronchopneumonia,
multiple nodules
– HRCT: Halo sign
 AIDS
• Infectious
– PCP
– Mycobacterial
– Fungal
• Noninfectious
– Kaposi sarcoma
– LIP
– lymphoma
 Pneumocystis jiroveci
• Most common in
CD4<200
• Perihilar, mid and lower
zone bilateral interstitial
or ground-glass
infiltrate
• Rapidly progressive to
entire lung
• Thin-wall cavity
• Pneumothorax
• TB
– Early stages: reactivation TB
– Later: primary TB
• Fungal
– Disseminated disease
 Kaposi’s sarcoma

• Ill-defined nodules
• Pleural effusions
• lymphadenopathy
Lymphocytic interstitial pneumonitis

• Mid and lower

zone reticular
infiltrate
• Slow progression
• No pleural or LN
involvement
 Lymphoma
• Atypical
mediastinal nodal
enlargement
• Pleural/ pericardial
effusions
• Pulmonary
infiltrate/ mass
 Diseases of the airways
• Trachea and bronchi
• Obstructive airway disease
• The lungs: collapse and consolidation
 Tracheal narrowing
• Fibrosing mediastinitis
– TB, histoplasmosis
– Wegener, relapsing polychondritis,
sarcoidosis
• Sabersheath trachea: elderly men, COPD
– Normal tracheal wall
– Reflex of abnormal intrathoracic pressure
• Tracheal stenosis
– Injury, iatrogenic
 Tracheal narrowing
• Primary tumors
– Benign: papilloma, fibroma
– Malignant: close to carina, squamous
– Localized mass or long stricture
• Tumors from other site
– Locally invasion: thyroid, esophagus or lung
– Distant metastasis: melanoma
 Bronchi
• Bronchiectasis
– Irreversible dilatation of one
or more bronchi
– Causes
• Post infection
• Kartagener, CF
– Tramline shadows or ring
shadows
– Dilated, fluid-filled bronchi:
gloved finger
– Air fluid level
Obstructive airways disease
 Asthma
• Remission:normal CXR
• Attack: hyperinflation
– Depress of the diaphragm
– Expansion of retrosternal air space
• Complication: PAH, pneumothorax, atelec
 Chronic bronchitis
• 50% normal CXR
• ↑ bronchovascular markings
• Bronchiectasis
• Emphysema
 Emphysema
• Panacinar
– Reduction of pulmonary vascularity
peripherally
– Hyperinflation of the lungs
– Alteration of the cardiac shadow and central
pulmonary arteries
– Increase retrosternal air space
– Long and narrow heart
– Cor pulmonale: RV dilatation
 Emphysema

• Bullous disease of
the lungs
– Round or oval
translucencies
varing in size
– Smooth, curved,
hairline shadow
wall
 Emphysema
• Unilateral emphysema
– Hypertransradiant hemithorax
– Childhood viral infection
– Expiration: displacement of the mediastinum
to the more normal side, restriction of the
ipsilateral diaphragm
 The Lungs
• Collapse
Indirect signs
– Elevation of the hemidiaphragm
– Mediastinal displacement
– Hilar displacement
– Compensatory hyperinflation
Complete collapse of a lung
RUL collapse
RML collapse
Lower lobe collapse
Lower lobe collapse
Lingular collapse
LUL collapse
 Rounded atelectasis
• Asbestos
exposure
• Secondary to
exudative
pleural effusion
 Consolidation
• Replacement of air by fluid or solid
material
• Causes
– pneumonia,
– pulmonary edema
– Hemorrhage
– Tumor: alveolar-cell CA, lymphoma
– Alveolar proteinosis
• Normal lung
volume: if no
collapse
• Consolidation c
patent airway 
air bronchogram
 Diffuse lung disease
• Sarcoidosis
• CNT diseases
• Systemic vasculitides
• Diffuse pulmonary fibrosis
• Pulmonary alveolar proteinosis
 Sarcoidosis
• Thoracic lymphadenopathy
– Bilateral, symmetric hilar enlargement
– LN: egg-shell calcification
• Parenchymal lung opacities
– Multiple nodular opacities: ground glass/
miliary shadows
– Peribronchovascular and subpleural
Sarcoidosis
 Connective tissue diseases
• SLE
• Rheumatoid disease
• Systemic sclerosis
• DM/PM
• Ankylosing spondylitis
 SLE
• Pleuritic chest pain:
effusion
• Decreased diaphragm
movement: atelectasis
of lower lobes
• Patchy consolidation:
+- cavitation
– Infection, pulmonary
edema, infarction
– Lupus pneumonitis
– Pulmonary
hemorrhage
 Rheumatoid disease
• Pleural effusions
– Low glucose, lymphocyte
predominate
• Pulmonary nodules
– Asso. Subcutaneous
nodules
– Caplan’s: nodules on
pneumoconiosis
• Fibrosing alveolitis
 Systemic sclerosis

• Pulmonary fibrosis
• Pulmonary artery
hypertension
• Dilated esophagus
• Honey comb
change eventually
 DM/PM

• Basal fibrosing
alveolitis
• Associated with
anti-synthetase
syndrome
• Anti Jo-1 Ab
 Ankylosing spondylitis

• Upper lobe fibrosis

• Bilateral
• Apical pleural
thickening
 Systemic vasculitides
• Wegener’s
granulomatosis
– Pulmonary masses
– Diffuse reticular or
irregular nodular
– Small pleural effusion
– Paranasal sinus
opacification
 Churg-Strauss Disease
• Asthma, eosinophilia
• Alveolar consolidations, diffuse coarse
reticulation
• Wax and wane
• Pulmonary infarcts
 Diffuse pulmonary fibrosis
• IPF
• Langerhans cell histiocytosis
• Tuberous sclerosis
• Lymphangioleiomyomatosis
• Neurofibromatosis
• ARDS
Idiopathic pulmonary fibrosis
 Langerhans cell histiocytosis
• Mixture of
discrete
nodules and
cystic spaces
• Sparing of the
lung base
 TS, LAM, NF

• Normal lung
volume
• Multiple thin-walled
cysts
• LAM: chylothorax
• NF: slow progress
• pneumothorax
ARDS
 Pulmonary alveolar proteinosis
• Type II pneumocytes overproduce a
proteinaceous lipid-rich material
• Xray: pulmonary edema
• Small, acinar, perihilar opacities
• Crazy paving pattern: thickening of
interlobular septa, ground-glass
shadowing
THE END