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(Unit-5) Vinod Kumar.R

Clinical summary
Mrs Prasanna 48 years of age C/O Exertional breathlessness 20 days NYHA Class 4 Dyspnoea 1 week -Fever -Anorexia -Hemoptysis few episodes

OnExamination
Patient was tachypnoeic RR 30/min Grade 2 Clubbing Central Cyanosis, HR -112/min, SpO2- 76% RA and improved to 98% with 6L/min O2 CVS - S1, S2 heard RS Bilateral Coarse Biphasic crackles, Scattered Rhonchi

But the patient did not respond to treatment and succumbed to her illness within 2 hours after admission

CXR PA View..... First X Ray

CXR:
PA View Adequate Penetration , Non Rotated Film in full Inspiration Trachea Midline Cardio-Thoracic Ratio: - Normal, Costo-phrenic , Cardio-Phrenic Angles free Multiple diffuse ,Parenchymal, not well defined, Non-Calcified nodular opacities seen in both lungs in all the zones ,more on the right side than on the left varying in size.

Differentials Of Multiple Pulmonary Nodules :

Neoplastic Metastases Malignant lymphoma/lymphoproliferative disorders
Inflammatory Granulomas Fungal and opportunistic infections Septic emboli Rheumatoid nodules Wegener granulomatosis Sarcoidosis Langerhan cell histiocytosis Congenital Arteriovenous malformations (Osler-Weber-Rendu Syndrome) Miscellaneous Hematomas Pulmonary infarcts Occupational (silicosis)

 In more than 95% of patients with multiple pulmonary nodules, the etiology of the nodules is (a) metastases or (b) tuberculous or fungal granulomas

 Pt has had menstrual irregularities for more than 1 year visited doctor 5 months back found to have mass descending PV advised Surgery but she refused and took native treatment. Past Gynaecological hx Per Vaginal Exm: showed hard mass involving the vaginal vault and extending from the uterine Cervix.

Cx Tissue biopsy : Uterine leiomyosarcoma identified

FINAL Diagnosis
LEIOMYOSARCOMA WITH MULTIPLE PULMONARY SECONDARIES (Cannon ball Metastasis )

CT THORAX

CAUSES OF CAVITARY PULMONARY NODULES

Carcinoma (bronchogenic, metastases especially squamous cell) Autoimmune (Wegener granulomatosis, rheumatoid nodules) Vascular (bland and septic emboli) Infection (especially mycobacterial and fungal) Trauma (pneumatocele) Young i.e., congenital (sequestration, diaphragmatic hernia, bronchogenic cyst)

SOURCE OF METASTASIS
breast, colon kidney, uterus, prostate, head, and neck (M.C). choriocarcinoma, osteosarcoma, Ewing sarcoma, testicular tumors melanoma, and thyroid carcinoma(L.C) Calcification most commonly with osteosarcoma and chondrosarcoma or after successful treatment of metastases. A miliary nodular pattern of metastases is seen most commonly with thyroid or renal carcinoma, bone sarcoma, trophoblastic disease, or melanoma.

CAUSES OF SOLITARY PULMONARY NODULES Neoplastic: Malignant Bronchogenic carcinoma Solitary metastasis Lymphoma Carcinoid tumor Congenital Arteriovenous malformation Lung cyst Bronchial atresia with mucoid impaction

Neoplastic: Benign Hamartoma Benign connective tissue and neural tumors (e.g., lipoma, fibroma, neurofibroma) Inflammatory Granuloma Lung abscess Rheumatoid nodule Inflammatory pseudotumor (plasma cell granuloma)

Miscellaneous Pulmonary infarct Intrapulmonary lymph node Mucoid impaction Hematoma Amyloidosis Normal confluence of pulmonary veins Mimics of SPN Nipple shadow Cutaneous lesion (e.g., wart, mole) Rib fracture or other bone lesion

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