An unusual cause of breathlessness and profuse micronodules

We describe a 21-year-old male with a history of smoking and subacute onset of breathlessness with normal cardiorespiratory examination. The presence of "track marks" and digital infarcts prompted evaluation for infective endocarditis and confrontational history taking revealed anorexia, weight loss over 3 months along with intravenous drug abuse of reconstituted tablets of tapentadol. Echocardiography was normal and blood cultures were sterile; computed tomography showed bilateral, diffuse, small centrilobular nodules with "tree-in-bud" appearance. In this clinicopathologic conference, we discuss the clinical and radiological differential diagnosis of centrilobular nodules, lung biopsy findings, and management options for patients with such a presentation.

Radiological findings of complications after lung transplantation

Abstract

Complications following lung transplantation may impede allograft function and threaten patient survival. The five main complications after lung transplantation are primary graft dysfunction, post-surgical complications, alloimmune responses, infections, and malignancy. Primary graft dysfunction, a transient ischemic/reperfusion injury, appears as a pulmonary edema in almost every patient during the first three days post-surgery. Post-surgical dysfunction could be depicted on computed tomography (CT), such as bronchial anastomosis dehiscence, bronchial stenosis and bronchomalacia, pulmonary artery stenosis, and size mismatch. Alloimmune responses represent acute rejection or chronic lung allograft dysfunction (CLAD). CLAD has three different forms (bronchiolitis obliterans syndrome, restrictive allograft syndrome, acute fibrinoid organizing pneumonia) that could be differentiated on CT. Infections are different depending on their time of occurrence. The first post-operative month is mostly associated with bacterial and fungal pathogens. From the second to sixth months, viral pneumonias and fungal and parasitic opportunistic infections are more frequent. Different patterns according to the type of infection exist on CT. Malignancy should be depicted and corresponded principally to post-transplantation lymphoproliferative disease (PTLD). In this review, we describe specific CT signs of these five main lung transplantation complications and their time of occurrence to improve diagnosis, follow-up, medical management, and to correlate these findings with pathology results.

Key Points

• The five main complications are primary graft dysfunction, surgical, alloimmune, infectious, and malignancy complications.

• CT identifies anomalies in the setting of unspecific symptoms of lung transplantation complications.

• Knowledge of the specific CT signs can allow a prompt diagnosis.

• CT signs maximize the yield of bronchoscopy, transbronchial biopsy, and bronchoalveolar lavage.

• Radiopathological correlation helps to understand CT signs after lung transplantation complications.

CT findings of fungal pneumonia with emphasis on aspergillosis

Fungal pneumonias are increasingly common in the population of immunosuppressed patients. The diagnosis of fungal pneumonias represents a challenge for clinicians, and the morbidity and mortality of these infections are high in immunocompromised patients. CT findings may be nonspecific; however, in the appropriate clinical setting, they may suggest and even help establish the specific diagnosis. This article provides an overview about the CT findings and possible differential diagnosis of the most common pulmonary fungal infections.

Rapidly progressing lepidic pulmonary metastases from a treated poorly differentiated hepatocellular carcinoma demonstrating new pathologic features of cholangiocarcinoma: A potential diagnostic pitfall that may mimic pneumonia

Although the lung is a common site for metastatic disease from extrathoracic malignancies, a pattern of lepidic growth of these metastases is considered rare. A 67-year-old man with a history of partial hepatectomy for hepatocellular carcinoma (HCC) presented to our hospital with dyspnea and a nonproductive cough. Chest radiographs and computed tomography imaging demonstrated consolidation in the right upper lobe and an ipsilateral pleural effusion. Findings were initially suspected to be secondary to infection, given the radiographic appearance and the rapid development from a normal computed tomography 3 months previously. However, the patient did not have convincing clinical evidence of pneumonia, and after little change after antibiotic therapy, a thoracentesis and pleural biopsy were performed that were positive for malignancy. Although immunostaining and morphology closely resembled the patient's primary HCC, new pathologic features of cholangiocarcinoma were found. We herein report the first case of rapidly progressing lepidic pulmonary metastases from an HCC that dedifferentiated into a hepatocholangiocarcinoma.

Molecular imaging of pulmonary diseases

Imaging holds an important role in the diagnosis of lung diseases. Along with clinical tests, noninvasive imaging techniques provide complementary and valuable information that enables a complete differential diagnosis. Various novel molecular imaging tools are currently under investigation aimed toward achieving a better understanding of lung disease physiopathology as well as early detection and accurate diagnosis leading to targeted treatment. Recent research on molecular imaging methods that may permit differentiation of the cellular and molecular components of pulmonary disease and monitoring of immune activation are detailed in this review. The application of molecular imaging to lung disease is currently in its early stage, especially compared to other organs or tissues, but future studies will undoubtedly reveal useful pulmonary imaging probes and imaging modalities.

Complications of Intravenous Substance Use Disorders (SUDs): A Multimodality Pictorial Essay for Cardiothoracic Radiologists

With the growing substance use disorders epidemic in the United States, a wide range of complications may be seen in both the acute and chronic clinical setting. This article will use a multimodality approach to review complications of intravenous substance use that cardiothoracic radiologists are likely to encounter. Radiologists should be aware of these multisystem complications that can affect the cardiovascular, respiratory, and musculoskeletal systems in order to make an accurate and timely diagnosis, which can drastically alter the management of these patients.

Malignant central airway obstruction

This review comprehensively describes recent advances in the management of malignant central airway obstruction (CAO). Malignant CAO can be a dramatic and devastating manifestation of primary lung cancer or metastatic disease. A variety of diagnostic modalities are available to provide valuable information to plan a therapeutic intervention. Clinical heterogeneity in the presentation of malignant CAO provides opportunities to adapt and utilize endoscopic technology and tools in many ways. Mechanical debulking, thermal tools, cryotherapy and airway stents are methods and instruments used to rapidly restore airway patency. Delayed bronchoscopic methods, such as photodynamic therapy (PDT) and brachytherapy can also be utilized in specific non-emergent situations to establish airway patency. Although data regarding the success and complications of therapeutic interventions are retrospective and characterized by clinical and outcome measure variability, the symptoms of malignant CAO can often be successfully palliated. Assessment of risks and benefits of interventions in each individual patient during the decision-making process forms the critical foundation of the management of malignant CAO.

Histopathology of fungal diseases of the lung

Fungal pneumonias can be a diagnostic problem. However, their recognition is important as they can pose a significant health risk, especially in the immunocompromised host. While many of these infections are accompanied by necrotizing or non-necrotizing granulomas, some might be characterized by cellular interstitial pneumonia, intra-alveolar frothy material or only minimal inflammatory change. Much of the tissue reaction is dependent on the immune status of the patient and the type of fungal organism. While many of the fungi can be identified in tissue, especially if using histochemical stains such as Grocott's Methenamine Silver (GMS) stain and/or Periodic Acid Schiff (PAS) stain, in some cases, these stains are negative and the organisms can only be identified in cultures or using special techniques such as PCR or fungal serology. Some fungi can be accurately identified in tissue based on morphologic features; others require culture for exact classification. Knowledge about immune status, geographic region and social history of the patient are helpful in identifying the fungus and, therefore, detailed clinical and travel histories are important. In this manuscript we aim to describe the most common fungal infections that occur in the lung, their morphologic features, and differential diagnoses.

Respiratory infections in immunocompromised patients: Lung findings using chest computed tomography

Respiratory infections and subsequent complications are one of the leading causes of high mortality in immunocompromised patients. Although chest radiograph and computed tomography are the commonly used diagnostic tools for the early diagnosis of lung manifestations of infections, they lack the specificity for the wide range of chest infections which can occur in immunocompromised patients. Systematic analysis of the imaging findings in correlation with the clinical settings along with comparison with the old images can expedite early and accurate diagnosis for subsequent appropriate management. Computer tomography findings in immunocompromised patients with respiratory infections, with regards to various clinical settings, will be discussed here.

Imaging of the Lungs in Organ Donors and its Clinical Relevance: A Retrospective Analysis

PURPOSE

The aim of the study was to retrospectively evaluate the diagnostic imaging that potential lung donors undergo, the reader variability of image interpretation and its relevance for donation, and the potential information gained from imaging studies not primarily intended for lung evaluation but partially including them.

MATERIALS AND METHODS

Bedside chest radiography and computed tomography (CT), completely or incompletely including the lungs, of 110 brain-dead potential organ donors in a single institution during 2007 to 2014 were reviewed from a donation perspective. Two chest radiologists in consensus analyzed catheters and cardiovascular, parenchymal, and pleural findings. Clinical reports and study review were compared for substantial differences in findings that could have led to a treatment change, triggered additional examinations such as bronchoscopy, or were considered important for donation.

RESULTS

Among 136 bedside chest radiographs, no differences between clinical reports and study reviews were found in 37 (27%), minor differences were found in 28 (21%), and substantial differences were found in 71 (52%) examinations (P<0.0001). In 31 of 42 (74%) complete or incomplete CT examinations, 50 of 74 findings with relevance for lung donation were not primarily reported (P<0.0001).

CONCLUSIONS

The majority of donor patients undergo only chest radiography. A targeted imaging review of abnormalities affecting the decision to use donor lungs may be useful in the preoperative stage. With a targeted list, substantial changes were made from initial clinical interpretations. CT can provide valuable information on donor lung pathology, even if the lungs are only partially imaged.

Differential Diagnosis of Cavitary Lung Lesions

Many different diseases present as cavitary pulmonary nodules. The spectrum of diseases ranges from acute to chronic infections, chronic systemic diseases, and malignancies. To decide on the most likely or correct diagnosis may be challenging. Knowledge of common and uncommon radiological findings in correlation with relevant clinical history and findings is necessary to make the right diagnosis and recommend the correct follow-up or step forward. The aim of this pictorial review is to present a brief overview of CT findings of common cavitary lung diseases seen in adult patients.

Multidetector Computed Tomography and MR Imaging Findings in Mycotic Infections

Fungal infections constitute a diverse spectrum of infections with variable clinical and imaging features. They are commonly opportunistic infections that affect immunocompromised individuals secondary to inherited or acquired disorders. Fungal infections may affect multiple organ systems and contribute to significant morbidity and mortality. Although the imaging features of some fungal infections are characteristic and permit their diagnosis, many mycotic infections manifest nonspecific findings. Definitive diagnosis often depends on histopathological analysis. Early diagnosis requires both clinical suspicion and supporting radiological evidence. Early treatment results in reduced morbidity and mortality. This article reviews the imaging findings in opportunistic and endemic fungal infections.

Pulmonary Infections: Imaging with CT

Computed tomography (CT) plays a key role in various kinds of pulmonary infections especially in immunocompromised patients, owing to its much higher sensitivity and specificity than the traditionally performed chest X-ray. CT permits the detection of the main infectious pattern and associated findings with high confidence and allows for the precise assessment of all involved structures, to potentially guide a bronchoalveolar lavage or another diagnostic procedure, and to ensure a reliable follow-up. It may be performed at a carefully chosen dose, which may nearly reach that of a chest X-ray in specific situations. The importance of post-processing tools is undeniable in some conditions, in particular for the evaluation of micronodules in the immunocompromised population. The wide spectrum of features of specific organisms according to the immune status, such as in aspergillosis or tuberculosis, must be known, as well as the potential of atypical presentations in case of Pneumocystis jirovecii (PCP) pneumonia when occurring in non-HIV immunocompromised patients. In all cases, underlying disorders must be considered as well as all the differential diagnoses. Overall, CT definitely helps clinicians to diagnose pulmonary infections and to make treatment decisions, especially in vulnerable patients.