A woman with breathlessness: a practical approach to diagnosis and management

Worsening breathless in a patient with severe chronic obstructive pulmonary disease (COPD) is a common diagnostic and management challenge in primary care. A systematic approach to history-taking and examination combined with targeted investigation of pulmonary, cardiovascular, thromboembolic and systemic causes is essential if co-morbidities are to be identified and managed. Distinguishing between heart failure and COPD is a particular challenge as symptoms and signs overlap. In low and middle income countries additional priorities are the detection of infections such as tuberculosis and human immunodeficiency virus (HIV). Clinicians need to be alert to the possibility of atypical presentations (such as pain-free variants of angina) and less common conditions (including chronic thromboembolic pulmonary hypertension) in order not to overlook important potentially treatable conditions.

Chronic pulmonary emboli and radiologic mimics on CT pulmonary angiography: a diagnostic challenge

Chronic pulmonary thromboembolism (CPE) is a challenging diagnosis for clinicians. It is an often-forgotten diagnosis and can be difficult to detect and easily misdiagnosed. The radiologic features on CT pulmonary angiography are subtle and can be further compounded by pathologic mimics and unusual findings observed with disease progression. Diagnosis is important because CPE can lead to progressive pulmonary hypertension, morbidity, and mortality. Moreover, chronic thromboembolic pulmonary hypertension is the only category of pulmonary hypertension with an effective curative treatment in the form of pulmonary endarterectomy. Therefore, CPE must be considered and recognized early. The features of chronic pulmonary emboli on CT scans can be categorized into vascular or parenchymal findings. Endoluminal signs include totally or partially occlusive thrombi and webs and bands. Parenchymal features such as mosaic attenuation and pulmonary infarction are also noted, in addition to features of pulmonary artery hypertension. Additional findings have been noted, including cavitation of infarcts, microbial colonization of cavities, and bronchopleural fistulae. As CPE can be diagnosed at different stages of its disease pathway, such findings may not necessarily arouse suspicion toward a causative diagnosis of chronic embolism. To aid diagnosis for clinicians, this article describes the characteristic vascular and parenchymal CT scan features of chronic emboli, as well as important ancillary findings. We also provide an illustrative case series focusing on CT pulmonary angiography specifically as an imaging modality to highlight the progressive nature of CPE and its sequelae, as well as important radiologic mimics to consider in the differential diagnosis.