1. Chest p78-85 (Sarcoid, CHF, Lung transplant, Alveolar disease)

Question 1

Sarcoid - trivia (4)

Answer 1

Multisystem disease that creates “Non-caseating granulomas”.
Commonly ages 20-40, black ethnicity.
Lungs most commonly affected (90%).
Bloods: Elevated ACE, Hypercalcaemia

Question 2

Sarcoid - features (4)

Answer 2

Mediastinal lymph nodes in 60-90%. Classically bilateral hila and right paratracheal.
Perilymphatic nodules with upper lobe predominance.
Late changes: Upper lobe fibrosis and traction bronchiectasis.
Aspergillomas common in cavities in end-stage.

Question 3

Sarcoid - Buzzwords

Answer 3

1-2-3 sign (bilateral hila and right paratracheal),
Lambda sign (as above, on gallium scan),
CT galaxy sign (upper lobe masses (conglomerate of nodules) with satellite nodules

Question 4

Sarcoid “Staging” (5)

Answer 4

On CXR:
0=normal,
1=hilar/mediastinal nodes only,
2=nodes & parenchymal disease
3=Parenchymal disease
4=end stage (fibrosis)

Question 5

CHF - stages (10)

Answer 5

Stage 1 - Redistribution:
- Wedge pressure 13-18.
- Cephalisation of big vessels
- Big heart and vascular pedicle
Stage 2 - Interstitial oedema:
- Wedge pressure 18-25
- Kerley lines
- Peribronchial cuffing
- less distinct contour of central vessels
Stage 3 - Alveolar oedema:
- Wedge pressure >25
- Airspace “fluffy” opacity
- Pleural effusion

Question 6

Commonest cause of right heart failure

Answer 6

Left heart failure (causes pulmonary venous HTN, which causes pulmonary artery HTN, which causes right heart failure)

Question 7

Other causes of right heart failure (2)

Answer 7

Chronic PE
Right valve issues (tricuspid regurg)

Question 8

Right heart failure - imaging (6)

Answer 8

Dilatation of azygous vein.
Dilatation of right atrium,
Dilatation of SVC,
Ascites,
Splenomegaly,
Contrast reflux into hepatic veins on CTPA

Question 9

Lung Transplant complications - <24hrs (2)

Answer 9

Donor-recipient size mismatch
- Mismatch up to 25% is ok.
- Compressed lung (by expanded emphasematous lung)
- Atelectasis on imaging
Hyperacute rejection
- Due to HLA and ABO antigens.
- Rapid, often fatal
- Imaging: massive, homogenous infiltration

Question 10

Lung transplant complications - 1-7 days (2)

Answer 10

Reperfusion injury
- Non-cardiogenic oedema, peaks at day 4
- Related to ischaemia-reperfusion
- Typically improves by day 7
Air leak/persistent pneumothorax
- Defined as continuous leak for >7 days

Question 11

Lung transplant complications - 8 days to 2 months (2)

Answer 11

Acute rejection
- ground glass opacities and interlobular septal thickening
- Improves with steroids
Bronchial anastomotic complications
- Leaks in first month
- Stenosis 2-4 months

Question 12

Lung transplant complications - 2-4 months

Answer 12

CMV infection
- Commonest opportunistic infection.
- Ground glass, tree-in-bud.
- Rare before 2 weeks

Question 13

Lung transplant complications - >4 months (4)

Answer 13

Chronic rejections
- Bronchiolitis obliterans
- Bronchiectasis, bronchial wall thickening, air trapping
- Affects 50% at 5 years
COP
- Occurs with chronic or (more commonly) acute rejection
- Responds to steroids
PTLD
- Usually 1st year, EBV in 90%
Upper lobe fibrosis
- Associated with chronic rejection

Question 14

Chronic rejection/bronchiolitis obliterans syndrome - trivia (2)

Answer 14

Main late complication of lung transplant.
Affects 50% by 5 years, most commonly 6 months.

Question 15

Chronic rejection - imaging (4)

Answer 15

CT:
- Bronchiectasis
- bronchial wall thickening
- Air trapping
- Interlobular septal thickening.
(Air trapping after 6 months = chronic rejection)

Question 16

Most common recurrent disease after transplant

Answer 16

Sarcoid (35%)

Question 17

Lung cancer after transplant - trivia (3)

Answer 17

Native lung still diseased and at risk.
Highest rate with pulmonary fibrosis.
Commonest risk factor is smoking.–

Question 18

Crazy paving on CT (5)

Answer 18

PAP (Pulmonary Alveolar Proteinosis).
Other causes:
- Oedema
- Haemorrhage
- BAC
- AIP (Acute interstitial pneumonia)

Question 19

Pulmonary alveolar proteinosis - imaging

Answer 19

Crazy paving (interlobular septal thickening with ground glass.

Question 20

Pulmonary alveolar proteinosis - Types (2)

Answer 20

Primary (90%)
Secondary (10%) - usually cancer or inhalation (silico-proteinosis)

Question 21

Pulmonary alveolar proteinosis - associations (4)

Answer 21

Increased risk of nocardia, including nocardia brain abscess.
Strongly associated with smoking.
Associated with alymphoplasia when seen in children <12months.
Can progress to pulmonary fibrosis

Question 22

PAP - Rx

Answer 22

Bronchiolar lavage

Question 23

Lipoid pneumonia - types (2)

Answer 23

Endogenous and Exogenous

Question 24

Exogenous lipoid pneumonia - Cause

Answer 24

Seen with aspiration of oils/fats, commonly elderly people on mineral oil/laxitives.

Question 25

Exogenous lipoid pneumonia - imaging (2)

Answer 25

CXR: area of lung opacification which is chronic/slowly increases with time. CT: Low attenuation/fat density in the consolidation.

Question 26

Acute exogenous lipoid pneumonia - cause

Answer 26

Seen in kids poisoned with hydrocarbons or people doing fire-eating

Question 27

Endogenous lipoid pneumonia - trivia/cause (2)

Answer 27

More common than exogenous. Post obstructive processes (cancer) causing build up of lipid laden macrophages.

Question 28

Why non-lung window? (3)

Answer 28

Mediastinal or rib findings? Soft tissue window - shows fat in lesion (hamartoma or lipoid pneumonia) Bone window - diffuse process like pulmonary microlithiasis

Question 29

Organising pneumonia - cause

Answer 29

Known as COP when unknown cause. Other causes include: - Infection, drugs, collagen vascular disease, fumes...

Question 30

Organising pneumonia - imaging

Answer 30

Patchy airspace consolidation or GGO (90%), Peribronchial or peripheral distribution, Irregular shaped opacities. Fibrosis usually absent. Reverse Halo Sign - consolidation around a ground glass centre.

Question 31

Chronic Eosinophilic Pneumonia - associations

Answer 31

Can be idiopathic or known antigen. Raised eosinophils. 50% also have asthma.

Question 32

Chronic eosinophilic pneumonia - imaging

Answer 32

Same as COP. Peripheral GGO or consolidation. Favours upper lobes.

Question 33

Hypersensitivity pneumonitis - trivia

Answer 33

Common, caused by inhaled organic antigens. Acute, subacute and chronic stages.

Question 34

Subacute hypersensitivity pneumonitis - imaging (3)

Answer 34

Patchy GGO, Ill defined centrilobular ground glass nodules (80%). Often mosaic perfusion and air trapping.

Question 35

Chronic hypersensitivity pneumonitis - imaging (3)

Answer 35

Looks like UIP + air trapping. Traction bronchiectasis and air trapping. Mix of everything (ground glass, air trapping, consolidation and normal lung)

Question 36

Reverse Halo & causes (atol)

Answer 36

Central ground glass with rim of consolidation Causes: COP (classic), also: - Fungal pneumonia - TB - Wegeners - Pulmonary infarct

Question 37

Halo sign + causes (4)

Answer 37

Solid nodule with surrounding ground glass Represents haemorrhage/invasion into surrounding tissues Causes: Invasive aspergillosis (classic), also: - Other fungus - Haemorrhagic mets - Wegeners