40 year old male RV positive , reports with progressively worsening dyspnoea, hpoxemia on room air .

Describe the radiological findings, differential diagnosis and next investigations.

Bilateral ,diffuse, reticulonodular infiltrates with perihilar distribution, most likely PCP , other differentials -koch's,LIP, CMV etc .LDH may be raised,Sputum/BAL likely to show PC on SM stain.If inconclusive Tranbronchial lung biopsy may be needed.

42 year old male , diagnosed to have a bad asthma 10 years ago, particularly worse since last 4 years, reports to your clinic with chronic respiratory failure, SaO2 = 70 % on room air, Patient has severe obstruction and restriction on spirometry with partial reversibility.

What does the CT image show ? How will you confirm your diagnosis?

Striking finding is extensive bronchiectasis.This overshadows patchy groundglass opacification.

Also note proximal location of the bronchiectasis.Combined with history of poorly controlled asthma the diagnosis is likely to be ABPA.

21 year old male, presented with fever and cough over 1 month.What is the radiological diagnosis?

How will you confirm it ?

Thick walled cavity and tree in bud type of infiltrates suggest tuberculosis.Sputum AFB should be positive looking at the size of the cavity.

57 year old male, recently detected Diabetes, fever and cough for 1month, received 3 different antibiotics -coamoxyclav,levofloxacin,Cefotaxime with no clinical benefit,Sputum AFB-3 days -negative,No growth on aerobic culture.Diabetes remained poorly controlled despite being on 60 units of insulin./day.What is the DD? How will you investigsate?

DD should include - Fungal infection particularly aspergillus due to necrotization and consolidation , tubercular and bacterial process. Bronchoscopy after lateral Xray/CT thorax to map the lesion will be indicated.

35 year old male, treated for tuberculosis for nearly 2 years.Reports with recurrent hemoptysis and cough with mucopurulent expectorations.He is sputum AFB positive every time he gets tested.His weight is static at 54 kg for past 3 years.What is he suffering from?How will you confirm the diagnosis?

Look at the new image. This is the same patient after a few weeks.Shows complete emptying of the fluid component and empty cavity wall.

Radiologically - first X ray is described as air fluid level within lung parnchyma. Can be seen in a lung abcess / lung cyst.Also notice surrounding lung tissue showed some consolidation - that will be usually seen in a lung abcess.

What is this radilogical pattern called as ? What is your diagnosis?

55 year old female , reported after 1 year of ATT with non responsive cough and worsening exertional dyspnoea. She was sputum smear negative and her TT was also negative.She had no weight loss . What is the likely diagnosis ? How will you confirm it ?

Evolving lung fibrosis in a perihilar and paralymphatic distribution.Sarcoidosis is likely.Endobronchial biospsies ,BAL or TBLB should establish the diagnosis.

This was diffuse alveolar hemorrhage . We initially attributed it to aspirin . Howevere she was ANCA positive and was eventually labelled Wegner's .she remained stable on low dose oral steroids for 3 years ( after initial pulse Endoxan )and actrually was in a different city. She succumbed to another massive alveolar hemorrhage with respiratory failure which happened suddenly.

55 year old lady on Aspirin 75 mg /day for last 5 years for IHD , reported to OPD with some dyspnoea on exertion and recurrent small hemoptysis for last 4 days.

What is the radiological pattern ? What are possible etiologies ?

Locate the segment ?

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New image

25 year old male , has cough with expectorations daily for last 3 years, needs frequent antibiotics What is the diagnosis, How will you confirm the diagnosis?

This is a case of malignant pleural effusion. Can you identify the intervention done ?

Talc pleurodesis is attempted with some success, talc is visible in lung base.

40 year old farmer female reports with severe exertional dyspnoea ,worsening over past 2 months,patient is hypoxic ,SaO2 -74 % on room air. She is on ATTfor last two months prior to this CT, ATT was started as X ray had showed some infiltrates. Sputum AFB was not attempted.

She has shown no improvement on ATT.clinically there is no clubbing .There are bibasal rales .

What are the radiological findings? What is the likely diagnosis?

Radiologically there is some ground glass opacification,There are areas of traction bronchiectasis but the most striking are lot of noduar densities in cebtrilobular distribution.Most likeky diagnosis is hypersnsitivity pneumonitis.

Can you tell whether this radiodensity is pleural or extrapleural ?

This is a loculated pleural collection.

What is a pregnant lady sign?

50 year old diabetic male, past h/o tuberculosis , presents with massive recurrent hemoptysis,fever and toxaemia.What is the CT scan thorax reflecting ? What is your diagnosis?

Necrotizing consolidation with large cavity with solid tissue within tha cavity and bits attched to wall. Clinical background makes it highly suggestive of invasive aspergillosis.

40 year old nonsmoker male presents with cough and  exertional dyspnoea . What is the radiological pattern ?What is the differential diagnosis?

Canon ball lung nodules, mostly metastatic disease.

In real life this was a tough conclusion to reach at, Bronchoscopy revealed endobrochial lesion LLL,Biopsy report adeno ca -first pathologist,second opinion no malignancy,CT guided FNA -no malignancy,tru cut biospy - no malignancy, Finally VATS biospy of a full nodule -adeno ca confirmed.

Another unusual feature of this disease - despite such widespread lung disease never had spread beyond lungs for nearly 5 years.He was one of our spectacular responders to Gefitinib.

Answer - Ill defined radiodensity on X ray chest PA view , can be consolidation /mass lesion.

CT thorax makes it more convincing for a mass lesion.Bronchoscopic biopsy -Histopath -AdenoCa

58 year old female with 10 kg weight loss over 6 months

Occasional hemoptysis and some cough.

What is Xray interpretation ? How will you investigate?

35 year old male ,with history of PTB 5 years ago , now presents with recurrent hemoptysis.

Read this Xray and give your final diagnosis.

Well defined rounded radiodensity with an air crescent on top.Diagnosis is aspergilloma

31 year old lady, fever, weight loss , loss of appetite , dry cough .

How will you confirm this diagnosis ?

Caseating paratracheal lymph node- Best way to get the diagnosis is to do a bronchoscopy and perform TBNA -Transbronchial needle aspiration from the node.Also collect corroborative data like ESR,TT,etc

Answer to yesterday's puzzle

35 year old, non smoker male , presents with exertional dyspnoea -for last 2 years, progressive.

Discuss the differential diagnosis?

?14 year old girl ,fever ,weight loss ,loss of appetite 2 months.

how will you proceed from here?

LUL fibrocavitary infiltrates. ESR,TT,Sputum AFB -3 days ,get the basics right.