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RadRes MegaPimp 1

Why would radiology flashcards without images be of any use at all? (Click to see answer.) Because the eyes don’t see what that mind doesn’t know. This set works best if SHUFFLED. Items are concise due to's 255 character limit per each question entry and answer entry. Good luck!
The following constellation of findings is pathognomonic for what condition?: areas of bone resorption, chondrocalcinosis, superscan on MDP, expansile lytic lesions with geographic nonsclerotic margins, metastatic soft tissue calcifications. Hyperparathyroidism, 1° or 2°
"Salt and pepper skull" is a buzzword for what condition? Hyperparathyroidism, 1° or 2°
Radiographs show subchondral bone resorption and collapse along only the iliac aspect of the sacroiliac joints. Top Dx? Hyperparathyroidism, 1° or 2°
Radiographs show calcification of medium sized vessels (vs large vs small vessels). Top Dx? Hyperparathyroidism, 1° or 2° (vs atherosclerosis vs diabetes, respectively)
Radiographs show concavity at the anterior articular surface of the calcaneus (or worse, destruction at the talonavicular joint). Top Dx? neuropathic joint (Charcot)
T/F: Urogenic pyelonephritis cannot occur without reflux. False. Uropathologic E. coli have fimbria that allow them to walk up the ureters even the absence of reflux.
What are the classes of emphysematous pyelonephritis? 1: Gas confined to collecting system; 2: Gas confined to renal parenchyma; 3A: Perinephric extension of gas/abscess; 3B: Extension of gas beyond Gerota fascia; 4: Bilateral EPN or EPN in solitary kidney. Huang et al (2000) modif'n of Michaeli et al
Buzzword (phrase): foamy macrophages in the kidney. Dx? XGP (xanthogranulomatous pyelonephritis)
Name the Dz: obstruction, hydro, nodularity to urothelium, can be lethal, renal destructive, tx with abx, but can't be reversed, Michaelis Gutman bodies on histo, infiltrative on CT malakoplakia
What kind of abscess can be low on T2? Fungal. Aspergillis, with metallic deposits lowering MR signal.
There are 3 main morphologies of renal calcifications. One is nephrolithiasis (calculi). What are the other two? dystrophic (can be tumor! RCC! or rim calcs in benign Bosniak II or IIF cyst, etc; take your time and figure it out), and nephrocalcinosis (medullary or cortical)
T/F: Most patients with renal TB have pulmonary findings FIRST. False. Although renal TB is thought to arise from primary lung involvment, most patients have no pulmonary stigmata of TB at the time of renal diagnosis. (Ref needed)
Urogram shows apillary necrosis, amputation of calix, dystrophic calcs. Top Dx? (any age/sex) renal TB
What are the causes of medullary nephrocalcinosis? RTA type 1 (distal), medullary sponge kidney, medications such as NSAIDS. These entities have generally preserved renal function.
Cortical nephrocalcinosis: What is the underlying pathology? damaged kidneys with reduced renal function
Which substance comprises the most lucent renal stones? uric acid (not brittle enough for lithotripsy, tx'd with pH tx, citrate.)
Staghorn calculi formation is due to what enzyme? Urease (in Klebsiella and Proteus species) produces the magnesium ammonium phosphate component of struvite stones.
Name this disease: Asymptomatic papillary subendothelial calcium carbonate and calcium phosphate deposits rimming the collecting system. Randall's plaque Radiographic patterns: 1. linear, may represent calcification surrounding tubules and vasarecta 2. Punctate/globular, probably represents interstitial calcific deposits and large calcific concretions enveloping papillary structures
Most common cerebral neoplasm in tuberous sclerosis. Subependymal Giant Cell Tumor (up to 15% of TS cases)
What is the organism responsible for neurocysticercosis? pork tapeworm Taenia solium
Communication between extracranial venous system and dural venous sinus is called ___. sinus pericranii
Intrahepatic Mucinous Cystic Neoplasm is an updated term used to describe _____. biliary cystadenoma and cystadenocarcinoma
Intraductal Papillary Neoplasm of the Bile Ducts is an updated term used to describe _______. biliary papilloma and papillomatosis
Esophgram shows linearly-arranged longitudinal plaques (dark/lucent, outlined by white barium) with intervening normal esophageal mucosa on esophogram. Top Dx? Candida esophagitis. Look for the longitudinal linear arrangement.
Esophgram shows “shaggy esophagus.” Top Dx. severe Candidiasis in the setting of immunosuppression (usually AIDS)
Giant esophageal ulcer on esophagram suggests ___. AIDS (Caused by either CMV or direct HIV; depends on viral culture of brushings showing CMV or not)
T/F: The size of a gastric or duodenal ulcer correlates with the likelihood of malignant disease. false. Giant ulcers may be benign, heal completely with tx. Smooth mound of edema with symmetric radiating folds suggest benignity. f/u UGI after tx, no EGD needed at this time. R/O malign (EGD) if irregular, nodular, clubbing, fused, no areae gastricae.
Varioliform erosions in the gastric mucosa on UGI suggests ___. erosive gastritis. Causes: PUD, NSAIDS, ASA, EtOH, stress, trauma, Crohn dz. Look for papillary mound with central divot (varioliform).
Large pedunculated intraluminal polyp in the esophagus on esophagram, fat-density components on CT. Most likely Dx? fibrovascular polyp (FVP). Can be dramatic, huge, flop into pharynx or mouth, benign but risk of asphyxiation so should be removed. DDx: malignant tumor, air bubble on esophagram.
Upper lobe small smoothly-round nodules and calcified hilar/mediastinal lymph nodes. Bilateral symmetrical distribution. Most likely Dx? Silicosis is most likely. Why upper? Lymphatic drainage in the lower lungs is much better. Hence, the lymph nodes get the lower lobe silicosis burden. Sarcoidosis is more irregular nodules, should be included in DDx.
Bilateral lower lobe small round nodules. Most likely lung mets.
Lower lobe predominance peripheral nodules with pleural plaques. Most likely Dx? asbestosis
Respiratory bronchiolitis vs DIP. What’s the difference? Same pathological process, just a different spectrum and time-course. Both involve smoking.
Mostly upper-lobe thin-walled cystic airspaces (not bullae or blebs) with bizarre shapes. Most likely Dx? PLCH (pulmonary Langerhans cell histiocytosis), aka EG
Lower lung zones cystic airspaces, NOT predominantly peripheral. 20% lymphocytes on BAL cell count. Most likely Dx? Lymphocytic interstitial pneumonia (LIP) is a syndrome of fever, cough, and dyspnea, with bibasilar pulmonary infiltrates consisting of dense interstitial accumulations of lymphocytes and plasma cells.
Diffuse cystic airspaces. Most likely Dx? LAM (look for female childbearing age, or older male/female with ???TS)
Explain the term “RB-ILD.” RB (respiratory bronchiolitis) is smoking-related inflam dz as seen on imaging and histopathology, +/- ILD. ILD (interstitial lung disease) is nonspecific, based on clinical eval (restrictive rather than obstructive, evaluated by PFTs, not imaging).
What is the cause of DIP? Desquamative Interstitial Pneumonia is caused by smoking, as is RB-ILD. Both are interstitial lung diseases and not airway diseases like COPD.
Hamman-Rich syndrome is same as _____. ARDS, which is caused by sepsis and shock. Acute interstitial pna (AIP) looks exactly the same on histopathology (diffuse alveolar damage, DAD).
lung disease: DAD = ? diffuse alveolar damage (DAD). Histopathological equiv of acute interstitial pna/AIP when not related to sepsis/shock (o/w ARDS, aka Hamman-Rich syndrome).
What defines the small airways with respect to the other parts of the airways? Cartilage, or lack thereof. Larger airways have cartilaginous walls. Small airways do not include the acini.
OP is the abbreviation for what most up-to-date term for the lung disease formally known by what name(s)? organizing pneumonia=COP=BOOP
UIP is the histopathological equivalent of what disease seen on imaging? IPF (idiopathic pulmonary fibrosis)
Peripheral fibrosis and cystic bronchiectasis, not limited to the lower lobes, and sparing the extreme periphery (subpleural sparing). Most likely diagnosis? NSIP, which is “nonspecific” and could be a lot of things… (idiopathic pulmonary fibrosis, smoking-related interstitial lung disease, hypersensitivity pneumonitis, and collagen, vascular disease)
NSIP may be a chronic sequela of what common usually-temporary lung disease? OP (organizing pneumonia) that did not resolve completely (as it usually does with tx).
Cysts along bronchovascular bundles, mostly upper lobes. Most likely Dx? sarcoidosis
Hypertrophied antral-pyloric fold on upper GI is classic for _________. antral gastritis
Spider-web collateral vessels in the liver are associated with _________. Budd-Chiari syndrome
High iron deposits in the liver, spleen, and bone marrow. Most likely Dx? secondary hemochromatosis AKA hemosiderosis
High iron deposits in the liver, pancreas, and heart. Most likely Dx? primary hemochromatosis AKA hereditary hemochromatosis
T/F: Schatzki ring of less than 20 mm is almost always associated with dysphagia and stuck food. false. The number is 13 mm. Above 20 mm, dysphagia is rare. From 13 mm to 20 mm, sx are variable.
When is it appropriate to inflate the balloon in a baby with suspected Hirschprung disease? Never. Risk of rupture d/t stiff narrow colon/rectum.
What are the size limits for normal appendix vs appendicitis? On ultrasound: 6 mm or less is definitely normal. Greater than 8 mm is definitely abnormal. CT limits are less defined. Up to 10 mm is considered by some to be normal (no compression by probe).
You see incidental cholestectomy on a CT in a child. What is the likely history? sickle cell disease
You see unilateral hilar adenopathy in a child being evaluated for cough. What Dx should you immediately think of? TB
Why is it dangerous to drain an abscess in the setting of empyema drainage? Unacceptable risk of bronchoplural fistula formation, and these patients respond well with conservative antibiotic therapy (after empyema drainage).
CT for headache shows degenerative cyst in choroid plexus in a pt over 30, no calcification, no enhancement, no evidence of hydrocephalus. choroid plexus xanthogranuloma (most likely UNrelated to HAs). Lipid-laden macrophages and giant cells in fibrotic granulation tissue. DDx: papillomas have calcs in 20%; Meningioma, ependymoma, AVM, and mets are unlikely w/o enhancement.
"Bag of worms" in the brain, think ... AVM. Know the Spetzler-Martin grading: Size: small (< 3 cm) = 1, medium (3-6 cm) = 2, large (> 6 cm) = 3. Location: noneloquent = 0, eloquent = 1. Venous drainage: superficial = 0, deep = 1. Total points are added for final grade 0-5.
Benign, focal malformation resembling neoplasm. Composed of tissue elements normally found at that site, but which are growing in a disorganized mass. Never malignant. hamartoma
Mass containing normal tissues but found in abnormal location. Form of heterotopia. choristoma
On CT obtained for leukocoria, you see calcified masses in both globes and pineal region. Most likely dx? Trilateral retinoblastoma (PNET). RB is an aggressive, WHO grade IV tumor with 92% survival if confined to globe (post-enucleation), 0% surv if extraglobal extension. Look for tetralateral disease (pineoblastoma/PNET & suprasellar tumor). 90% calcified.
The 7 bones of the orbit are ________. Frontal, Zygomatic, Maxillary, Lacrimal, Ethmoid, Palatine, Sphenoid (the last four in order from front to back making up the medial wall (including the lamina papricea) and back wall (Sphenoid bone) of the orbit.
What is the annulus of Zinn? Connective tissue ring at the posterior orbit (apex of the conus) to which the four rectus muscles attach as well as the posterior belly of superior oblique and levator palpebrae muscles.
V-shaped morphology of retinal detachment on axial is due to what structures? The retina is anchored by optic disk posteriorly, ora serrata anteriorly.
When U-shaped morphology of retina is seen, what does it mean? Choroidal detachment, contusion, or serous ocular hypotony. Choroid is anchored by vessels.
Most common cause of pulmonary metastases in the young pediatric population? Wilms tumor
Amnion fuses with the chorion by what gestational age? 16 weeks
What is the earliest gestational age you can reliably expect to see the amniotic membrane by U/S? 7 weeks
Most common site of ectopic pregnancy is ________. ampulla of fallopian tube (although there are much higher rates of atypical locations in IVF patients).
Most dangerous ectopic pregnancy location is _______. myometrial interstitium (present larger, later, more arterial involvement).
Von Meyenburg complexes are also known as _______. biliary hamartomas
Distal CBD stricture in setting of thickened nodular bile ducts. AIDS colangiopathy is associated with distal CBD stricture, while PSC is NOT.
What structures pass through the annulus of Zinn? The optic nerve, CN III, CN VI, nasociliary nerve (V1), and ophthalmic artery. Frontal and lacrimal branches of V1, the CN IV, and the ophthalmic vein pass lateral to the annulus.
lung disease: AIP? Acute interstitial pneumonitis (aka acute interstitial pneumonia, aka Hamman-Rich syndrome) is the radiological equivalent of diffuse alveolar damage (DAD), which is a histopathologic diagnosis. Clinical syndrome = ARDS.
What areas of the brain do NOT have a blood brain barrier? Choroid plexus, pineal gland, pituitary stalk, anterior pituitary (adenohypophysis), hypophyseal portal system, dura (falx/tentorium), and chemoreceptor trigger zone (area postrema in the medulla oblongata along the floor of the fourth ventricle).
Hemangioblastoma and JPA both have heterogeneous enhancement on MR. Which has increased perfusion, and which has decreased perfusion? JPA has decreased perfusion. Hemangioblastoma = increased.
Phakomatosis featuring focal-regional area of pial enhancement with underlying cerebral atrophy. Sturge-Weber syndrome, aka encephalotrigeminal angiomatosis or leptomeningocapillary angiomatosis
Omphalocele, macroglossia, and organomegaly. Dx? Beckwith–Wiedemann syndrome. Most (>85%) cases of BWS are sporadic.
Exomphalos, large tongue, large body and/or long limbs, ear creases/pits, and neonatal hypoglycemia. Dx? Beckwith–Wiedemann syndrome. Most (>85%) cases of BWS are sporadic.
Thin, smooth, linear, periventricular/ependymal enhancement. cytomegalovius (CMV). Look for immunodeficiency.
Thick, irregular, periventricular/ependymal enhancement. Lymphoma (especially primary CNS). Look for immunodeficiency.
Brain lesion with round/ovoid convex ring-enhancement with smooth, uniform, thin (<10 mm) margins (on CT or MR). abscess (benign), could also be subacute hematoma. Not malignant.
Brain lesion with variably thick, undulating, irregular rim enhancement (CT or MR). malignant (necrotic or fluid-secreting neoplasm). Can't tell actual grade of tumor by enhancement pattern alone.
Ring/Rim-enhancing lesion in the brain. DDx? MAGICAL DR: M–Mets, Multiple Sclerosis; A–Abscess (also cerebritis); G–Glioblastoma, granuloma; I–Infarct (esp. basal ganglia); C–Contusion (rare); A–AIDS/toxo, etc.; L–Lymphoma (in AIDS); D–Demyelination (active); R–Resolving hematoma & radiation
Mass with high amino acid, acetate and succinate peaks on MR spectroscopy of brain. Dx? brain abscess
Brain "tumor" with restricted diffusion on DWI/ADC. Dx? abscess (although CNS lymphoma can also do this) (Malignant neoplasms typically do not have restricted diffusion.)
What 2 brain tumors classically involve the corpus callosum in a "butterfly" pattern? lymphoma and GBM, mainly
True cystic fluid-secreting tumor (epithelial lesions) in the brain. DDx? Rathke cleft cyst; Epidermoid, dermoid; -Craniopharyngioma.
“Cystic” brain tumor with mural nodule. DDx? Not a true cyst (no lining). Fluid secreting tumors: Pilomorphic xanthroastrocytoma (PXA); Hemangioblastoma; Ganglioglioma.
"Bubbly" cystic tumor in the brain. DDx? Not a true cyst (no lining). Fluid secreting tumors: Pleomorphic xanthoastrocytoma (PXA); Ganglioglioma; DNET.
Brain tumor with interrupted rim-enhancement (“open ring sign”), absent vasogenic edema (signal abnormality ends at edge of enhancement). DDx? tumefactive demyelination, fluid-secreting “cystic” neoplasm. Ref: (1) Masdeau JC, et al. J Neuroimaging. 1996;6:104-107. (2) Masdeau JC, et al. Neurology. 2000;54:1427-1433.
Lymphoma in the CNS is usually primary? or secondary (metastatic)? Primary lymphoma is much more common than secondary. Almost always B-cell.
CNS mass lesion in AIDS patient. DDx? Toxoplasmosis (top Dx) and primary CNS lymphoma (except in pediatric AIDS patients, wherein lymphoma is top Dx). Lymphoma is sharply hypermetabolic on FDG PET (also high thallium uptake).
Hyperattenuation on NECT and hypointense signal on T2 is characteristic for what CNS tumor? lymphoma
"Classic" location for CNS lymphoma? Most common location for CNS lymphoma? (They are not the same.) Deep gray matter is "classic," but cerebral white matter is more common (55% vs 33%).
Child or young adult with refractory epilepsy, peripheral temporal lobe cystic/solid tumor containing calcifications, with little mass effect or surrounding edema. Ganglioglioma WHO I or II. (if only neurocytes on path =gangliocytoma, WHO I). 6% degenerate to WHO III (glial cells). DDx: pleomorphic xanthoastrocytoma (PXA), DNET (gross calcs are unusual).
What CNS tumors are infamous for CSF seeding/spread? cerebellar PNET (medulloblastoma), ependymoma, ATRT, pineal region germinoma/seminoma
Child <1yo with large heterogeneous mass attached to dura running along the meningocerebral interface of the frontal and parietal lobes with cyst-like areas, intense enhancement, no calcifications. Top Dx? Desmoplastic Infantile Ganglioglioma (DIG) /Astrocytoma. Rare WHO grade I variant. Vast majority are <1 yo. Can show vasogenic edema. Aggressive appearance but favorable prognosis.
Headache, blurred vision, and vomiting suggest what neurological condition? Elevated intracranial pressure. Wide DDx. Needs imaging.
Cerebellar mass with no enhancement, no surrounding edema, striated appearance on MR, minimal hypoattenuation on CT, and internal flow voids. This is pathognomonic. Dx? dysplastic cerebellar gangliocytoma (Lhermitte-Duclos disease, /ler-MIT du-CLO/, LDD). Hamartoma vs neoplasm (hamartoma favored). Cowden syndrome = Lhermitte-Duclos is combined with thyroid cancer, breast cancer, &/or macrocephaly.
Variety of mucocutaneous lesions, macrocephaly, and hamartomas and neoplasms in the breast, thyroid, colon, genitourinary organs, and central nervous system (meningioma and glioma). multiple hamartoma-neoplasia complex, aka Cowden disease/ syndrome. Named the condition after the surname of the first patient described. Autosomal dominant inheritance. Mutation in PTEN tumor suppressor gene.
20yo with partial seizures and a low-attenuation “soap bubbly” mass in the temporal lobe on CT with skull remodeling. No calcifications. No surrounding edema. Top Dx? dysembryoplastic neuroepithelial tumor (DNET). Peak 10-30 yrs. WHO I. Excellent prognosis even with partial resxn. Very rare transform’n. Temporal lb 62%. Frontal lb 31%. caudate nucl, cerebellum, pons. Calcs uncommon (5%). +/- enh. Not always “bubbly.”
Older teen with seizures, imaging shows large temporal lobe cyst-like mass with an intensely-enhancing mural nodule, situated at the meningocerebral interface with leptomeningeal enhancement and perivascular extension. Top Dx? pleomorphic xanthoastrocytoma (PXA). Classic enhancing mural nodule <50%. Calcs rare. Edema unusual. M=F. Wide age: 5-82 yrs. Usually adolesc or yng adults. Highly amenable to surgical resection. WHO II. 20% malign transform’n. 81% surv @5yrs, 70% @10yrs.
Young boy with large heterogeneous supratentorial mass with calcifications, cystic/necrotic areas, some surrounding vasogenic edema, hypointense on T2. Top Dx? Supratentorial PNET. “Cerebral medulloblstma” 6% of pediatric PNETs. Age 4 wks to 10 yrs (mean 5.5 yrs). Boys 2:1. WHO IV. Poor progn, especially in <2 yo. 34% surv @5yrs c/t 85% for cerebellar PNET/medulloblstma. Calcs ~60%. Edema usually not extensive.
Toddler with lobulated mass at the cerebellopontine angle with necrosis and hemorrhage, foraminal extension, associated cranial nerve VI and VII palsy. Atypical Teratoid/Rhabdoid Tumor (ATRT). WHO IV. Most die w/in 1 yr. 94% <5 yo. 52% in post fossa. NOT germ-cell; rhabdoid cells with primitv neuroepith/mesench elements. Biol behvr & histo sim to malign rhabdoid tumor of kidney (s.times assoc’d).
You see pleural cavity open to the air in a patient with a history of chronic empyema or non-small cell lung cancer. What can you say about this patient's treatment history? This patient likely has had an Eloesser procedure. Shapiro, M., Eloesser Window Thoracostomy for Treatment of Empyema: Radiographic Appearance, AJR, 150:549-552, March 1988
What two pathological entities cause RANDOM DISTRIBUTION of tiny nodules in the lungs? miliary TB and metastatic malignancy
Staging of sarcoidosis? 0: Sarcoidosis not involving lungs or mediastinal nodes. 1: nodes only. 2: nodes & lung parenchyma. 3: lung parenchyma only. May progress to fibrosis. Poor lymphatic clearing? 4: fibrocystic, often w/ upward hilar retractn, cystic/bullous change
Sarcoidosis DDx? TB, fungal (histo), Pneumoconiosis (Silica, beryllium), Hypersensitivity pneumonitis, Lymphoma
Lymphangiomyomatosis (LAM) is associated with ___increased/decreased___ lung volumes. increased
What is the world geographic distribution of sarcoidosis? High incidence: Northern Europe. Low incidence: Asia.
What is the underlying pathological process that initiates sarcoidosis? respiratory exposure to antigen in combination with genetic/phenotypic susceptibility (with markedly variable responses and no clear causative antigen)
Löfgren syndrome? Acute sarcoidosis including triad of erythema nodosum, bilateral hilar adenopathy, and arthritis. Higher prevalence among Scandinavian, Irish, African and Puerto Rican women. Löfgren syndrome has good prognosis, >90% resolve within 2 years.
What is lupus pernio? Chronic disfiguring indurated skin lesions, often purplish. Resembles frostbite as it is seen on ears, cheeks, lips, nose, hands, fingers and forehead. Pathognomonic for (and a subset of) sarcoidosis. Rarely experience disease remission.
What enzyme in the blood can be used to help diagnose and monitor sarcoidosis? angiotensin-converting enzyme (ACE)
Presuming linear extrapolation, a CT with effective dose of 10 mSv increases lifetime risk of cancer by how much? Risk = 1 in 2000 (0.005, or 0.5%). References: Pierce, DA, et al. Radiation Research. 2000;154:178. Cologne, et al: Lancet. 2000;356:303-07.
T/F: It is possible to reduce chest/mediastinal CTA absorbed dose down to 1.2 mGy for a 3 yo child. TRUE. Parameters: 50 mA, 80 kV, 1.5 mm collimation, 0.5 second scan, single phase. Compares to 7–15 mGy in an adult (200 mA, 120 kV, 0.75 mm collimation, and two phases)
To decrease CT dose with kVp adjustments, the kVp should be ___increased/decreased___. Decrease in kVp can result in 30%–50% decrease in dose & increased contrast.Rationale: K-edge of iodine is 32 keV. Contrast improves as kVp and kV-avg approaches the K-edge.
T/F: Myocardial bridging is a rare but serious cause of myocardial ischemia. FALSE. It is very common. >50% on autopsy. Some can have ischemia but difficult to prove. Most have no clinical issues.
What is the most common cause of coronary artery aneurysm in the US? atherosclerosis. Kawasaki is classic (3-15% of cases) but not as common of a cause in the US. Kawasaki is, however, the most common cause worldwide. Congenital is also possible.
T/F: Absorbed dose (Gy) values are equivalent to effective dose (Sv) values when discussing x-ray photon irradiation of specific organs. FALSE. Effective dose is affected by individual organ/tissue radiosensitivities. Only whole-body irradiation can be discussed in equivalent terms since since all people are assumed to have same proportions of radiosensitive organ mass.
CTDIvol is measured in what units? Gray (not tissue-specific)
DLP is measured in what units? mGy-cm. This is multiplied by k values for each body part/region to get EFFECTIVE DOSE (Sv).
What is the histological etiology of vertebral hemangiomas? Neoplasm? Vascular malformation? Harmartoma? harmartoma. Fat shows up bright on T1. Can be compressive/aggressive, usually T3-T9 region (unusual).
Discitis in a patient with sickle cell disease. Most likely pathogen? Staphylococcus. These patients are more predisposed to Salmonella infections, but Staph is still most common.
Dense calcification/ossification along the posterior margins of the vertebral bodies in the upper C-spine extending to upper T-spine with assoc’d DISH. OPLL (ossification of the posterior longitudinal ligament). Aunt Minnie Dx. Starts as calcification, then frank ossification.
Enhancing T2 bright lesion with expansion of the cord. tumor (primary or metastatic)
Enhancing T2 bright lesion without expansion of the cord. inflammation (myelitis or MS)
On MR of lumbar spine, nerve roots clumped together, not layered in usual ordered configuration. arachnoiditis
Synovial cyst vs ganglion cyst at the facet joint. What is the differentiating feature to look for? Ganglion cyst is not in continuity with the joint. Facet joint synovial cyst (and ganglion cyst?) can impinge on foramen and/or cord and may bleed &/or have rim of hemosiderin related to degeneration or trauma.
Describe Modic changes. Type 1: edema, vascularized marrow, low T1, high T2, enhances. Type 2: proliferation of endplate fatty marrow, high T1 and T2. Type 3: dense bone devoid of marrow (sclerosis), low T1 and T2.
Extramedullary intradural tumor with brisk enhancement and high intensity rim with low intensity center (target-like) on MR. Target sign is specific for neurofibroma, but not sensitive. Thought to be a marker for benignity, i.e., not malignant peripheral nerve sheath tumor. Rarely seen in schwannomas.
Light bulb enhancement, no target sign, extramedullary intradural tumor in the spine. What is the most likely Dx? meningioma
What is the major risk factor for acquired epidermoid cyst? LP during neonatal period suggests noncongenital etiology. Epidermoid cysts can have only mild rim enhancement, nothing bright.
T/F: All CNS dermoid cysts are congenital. True. Dermoid cysts are congenital, but epidermoid cysts may be acquired (look for history of neonatal LP which can seed the CSF space with epidermal rests).
Define the modiolus. central axis of the cochlea containing the final pathways of the cochlear nerve, with the cupola at its apex.
Name the contents of the epitympanum. Head of the malleus. Short process of the incus. Prussak's space. Ligaments (anterior and superior malleal, and posteror incudal).
Name the contents of the mesotympanum. Stapes (entire), malleus (all but the head), and incus (all but the short process). Tensor tympani and stapedius muscles (innervated by V3 and VII, respectively). Nerves: chorda tympani (VII), Jacobson/tympanic nerve (IX).
Define the Jacobson nerve. aka tympanic n. Br of CN IX. Contns both sensory & secretory fibers. Sensory fibers supply mid ear. Parasympath fibers =>> lesser petrosal n., secretomotor to parotid. Secretory fibers to otic ga. Sympath fibers to deep petrosal n. via carotid plexus.
What are 4 names for the major ganglion of CN V? trigeminal ganglion, semilunar ganglion, Gasserian ganglion, or Gasser's ganglion.
Define Prussak's space and its importance. Pars flaccida of TM laterally, scutum & lat malleal ligament superiorly, malleal short process inferiorly, & malleal neck medially. Debris in retracted pars flaccid can form cholesteatoma, erode ossicles, inner ear, cranium. Scutal blunting is 1st sign.
Young Caucasian woman with bilateral hearing loss, family history of hearing loss at young age. What is the classic imaging appearance of the most likely condition based on this information? "Halo sign" on temp bone CT. Otosclerosis, aka otoSPONGIosis. Conductive HL due to fix’n of stapes footplate in oval window from otosclerotic /spongiosis w/in labyrinthine capsule & cochlea (+/- sens/neur HL). AD genetics, variable penetrance. F:M 2:1.
Asymmetric (L-R) exophytic bony overgrowth of the lining of the external auditory meatus. exostosis of EAC (aka surfer’s ear). Cold water exposure. Usually asymmetric d/t chronic asymmetry of cold-water exposure (wind directions, leading ear strikes water). Pain, conductive HL, & incr risk of external otitis (swimmer’s ear infx).
What normally lies in the hypotympanum? Nothing but air.
Define the Michel deformity. aka complete labrynthine aplasia. Extremely rare congenital absence of the inner ear structures. Early failure in development correlating to the third week of gestation.
Most common radiologic finding in early-onset progressive sensorineural hearing loss (SNHL). large endolymphatic duct and sac (LEDS). Large vestibular aqueduct syndrome (dilated on T2, should be < lateral semicircular canal). Often assoc’d w/ incompl partition cochlear anomalies.
Female child with right-sided pulsatile tinnitus, conductive HL, otalgia. Top Dx? Consider aberrant internal carotid artery. Look for enhancing mass in hypotympanum. 90% females. More common on right side.
You see absent internal carotid artery on head CTA or MRI done for unrelated reasons. What is the concern? High association with intracranial aneurysms. Nearly 30% present with subarachnoid hemorrhage. May be incidental discovery.
Incidental finding of high jugular bulb and poorly pneumatized mastoids. What is this called? What is the significance? This is called “megabulb” and is the most common vascular anomaly of petrous temporal bone. 3%-7% incidence, more common on right side. (75% of people have jugular vein larger on right). Has surgical impact (need to avoid).
Child with hearing loss and MR evidence of globular mass in the epitympanum and involving the incudostapedial joint, follows fluid signal intensity on T2 and FLAIR, with mild peripheral enhancement. Low T1. Top Dx? congenital cholesteatoma (epidermoid). Aberrant epithelial rests +/- bone destruction. DDx: Cholesterol granuloma would be T1 bright but otherwise can have similar appearance.
Encephalocele and unilateral fistula through the tegmen tympani on coronal MR in a young child >1 yr old. congenital dehiscence of tegmen tympani. Rare (requires dural weakening). Coronal plane offers best view. Normally there is fusion of petrosquamosal suture by 1 yr of age. Tiny openings are present in up to 34% of population.
What must occur prior to MR evaluation of a fetus? Level 2 sonography and determination by level 2 MR personnel-designated attending radiologist that the risk benefit ratio warrants MRI. IV contrast is NOT recommended.
What is the normal AFI range (amniotic fluid index) and how is it calculated? AFI between 8-18 is considered normal, <5-6 = oligohydramnios, >20-24 = polyhydramnios. Unobstructed vertical depth of deepest fluid pocket in each of 4 quadrants is measured and added.
Define low-lying placenta. Placental margin within 2 cm of the internal cervical os.
Define central previa. Placenta centered over the internal os (subset of complete previa).
What is the layer invaded by the placenta in placenta accreta? Decidua basalis (superficial invasion). This type (accreta vera) is the most common, 75% of placenta acreta cases. Others are placenta increta (penetration into the myometrium) and placenta percreta (serosal penetration and beyond). Check Doppler flow.
DDx for oligohydramnios. Renal abnormalities. Premature rupture of membranes. Placental insufficiency. Fetal demise. Post-dates. Chromosomal abnormalities.
Describe the features of Potter sequence/syndrome. No NL kidneys. No fluid-filled bladder. Pulmonary hypoplasia. Clubfoot. Hip dysplasia. Facies: low-set ears, hypertelorism, prominent infraorbital folds, flat nose, receding chin. Classically d/t bilateral renal agenesis (BRA). Sirenomelia may also occur.
Clenched hands on fetal ultrasound. Camptodactyly (fingers bent over) and clinodactyly (fingers inclined to one side or the other). Trisomy 18 (Edwards)
Rocker-bottom feet on fetal ultrasound. Trisomy 18 (Edwards)
What nonchromosomal genetic disorder is often confused with Turner syndrome when it occurs in females? Noonan syndrome.
What characteristic features of Turner syndrome are most likely to be encountered in radiology? Webbed neck from cystic hygroma in utero or infancy. Broad chest (shield chest). Coarctation of the aorta. Bicuspid aortic valve. Horseshoe kidney. They also have primary amenorrhea and infertility.
Name 4 causes of polyhydramnios. 1. Proximal GI obstruction, 2. facial/neck mass, 3. neurologic disorder of swallowing or propulsion, 4. maternal diabetes, 5. fetal anemia, 6. AVM, 7. chromosomal abnormalities.
What 4 measurements are most important in dates analysis in the second trimester? BPD, HC, AC, and FL.
What is the ideal gestational age range (based on LMP or U/S dates) for second-trimester U/S evaluation? 18-22 weeks
What is the normal size range for the cistern magna at 2nd trimester ultrasound? 2-10 mm
What is the normal size range for the nuchal fold at 2nd trimester ultrasound? <5 mm. Do not confuse this with NT evalaluation (11-14 weeks, >3 mm is abnormal).
What is the normal size range for the lateral ventricles at 2nd trimester ultrasound? Less than 10 mm. Lateral ventricles measuring greater than 10 mm transverse at the atria defines fetal ventriculomegaly.
What is the normal separation of the choroid plexus from the medial wall of the lateral ventricle at 2nd trimester ultrasound? <3 mm
What is the normal size range for the CSP at 2nd trimester ultrasound? The cavum septum pellucidum should measure no more than 10 mm across.
What are the required and ideal gestational age ranges for nuchal translucency (NT) evaluation? 11-14 weeks (more precisely, 11 weeks 4 days and 14 weeks 3 days). Abnormal if >3 mm.
At what gestational age does CRL become less usefull than other fetal measurements for determination of gestational age and dates? CRL is useful until about 10 to 12 weeks. Charts provide GA estimations accurate to approximately 0.5 week's menstrual age. Brant&Helms 3rd Ed pg 2543.
Define BPP as it pertains to fetal ultrasound. 5 variables: Fetal movement, Fetal tone, Fetal breathing, Amniotic fluid volume, and Fetal Heart Rate. 2 points for normal response, 0 for worst. Extreme risk of fetal demise w/in 1 wk with total score of 0 or 2, no immediate risk with score of 8 or 10.
What conditions are associated with theca lutein cysts? Exaggerated corpus luteum response to high levels of beta-hCG, appears as multicystic ovarian enlargement. They occur with gestational trophoblastic disease, multiparous pregnancy, gest'l diabetes, or in association with use of ovulation-inducing drugs.
Define chorioangioma. Benign solid hypoechoic vascular mass in placenta, +/- septations, usually close to chorionic surface. Feeding vessels show arterial waveforms at fetal heart rate. Vascular shunting may cause high-output heart failure and hydrops.
Banana and lemon sign (US), low lying torcular herophili, cervicomedullary kinking, towering cerebellum wrapping brainstem, compacted cerebral gyri (stenogyria), callosal dysgenesis, enlarged massa intermedia are classical for what fetal condition? Chiari II malformation. No associated fetal chromosome or syndrome. Rather, the cranial abnormality is due to the leakage effects of spinal dysraphism (usually myelomeningocele), prevented by maternal folate supplementation.
Mild macrocephaly, absent cortical mantle, intact cerebellum, and intact falx (may be disrupted/vestigial). hydranencephaly
Partial absence of the anterior interhemispheric fissure and absent CSP. Most of falx present. lobar holoprosencephaly
Partial fusion of hemispheres and formation of a portion of the posterior interhemispheric fissure and falx. semi-lobar holoprosencephaly
Large central monoventricle, small brain, fused thalami, absence of corpus callosum, CSP, and falx. alobar holoprosencephaly (most severe form of holoprosencephaly)
EXIT procedure is used in response to what life-threatening fetal germ cell tumor? EX-utero Intrapartum Treatment procedure. Modif’d C-sxn. Partial delivery thru uterotomy, intact umbilical cord and placental support, pediatric ENT surgeon establishes airway. Once EXIT is complete, umbilical cord is cut/clamped and infant is delivered.
Main 5 differential diagnoses for fetal lung abnormality on U/S. CDH, CPAM, sequestration, bronchogenic cyst, and CLO (congenital lobar overinflation/"emphysema")
Physiologically herniated bowel returns to the abdomen by what fetal age? 12 weeks
Omphalocele or gastroschisis: which is associated with increased risk of other congenital abnormalities? omphalocele
Eagle-Barrett syndrome is synonymous with _____ . prune belly syndrome
Congenital Obstructive Posterior Urethral Membrane is synonymous with ____. COPUM = posterior urethral valves (PUV). Thick walled, trabeculated bladder.
Kleeblattschädel (aka _________) is most/classically typical of what congenital deformity? clover leaf skull. Typical of thanatophoric dwarfism (skeletal dysplasia). Can also be seen in other acrocephalopoly(syn)dactylies (Crouzon, Pfeiffer, Carpenter, Apert…) and de novo FGFR gene mutations.
The 3 most common lethal skeletal dysplasias are _______. Thanatophoric dysplasia, Jeune syndrome (asphyxiating thoracic dystrophy), and type II osteogenesis imperfecta (OI).
What is the significance of an echogenic intracardiac focus on fetal U/S? May be associated with aneuploidy in at risk population or if other markers present. Not significant if no risk factors and other markers are normal.
What are the two main chromosomal abnormalities associated with 2-vessel cord? Trisomy 13 (Patau) and Trisomy 18 (Edwards).
DDx for echogenic bowel? Chromosomal anomalies (especially trisomy 21), cystic fibrosis, multiple intestinal atresias, and swallowed blood. Should be bright as bone.
Define primary amenorrhea. No menstruation by 16yo. Assoc’d w/ polycystic ovary syndrome (PCOS) and Turner syndrome (single X chromosome).
Enlarged ovaries, cysts along periphery. Clinically correlate for e/o PCOD (polycystic ovarian disease).
16 yo girl has not had menses and on ultrasound the uterus and ovaries maintain prepubertal sizes. Turner syndrome likely. Chromosomal test.
Precocious puberty is defined as ____. Menses, thelarche, adrenarch prior to 8 yo. Most are caused by CNS lesion.
Name the fascial spaces of the suprahyoid neck. There are 9. Superficial space. Masticator space. Parotid space. Carotid space. Parapharyngeal space. Pharyngeal mucosal space. Retropharyngeal/danger space. Perivertebral space. Posterior cervical space. Now name their contents and potential pathology.
What are the 4 main layers of the deep cervical fascia? Superficial (investing layer), Middle (pretracheal/visceral, around thyroid, trachea, and esophagus), and Deep (perivertebral, surrounds paraspinal muscles including scalenes), and [Carotid sheath – space formed by trigone of other layers].
Define the PHACES association. Posterior fossa malformations; Hemangiomas; Arterial anomalies; Cardiac anomalies; Eye anomalies; Sternal cleft, supraumbilical raphe.
What are the contents of the parapharyngeal space. fat, branches of V3, IMAX branches, ascending pharyngeal artery, pharyngeal venous plexus, salivary gland rests
Define infantile hemangioma. Not present at birth but appears within first few weeks. 60% in head and neck; 3:1 M:F. Three phases: proliferating, involuting, and involuted (by age 5).
Define congenital hemangioma. Fully formed and full size at birth; look/ behave differently than infantile hemangiomas; 2 types: rapidly involuting congenital hemangioma (RICH) (by 14 months), and non-involuting congenital hemangioma (NICH)
Nonencapsulated fatty masses distributed symmetrically in the neck of a 50 year old man. Madelung disease aka Multiple Symmetrical Lipomatosis (MSL), Benign Symmetric Lipomatosis, or Lanois-Bensaude Syndrome. Almost exclusively a disease of middle-aged alcoholic men. Appearance of lesions is preceded by 10 years of heavy drinking.
What are the two most common malignant tumors of salivary glands (or salivary gland rests)? Most common is mucoepidermoid carcinoma (MECa), then adenoid cystic carcionma (ACCa).
What are the contents of the carotid space? internal carotid artery; internal jugular vein; deep cervical (internal jugular) lymph node chain; cranial nerves IX, X, XI, and XII; sympathetic chain.
Describe the classic location for the most common branchial cleft cyst. 2nd branchial cleft cyst. At/caudal to the angle of mandible. -posterior to submandibular gland -anterior to SCM -lateral to carotid space Occasionally see “beak” pointing medially between ECA and ICA.
Hyperenhancing tumor at the skull base with “salt and pepper” appearance on MR. paraganglioma, aka glomus tumor
Young adult patient with pulsatile tinnitus, cranial neuropathy affecting IX-XII, and mass with permeative erosive changes at the skull base with amputation of the jugular spine. jugular paraganglioma, aka glomus jugulare
What percentage of glomus tumors in the head and neck are malignant? No more than 15%, even with erosive changes at the skull base (jugulare, more like 3% malignancy).
“Splaying” of the ECA and ICA and “filling-in” of the bifurcation is pathognomonic for what tumor? carotid body paraganglioma
Enhancing lesion with calcifications in the high carotid space displacing the internal carotid artery anteriorly, with sclerosis of the jugular tubercle and lack of bony erosion. Most likely Dx? meningioma from the jugular foramen
Homogeneously dense/isointense lesion in the carotid space with heterogeneous enhancement and no flow voids, displacing the internal carotid artery anteriorly. Most likely Dx? vagal schwannoma
What skull base window to the middle cranial fossa should be particularly evaluated in a patient with a tumor in the masticator space? Why? foramen ovale (contains V3). The fascia attaches medially.
T/F: Paragangliomas may exhibit calcifications occasionally. FALSE. Think meningioma (also enhances vividly).
Vividly enhancing tumor smoothly enlarging jugular foramen without erosion. Mass appears to be centered in the posterior carotid space. Most likely Dx? vagal paraganglioma (glomus vagale), not jugulare.
Skull base mass, homogeneously iso/low on T1, bright on T2 with heterogeneous enhancement. No salt and pepper appearance. What should be the top Dx? Vagal schwannoma. Also think of neurofibroma (NF1 hx?).
What is the genial tubercle? ”Chin” of the mandible.
T2 sequence in cardiac MR best demonstrates what myocardial pathology? edema
Delayed post-gad T1 sequence in cardiac MR best demonstrates what myocardial pathology? necrosis and scar, which look identical (1st pass perfusion, enhancement defect). Similar pattern on delayed post-contrast CT.
Immediate post-contrast images (CT or MR) best demonstrate the presence of what type of myocardial pathology in the setting of MI? microvascular obstruction (Bonus: what is this and what does it signify?)
What is microvascular obstruction (MO) and what is its significance in the setting of MI? MO is downstream occlusion by dying blood cells and debris such that even with restored epicardial blood flow the infarct core will not promptly reperfuse. Predicts increased complications (unstable angina, reinfarction, CHF, embolic stroke, death).
What are the 3 main subacute complications of myocardial infarction? Rupture of ventricular aneurysm with tamonade, acute dilation/remodeling, and Dressler syndrome (pericarditis).
What is Dressler syndrome? acute myocarditis/pericarditis following myocardial infarction
Name four ways to evaluate viability of myocardium. Response to inotropic stimulation (dobutamine echo); glucose metabolism (PET), presence of cellular transport mechanisms (Tl-201 SPECT), presence of fibrosis (MRI or CT).
What is the main purpose of delayed images on cardiac MR? To see if there is damage to myocardium where there is reestablished perfusion.
Thin walled bulge along the myocardial wall in a patient with acute chest pain and grossly positive serum TnI and history of syndrome X. Second infarction (positive TnI) and ventricular aneurysm from separate old infarction. Syndrome X= truncal obesity with combined DM, HTN, and HL.
Bulblike outpouching of contrast into the myocardium in a patient hospitalized for acute MI 4 days prior. Most likely Dx and disposition? impending myocardial rupture. Emergent thoracic surgical consultation.
Unilocular nonenhancing thin-walled encapsulated structure with barely-perceptible thin septations, central simple fluid density, adjacent to the right anterior cardiophrenic angle. History of cardiac surgery. Most likely Dx? pericardial cyst. Most are congenital, but they can also form after surgery. Variable locations along the pericardium bt R ant cardiophrenic angle is most typical. Benign, no tx unless mass effect.
Leftward rotation of the cardiac axis and apex. Lung tissue interposed between aorta and main pulmonary artery. Prominent atrial appendage. Most likely Dx? Congenital absence of the pericardium. Partial is most common.
T/F: Uremia is a known cause of pericardial effusion. True. Usually chronic renal disease.
At what CT density in a fluid collection should blood/hematoma/hemothorax be suspected? above 40-45 HU, less than 100 HU
Low BP, JVD, and muffled heart sounds indicate what abnormality? What is the eponym for this triad? Beck’s triad is associated with acute cardiac tamponade, usually from a large pericardial effusion.
Tubular cardiac ventricles, dilated atria, paradoxical septal motion with straightening on MR and US, adherence, normal thin pericardium, history of Hodgkin disease 3 years ago. Most likely Dx? pericardial constriction
T/F: The presence of calcification confirms pericardial constriction and the absence of calcification excludes it. FALSE. There is tremendous overlap between the presence of pericardial constriction and the presence of pericardial calcification. Pericardial constriction must be confirmed by clinical symptoms and abnormal hemodynamics.
What are the indications for surgical correction of aortic aneurysm? Any symptomatic. Any asymptomatic ascending aortic caliber >5.5 cm(non-Marfan), >5.0 (Marfan); descending aortic caliber >6.5 cm(non-Marfan), >6.0 cm (Marfan). Growth >1 cm/yr. 30%–68% rupture risk without surgery. (AIRP Aortic Dz)
Most common causes (3) of ascending aortic aneurysm? Acquired medial degeneration (aka “cystic medial necrosis” – path dx), which can also occur in the setting of Marfan disease and other inherited syndromes. Bicuspid aortic valve (AV). Infection (“mycotic”) is rare (syphilis, bacterial, fungal).
Most common cause of descending thoracic aortic aneurysm? atherosclerosis (90%), just like abdominal aneurysms. Remaining 10% are due to chronic dissections.
Name the syndrome: hypertelorism, bifid uvula and/or cleft palate, arterial tortuosity with aneurysms and dissections, scoliosis, pectus excavatum or carinatum, contractures of fingers and toes (camptodactyly), long fingers and lax joints, and club foot. Loeys-Dietz syndrome, an AD genetic syndrome which has features similar to Marfan syndrome, but which is caused by mutations in genes encoding transforming growth factor beta receptor 1 (TGFBR1) or 2 (TGFBR2).
Describe the spectrum of acute aortic syndromes. Dissection, intramural hematoma, penetrating aortic ulcer (PAU), & ruptured aortic aneurysm. Acute: <14 days fr Sx onset. Complic’ns: ischemia, frank rupture. All can occur with same underlying process: atherosclerosis. Marfan’s & E-D also important.
Why is it possible to have an aortic intramural hematoma without intimal disruption? Intramural hematoma (IMH) is often (usually?) caused by rupture of the vaso vasorum into the tunica media. A third of these lead to dissection. Another third lead to rupture. IMH in the ascending aorta requires surgical repair.
Constant, fixed circumferential/crescentic increased density within the aortic wall. What does this describe? intramural hematoma (vs classic dissection which often spirals longitudinally around aorta). IMH is a dynamic process; change often observed in first 30 days. Possible changes: resorption, stability, migration, or progression.
Atheromatous plaque focally ulcerates and tunnels into the tunica media media. What does this pattern of acute aortic syndromes describe? penetrating aortic ulcer. Complications include pseudoaneurysm, dissection, and/or rupture. Threshold measurements for repair: width >2 cm, depth >1 cm.
What are the threshold measurements for repair of penetrating aortic ulcer? width >2 cm, depth >1 cm.
Of the following diseases, which has not been implicated in aortitis?: Takayasu, giant cell arteritis, RA, Crohn dz, SLE, nonspecific granulomatous dz, asbestos, salmonella, staphylococcus, streptococcus, fungi, TB, syphilis. Asbestos has been assoc'd w/ chronic periaortitis, but never clinical aortitis. All others listed are possible causes of aortitis. The only well-documented extrapulm CAs attributed to asbestos exposure are peritoneal mesothelioma and perhaps GI adenoCa.
Describe aortic sarcoma. Intimal neoplasia & organized thrombus. Mimics severe atherosclerosis. Poor survival, 8% @5 yrs: stenosis/occl/isch, infiltrn/recurrnc, mets, embolizn, rupture d/t necrosis. Tx: endarterectomy vs resection/graft interposition, adjuvant chemo.
What is adrenarche? Adrenarche is the pubertal development of the zona reticularis in the adrenal cortex, involved in secretion of androgens such as DHEA and DHEAS related to the appearance of pubic hair.
Diffuse airspace opacification affecting all 5 lobes with costal sparing on CT, patient on mechanical ventilation for acute respiratory failure, no significant fever. Top Dx? AIP (acute interstitial pneumonia). Resembles ARDS but no known cause like sepsis/shock.
Diffuse airspace opacification affecting all 5 lobes with traction bronchiectasis, volume loss, and costal sparing on CT, patient on mechanical ventilation for acute respiratory failure, no significant fever. Top Dx? organizing phase of AIP (acute interstitial pneumonia).
Name four major pathways to pulmonary fibrosis. IPF/UIP; AIP/ARDS/DAD/organizing phase; COP/incorporation/NSIP; and RB-ILD/DIP.
Name some exposures and familial patterns associated with sarcoidosis. Occupational: Insecticides/Agricultural work, Firefighting (but neg assoc with cigarette smoke), Molds/Bioaerosol, Bird handling; Mycobacterial infection; Genetic features: Monozyg twins, Familial (5x’s), Gene-specific;
What is the most common cause of death in patients with sarcoidosis? cor pulmonale. Associated with pulmonary fibrosis along bronchovascular bundles & subsequent pulmonary hypertension, cardiac arrhythmia, & right heart failure. Also pulmonary hemorrhage from aspergilloma/mycetoma (goes invasive with steroids).
What is the Kveim-Siltzbach test? Skin test for sarcoidosis. Part of spleen from pt with known sarcoidosis is injected into skin of pt suspected to have sarcoidosis. (+) if granulomas are found 4–6 wks later. False negatives on glucocorticoids. Not commonly performed.
What fungus is present in 40-50% of sarcoidosis cystic lesions? Aspergillis. Steroids may convert to invasive process, may hemorrhage.
Child w/ CT showing hyperinflation w/ bilateral subsegmental cystic bronchiectasis, air-fluid levels, bronchial wall thickening, & mucus plugging. Expiratory CT shows collapse of bronchi & distal air trapping. Trachea & central bronchi remain NL on both. Williams Campbell syndrome, a rare form of congenital cystic bronchiectasis d/t defective 4th-6th order bronchial cartilage, with preservation of the trachea and main bronchi (distinguishing feature). Usually presents in childhood.
28yo AA male with recurrent pneumonia, CT shows bronchiectasis, fibrosis, and emphysema. There are also dilated trachea and bronchi with saclike outpouchings between tracheal cartilages. Most likely Dx? tracheobronchomegaly aka Mounier-Kuhn syndr. Rare AR congen dz w/ elastic fiber atrophy & thinning of tracheal and central bronchial muscle, leading to dil’n & sputum retent’n. Tracheal size incr w/ Valsalva, narrows w/ Müller. 95% male, >African descent.
What is the Müller maneuver? After a forced expiration, an inspiratory attempt against closed mouth and nose, whereby markedly negative intrathoracic pressure is created; the reverse of Valsalva maneuver.
Name 11 lung diseases with obstructive physiology. Emphysema, bronchitis, bronchiectasis, asthma, LAM (lymphangioleiomyomatosis), constrictive bronchiolitis/BO, panbronchiolitis, sarcoid, alpha-1 deficiency, ABPA (allergic bronchopulmonary aspergillosis), PLCH (pulmonary Langerhans cell histiocytosis).
By the time FEV1 is abnormal (<80% of NL) in a smoker, how much of the alveolar tissue is destroyed? 0.9
Emphysema with lower lobe predominance. Dx? panacinar emphysema due to alpha-1 antitrypsin deficiency
Definition for chronic bronchitis? Cough and sputum for 3 months of 2 consecutive years with increased secretions and thickening of the airways. There is mosaic attenuation on CT, +/- RB. Smoking-related.
Scattered upper-lobe nodules 0.5-1 cm in size, over time replaced by cysts, eventual emphysema, honeycombing, fibrosis. No effusions or adenopathy. Smoking history. Likely Dx? pulmonary LCH. Immunoperoxidase staining should be positive for CD1a and S-100 protein. Electron microscopy should show X-bodies, Langerhans cell granules, and Birbeck granules.
What is the natural history of pulmonary LCH? Usual clinical resolution but with persistent radiographic abnormalities. Occasional clinical progression with fibrosis and honeycombing. Rapid progression can lead to death.
“Signet rings” and “Tram tracks” on CT indicate what phenomenon (common to many pulmonary diseases)? bronchiectasis
What features characterize intrinsic asthma as opposed to extrinsic asthma? Intrinsic asthma: Lack of atopy history, absence of external triggers, older age group, increased blood & sputum eosinophils, fixed or progressive airway obstruction.
Reticulonodular pattern in the bilateral lung bases on CXR. Patchy GGOs with areas of scattered peripheral honeycombing and traction bronchiectasis on CT. H/O progressively worsening dyspnea and long-term environmental exposures. Most likely Dx? chronic hypersensitivity pneumonitis. Fibrosis in addition to noncaseating granulomas and giant cells on transbronchial lung biopsy.
Reticulonodular pattern in the bilateral lung bases on CXR. Patchy GGOs with centrilobular nodules in the upper lobes on CT. H/O intermittent dyspnea and environmental exposures over several months to years. Most likely Dx? subacute hypersensitivity pneumonitis. Noncaseating granulomas and giant cells on transbronchial lung biopsy.
Chest CT shows consolidations and central bronchiectasis with bifurcating finger-in-glove opacities. Repeat CT shows varying distribution. H/O worsening asthma, hemoptysis. CBC shows eosinophilia. Dx? allergic bronchopulmonary aspergillosis (ABPA). Tx: steroids. “Gloved-finger” opacities = mucous filled airways. Pleural disease is uncommon. Usually atopic. Elevated serum IgE. Skin test: immediate reactivity.
What percentage of sarcoidosis patients present with obstructive lung disease? at least 50% (per Dr. Galvin, AIRP)
40 yo Japanese man with cough, SOB, hyperinflated lungs on CXR. CT shows centrilobular 2-6 mm nodules and branching opacities, mosaic attenuation, bronchiectasis. Top Dx? panbronchiolitis (diffuse). Slowly progressive with 15 yr mean survival. Tx involves erythromycin (may not be antibacterial effect).
Cough, dyspnea, and malaise. Clinical airways obstruction. Prior childhood infection/exposure. CT shows hyperinflation (localized or diffuse), mosaic attenuation, air trapping, central bronchiectasis, discrete airway-associated nodules. Top Dx? constrictive bronchiolitis aka bronchiolitis obliterans. Small airways fibrosis & inflame’n, mos/yrs after exposure/infection. Rare variant: Swyer-James syndrome: unilateral lung, chronically hyperlucent, not necessarily hyperinflated, may constrict.
Chronic unilateral lung hyperlucency, CT shows mosaic attenuation, air trapping, central bronchiectasis in one lung only, exposure/infection history as an infant. Constricts over time, abnormal lung growth. Dx? Swyer-James syndrome, variant of constrictive bronchiolitis aka bronchiolitis obliterans aka obliterative bronchiolitis.
28 yo woman with progressive dyspnea, hemoptysis, clinical e/o obstructive lung disease. CT: diffuse bilateral upper and lower lobe thin-walled cysts with adenopathy. Likely Dx? Lymphangioleiomyomatosis (LAM). Smooth musc proliferation. Rare males w/ TS. Probably neoplastic r/t tuberous sclerosis and renal AMLs. Variable slowly progr course, progressing to cor pulmonale, respiratory insufficiency. Tx: oophx, progest, sirolimus.
Diffuse reticulonodular pattern on CXR. Centrilobular and peribronchial nodules 3-12 mm, air trapping, & mosaic attenuation on CT. Newly dx’d RA. Top Dx? follicular bronchitis. Multifocal hyperplasia of BALT (bronchus) w/ rxv germinal centers along bronchioles, branch points. Antigenic stim by infection, AIDS, CVDs, hypersensitivity rxn. DDx: respiratory bronchiolits, hypersensitivity pneumonitis.
CXR: lower lobe reticulonodular pattern. CT: lower lobe groundglass centrilobular nodules, thin-walled cysts, thickened bronchovascular bundles, and lymphadenopathy. No pl effusion. 41yo woman w/ Sjögren syndrome, cough, SOB, restrictive PFTs. Dx? lymphocytic interstitial pna (LIP). Diffuse hyperplasia of BALT causes thickening of the interstitia.
42yo F with SLE, CT shows solitary subpleural mass in the right lower lobe, focal indistinct consolidation with air bronchograms, no lymphadenopathy. Bx shows polyclonal lymphoid proliferation. Dx? nodular lymphoid hyperplasia. Benign pseudolymphoma. Surgical excision is curative.
49yo man with consolidations, 2 large masses in the left lower lobe, effusion. Bx: CD20+, monoclonal, small round blue cells involving alveolar wall and peribronchiolar/perivascular spaces. Dx? low-grade B-cell lymphoma aka BALT lymphoma. 5-year survival 85%–95% after surgical resection.
48yo man with cough, SOB, malaise, weight loss, skin rash. CT: reticulonodular pattern with multiple bilateral mid and lower lobe nodules, occasional cavitations, hilar adenopathy. Top Dx? lymphomatoid granulomatosis. EBV-related angiocentric Bcell lymphoma w/ predominent reactive T-cell infiltrate. Nodular infarctions. Extrapulm involvemt: CNS 37–53%; Renal 32–40%; Skin 39–53%. High mortality 53–90%. 12–47% fail tx and proceed to lymphoma.
What virus is associated with AIDS lymphoma (besides HIV)? In the setting of T-cell impairment, Epstein-Barr virus causes diffuse polyclonal expansion and eventual malignant transformation.
What size do particles need to be to deposit in the lung parenchyma (alveoli)? 20% of particles 1-5 microns will deposit in the alveoli.
What is silicoproteinosis? acute (weeks-months) lower lobe silica exposure resulting in inflammation, exudate, leading to silicotic alveolar proteinosis. Related to type II pneumocyte hyperplasia. More nodular than idiopathic pulmonary alveolar proteinosis.
What is progressive massive fibrosis? cancer-mimic conglomeration of nodular lesions (especially silicotic nodules, anthracotic nodules) Greek: anthrax=coal
Rapidly progressive coal workers’ pneumoconiosis is related to what contaminant in the coal dust? silica
T/F: Patients with silicosis have increased incidence of BOTH tuberculosis AND cancer. TRUE
Differentiate round atelectasis from rounded pneumonia. Totally different diseases. Rounded atelectasis is a mass-like folding of inflamed, collapsed lung, preceded by pleural effusion. Round pneumonia occurs in children less than 8 yo, due to undeveloped pores of Kohn and canals of Lambert.
Mean pulmonary artery pressure above ___ mm Hg constitutes pulmonary hypertension. >25 mm Hg. Normal wedge pressure indicates pulmonary arterial hypertension.
Above what transverse diameter of the main pulmonary artery is there greater than 85% sensitivity and specificity for pulmonary arterial hypertension? >3 cm
What do the following signs indicate? RV strain & hypertrophy. RV anterior free wall >6 mm. RV chamber dilatation: RV/LV >1. Septal flattening or curve reversal. Regurgitant flow @ pulmonary and tricuspid valves. Increased glycolytic activity on FDG PET. cor pulmonale, result of advanced pulmonary HTN. Causes: Idiopathic; Eisenmenger from ASD, VSD, PDA, TAPVR; chr hemolytic anemias; IV talcosis (IVDA); schisto; tumor thrombi; chronic PE; mediastinal fibrosis; COPD; ILD; collagen vasc; HIV; sarcoid; OSA.
Chronic inhalational lung diseases are strikingly upper lobe for what physiologic reason? Improved lymphatic clearance in the lower lobes clears the junk to the nodes. Lymphatics in the lower lungs are better because of greater blood flow, greater osmotic pressures.
Subperiosteal resorption along radial aspect of middle phalanges of index & middle fingers is pathognomonic for this condition. Hyperparathyroidism, 1° or 2°
35yo male smoker with cough, SOB. CT shows large areas of groundglass opacity outlined by thickened secondary lobular septae, with patchy areas of sparing. Top Dx for this pattern? pulmonary alveolar proteinosis PAP. Crazy paving. Autoimmune disease. Deficient surfactant clearance. Build up of surfactant assoc’d lipids and proteins. Smokers 3:1. Male 3:1. Age range 20-50 yrs. Can proceed to fibrosis over years. Tx’d with lavage.
Posterior lower lobe pleural-based nodule with ovoid shape, spiculations extending into the parenchyma and along the pleura, with volume loss. Top Dx? round atelectasis. f/u to secure benignity.
Name 4 lung diseases highly associated with PTX. emphysema, asthma, LAM, LCH
“Classic” cause of crazy paving on CT is _______. What are other causes? pulmonary alveolar proteinosis PAP. Also DAD/AIP/ARDS, cardiogenic edema, infection (esp TB, PCP, Nocardia), diffuse alveolar hemorrhage.
Why does pulmonary edema tend to spare the periphery? Bucket handle motion of ribs increases lymphatic drainage at the periphery anteriorly and at the bases.
Mediastinal lymphadenopathy with unusually high CT density (not calcific), with associated pleural effusion and layering material. Think anthrax with hemorrhage.
Serum c-ANCA is sensitive and specific for what vasculitis? Wegener granulomatosis (Cytoplasmic anti-neutrophil cytoplasmic antibody has 99% specificity and 96% sensitivity in active disease.) Cyclophosphamide is effective tx. Remember "c."
Three pulmonary arteritis vasculitides with p-ANCA positivity. Churg-Strauss syndrome (CSS), microscopic polyangiitis, and collagen vascular diseases (perinuclear ANCA)
What are the three top large-vessel arteritides affecting the chest? Takayasu arteritis, Behçet disease, and giant-cell aortitis
What is Goodpasture’s disease? Type II hypersensitivity characterized by direct antibody deposition in the renal glomeruli. Also one of the 4 childhood diseases most frequently associated with pulmonary hemorrhage.
50yo East Asian man with hemoptysis, chronic illness, multiple lung nodules, some with cavitation, pulmonary arterial aneurysm on angiography obtained for concerns of PE. Also c/o chronic sinus congestion and poor urine output. Top Dx? Behçet disease. Classic triad: sinusitis, pulmonary symptoms, and renal insufficiency. Also look for saddle nose deformity, nasal septal destruction, subglottic stricture, tracheobronchial mucosal ulcerations, otitis media, cochlear nerve vasculitis.
T/F: Air-fluid levels in cavitating Wegener granulomas are most likely from hemorrhage. False. Hemorrhage can occur, but should be the top concern.
Anti–glomerular basement membrane antibody disease with combination of glomerulonephritis and pulmonary hemorrhage is commonly referred to as _____. Goodpasture syndrome. Target antigen is alpha-3 chain of type IV collagen in the alveolar and glomerular basement membranes. One of the 4 childhood diseases most frequently associated with pulmonary hemorrhage.
What is the most common cause of pulmonary-renal syndrome? microscopic polyangiitis. No longer considered microscopic polyarteritis nodosa. (+) p-ANCA.
Vasculitis with renal, musculoskeletal, pulmonary, GI and cutaneous manifestations, diffuse ground glass on chest CT, (+) p-ANCA, 5th decade onset, male predominance. Dx? microscopic polyangiitis. No longer considered microscopic polyarteritis nodosa.
28yo with new onset asthma, allergic rhinitis, diarrhea and eosinophilic peritonitis, eosinophilia on CBC, elevated IgE, (+) RA and p-ANCA, predominantly peripheral lung parenchymal opacifications with diffuse numerous small nodules on CT. Top Dx? Churg-Strauss syndrome (CSS), aka allergic granulomatosis, a diffusely multisystem medium and small vessel autoimmune vasculitis. M=F. (+) p-ANCA. Excellent response to steroids.
49yo woman with cough, SOB, chest pain, fever, weight loss. CT shows hilar LAD and numerous diffusely scattered small perivascular lung nodules, some cavitating. Top Dx? necrotizing sarcoid granulomatosis. 100% lung involvement. Prompt response to steroids. No reported deaths.
What angioinvasive lymphoma is related to EBV, dominated by reactive T-cell infiltrate, and demonstrates lung involvement in all cases? lymphomatoid granulomatosis
Lymphomatoid granulomatosis is related to what pathogen? Epstein-Barr virus
22yo chronic asthmatic with cough, SOB, fever, hemoptysis, eosinophilia, (-) ANCA and cultures, and no response to Abx. CT: unilateral nodules and consolidations centered about the airways, bronchiectasis, and mucoid impaction. Top Dx? bronchocentric granulomatosis. Must rule out treatable infection and Wegener granulomatosis. Good response to steroids. Some remit spontaneously.
50yo with cough, SOB, fever, hemoptysis, eosinophilia, (+) RF, (-) ANCA, (-) cultures, and no response to Abx. CT: unilateral nodules and consolidations centered about the airways, bronchiectasis, and mucoid impaction. Top Dx? bronchocentric granulomatosis. Must rule out treatable infection and Wegener granulomatosis. Tx with steroids. Asthmatics are more responsive.
T/F: Necrotizing sarcoid granulomatosis has an excellent prognosis and responds well to steroids. True. No reported deaths.100% lung involvement. CT shows hilar LAD and numerous diffusely scattered small perivascular lung nodules, some cavitating.
DDx for multiple vessel-associated pulmonary nodules? List 4 or 5. metastatic disease, multifocal infection (fungus, TB), septic emboli, vasculitis. Sarcoid involves all parts of the lungs, more inhalational than vessel-associated.
What pulmonary diseases predispose to development of mycetoma? Sarcoid, TB, ABPA all predispose to mycetoma. There may be others. Remember that immunodeficient people tend to get invasive aspergillosis, not a walled-off fungus ball (mycetoma).
How can one discern whether a mass within a cavitation is a fungus ball or cancer? Cancer will not be mobile with change in position. Fungus ball may (probably will).
Whispy densities and tree-in-bud opacifications in the RML and L lingual in a thin elderly Caucasian woman. Dx? nontuberculous mycobacterial infection, aka MAC, aka MAI
How can a radiologist tell that a lesion superimposed over the mediastinum on CXR is actually within the lung? If the lesion is circumscribed on all sides by lung-density on PA and lateral, it must be within the lung.
What is the most mild form of holoprosencephaly? Septo-optic dysplasia. 50% have schizencephaly. Can be seen with or without corpus callosum agenesis.
What is the worldwide leading cause of death from infectious disease? TB. 2–3 million deaths/year
Define Ranke complex. Ghon complex in its calcified state (calcified peripheral lung nodule in conjunction with calcified ipsilateral hilar/mediastinal LAD, an indication of primary TB). Visible on CXR.
Most common sites of extrapulmonary TB are ____. Choose 5. Mediastinal lymph nodes, liver, spleen, kidneys, and spine.
T/F: A positive PPD indicates exposure to but not necessarily infection from TB. False. A positive PPD indicates at least latent-stage TB infection, which should be treated to prevent active TB.
What percentage of persons with positive PPD go on to develop active TB within 2 years? 5% for general population. 50% if HIV positive.
What percentage of persons with positive PPD go on to develop active TB within their lifetime? 5-10% lifetime risk
Within how many years do 5% of (+)PPD patients develop active TB? 2 years
Children with mediastinal adenopathy and decreased lung volumes have __________ until proven otherwise. TB
Random tiny nodules in TB indicates what type of spread? hematogenous (miliary TB).
Airway nodules in TB indicates what type of spread? endobronchial
Define Rasmussen aneurysm. pulmonary artery aneurysm as a complication of active TB
What tumor most commonly metastasizes to the mediastinum (not counting lymphoma)? What are some others? Renal Cell Carcinoma. Others: Testicular, SCC from head/neck, breast ca, melanoma, gastric ca, and thyroid.
T/F: The vast majority of patients with myasthenia gravis have a thymoma. False. Most (85%) have follicular thymic hyperplasia. Only 15% have thymoma.
What percentage of patients with myasthenia gravis have thymoma? 30-50%. Not more than half.
60yo with R anterior mediastinal cystic mass mural nodules and curvilinear calcification and no evidence of invasion or lymphadenopathy anywhere. Most likely Dx? thymoma. Masaoka-Koga stage I or IIa (can’t tell by imaging alone). Needs resection.
58yo with L anterior mediastinal solid mass with coarse calcifications and CT evidence of invasion into the left brachiocephalic vein. No lymphadenopathy. No effusions. Most likely Dx? thymoma. Masaoka-Koga stage III.
What are three parathymic syndromes associated with thymoma? myasthenia gravis, pure red cell aplasia, and hypogammaglobulinemia
What kind of follow-up is recommended for patients after complete resection of thymoma? Think of all thymoma as Ca. Yearly CT for 5 years, alternate annual CXR and CT until 11 years, and then annual CXR for rest of life. If stage III or above, incomplete resection, or frank thymic carcinoma, CT should be every 6 months for first 3 years.
43yo man with weight gain, insomnia, emotional lability, new development of acne, and small right sided mass in the anterior mediastinum, crossing midline. Mediastinal LAD is present. Most likely Dx? thymic carcinoid. 50% are functionally active. ACTH secretion causes Cushing syndrome (33%–40%). Unusual but can be present in MEN-1 patients (19%–25%).
Top Dx in a 15 yo patient with stridor, dysphagia, and large solid anterior mediastinal mass? lymphoma
What is WDHA syndrome? WDHA syndrome (watery diarrhea, hypokalemia, and achlorhydria syndrome), aka pancreatic cholera, is due to a secretory non–β-cell pancreatic tumor, and can be seen (rarely) in patients with MEN-1.
What is Wermer syndrome and what are its features? multiple endocrine neoplasia type 1 (MEN-1). 3 P’s. Parathyroid adenoma (PTH-secreting, hyperPTH and hyperCa2+); Pancreatic islet cell tumors (esp insulinoma, gastrinoma); (Pituitary adenomas (mostly prolactinomas, can be more aggressive than sporadic).
What organ cell-type do thymic carcinomas most resemble? Lung. Small-cell tumors often secrete ACTH (similar to thymic carcinoid). Other lung cancer cell types can show up in thymic carcinomas (adeno, SCC, etc).
28yo male with incidental discovery of largely fat-containing well-defined mass extending across the anterior mediastinum and insinuating itself between structures with minimal mass effect despite large size. Most likely Dx? thymolipoma
28yo male with stridor and dysphagia. CT shows fat-containing well-defined mass extending across the anterior mediastinum and diplacing trachea and great vessels. This is most worrisome for _____. thymic liposarcoma. May be a thymolipoma, but these typically do not cause mass effect. Malignancy must be excluded. Surgical consultation is indicated due to symptoms.
Rather than just the “four T’s,” what should be the differential diagnosis for an anterior mediastinal mass? “Teratoma” should be replaced by “germ cell neoplasms, mostly teratoma but also seminoma and mixed, and “Thymoma” should include carcinoma, carcinoid, and lipothymoma. “Terrible lymphoma” and “Thyroid” usually have characteristic imaging features.
What causes the low-density contents of a mature teratoma? Usually this is due to sebum and other lipid-rich material (hence, “cystic”), rather than actual adipose tissue. Both can be found in a mature cystic teratoma.
What life threatening event not related to compression or mass effect can occur with a large mature cystic teratoma? Rupture can be especially damaging to a young child. Reaction to cystic contents can be severe.
Which germ cell tumor responds particularly well to radiation? seminoma
What sex-linked genetic disorder has a particularly high rate of nonseminomatous germ cell tumors? Klinefelter syndrome. XXY
What is 45X aneuploidy? Turner syndrome
What is 45XXY aneuploidy? Klinefelter syndrome
Differentiate ganglioglioma (1), gangliocytoma (2), paraganglioma (3), ganglioneuroma (4), ganglioneuroblastoma (5), and neuroblastoma (6). GG/GC=bubbly brain tumors, WHO I-II (GC is WHO I, no glial). PG= catecholamine-secreting from sympathetic system, adrenal medulla, Zuckerkandl. 4/5/6: paraspinal/CN tumor spectrum. GN: excision curative; GNB: very good prognosis; NB: limited prognosis.
What is the most common middle mediastinum tumor other than lymphadenopathy? Foregut malformation, most commonly bronchogenic cyst.
The preferred term for pineal-region dysgerminoma, aka atypical teratoma, aka “pinealoma,” aka “seminoma” is ______. pineal-region germinoma. These are histologically indistinct from germinomas at other locations including the testes, and occur in the same patient population (mostly male), and respond similarly well to radiation (and chemo).
What is Parinaud's syndrome? Compr of CN3 & tectal superior colliculus (vertical gaze ctr), characteristic upgaze paralysis, accommodative paresis with light-near dissoc’n (pseudo-Argyll Robertson), eyelid retract’n (Collier sign), & conjug downgaze in 1° position "setting-sun sign"
What is the most common mediastinal neurogenic neoplasm? schwannoma. 65% are asymptomatic.
Neurilemoma is aka __________. schwannoma
Neuroblastoma has a ________ 2-year survival and a _________ 5-year survival. 50% and 10%. It’s bad.
In the setting of neurofibromatosis, what is the 5-year survival of MPNST? What about solitary (no NF1)? 30% in NF1 patients. Better for solitary: 75%. (2012 AIRP)
What is the most common congenital cyst of the mediastinum? bronchogenic cyst. Abnormal ventral foregut bud. Failure to induce mesenchymal development to lung parenchyma. Mediastinum (85%), pericardium, diaphragm, pleura, lung.
35yo male with right-sided thoracic spine dermatomal pain/numbness prompting CT which shows fluid-filled right paraspinal mass extending into the central spinal canal. Density of fluid is that of water. Most likely Dx? meningocele. DDx should include arachnoid cyst (do not typically extend beyond CNS boundaries) and meningomyelocele (look for nerve tissue).
28yo woman with chronic cough, no h/o PNA, asthma, or lung disorder. CXR shows 3 cm mass inferior to the carina. CT shows homogeneous density 30 HU, well circumscribed, spherical. Most likely Dx? bronchogenic cyst (especially if water density or air-fluid level and no peripheral enhancement to suggest abscess. Typically unilocular. Consider also lymphadenopathy, especially lymphoma.
What is DILS? aka diffuse infiltrative lymphocytosis syndrome. Occurs in HIV+ patients with low CD4 count. Painless parotid and submandibular swelling and sicca symptoms, similar to Sjögren. Typically improves with HAART. Mass should be resected to rule out neoplasm.
AIDS patient with parotid and submandibular swelling, dry mouth and dry eyes, low CD4 count, and a well-circumscribed multilocular cystic mass in the anterior mediastinum with enhancing tissue septa. Most likely diagnosis? DILS: Diffuse infiltrative lymphocytosis syndrome. Typically improves with HAART. Mass should be resected to rule out neoplasm.
Normal thickness for thymus under 20 years of age? Over age 20? 1.8 cm under age 20. 1.3 cm over age 20.
Name 2 causes of diffuse thymic enlargement. lymphoid hyperplasia (myasthenia gravis, hyperthyroidism, lupus, scleroderma, rheumatoid arthritis, cirrhosis) and rebound hyperplasia (post-chemotherapy (2 weeks–14 months), from steroids, or from severe insult).
Key MR finding in mediastinal cysts and thymic hyperplasia is _______. chemical shift
What is the difference between lymphangioma and lymphatic malformation? Nothing. This is a trick question. Lymphangioma and lymphatic malformation are often used interchangeably. They may be developmental vs neoplasm vs hamartoma.
Large multilocular fluid-density cystic mass with well-defined borders, visible septae, extending between structures, with minimal rim enhancement. Location in the neck or mediastinum. Most likely Dx? Lymphatic malformation (lymphangioma).
What are the features of Rendu-Osler-Weber syndrome? aka hereditary hemorrhagic telangiectasia (HHT): AD genetic disorder affecting proteins in TGF-β signaling pathway; AVMs and telangiectasias in the skin, lips, mucous membranes, lungs, liver, brain, and spine. Common sx: epistaxis, ICH, and GI bleed.
What is the eponym for hereditary hemorrhagic telangiectasia (HHT)? Rendu-Osler-Weber syndrome
What percent of mediastinal contour abnormalities on CXR end up being vascular? 0.1
What is the underlying pathology in primary achalasia? deficiency of ganglion cells in myenteric plexus at the lower esophageal junction (LES)
What are the 2 most common causes of secondary achalasia? Chagas disease, chronic scleroderma with secondary inflammatory stricture, & malignancy at the GE junction
What are the two forms of the rare lymphoproliferative disorder Castleman disease? What pathogens are associated? What cytokine is associated? Localized/unicentric: often cured w/ rsxn. Multicentric: treated more like lymphoma (but polyclonal), can develop true lymphoma. Associations w/ HHV-8 (esp in HIV), & incr IL-6. Prognosis partly depends on cell type (hyaline vascular and plasma cell).
What are two features of lymphadenopathy of Castleman disease that distinguish it from that of lymphoma? Castleman disease can enhance intensely, and can show a characteristic “arborizing” pattern of calcifications. AJR March 2004. 182(3); 769-775. Fungal/TB infection remains in the DDx.
What drug has a risk of retroperitoneal fibrosis? methysergide
What are the causes of medullary nephrocalcinosis? "HAM HOP". Hyperparathyroidism, acidosis/RTA I/distal, medullary sponge kidney, hypercalcemia/-uria, oxalosis (can also cause cortical), papillary necrosis (NSAIDS, TB).
What are the causes of cortical nephrocalcinosis? "COAG": Cortical necrosis (dystrophic calcs), oxalosis (also causes medullary), Alport syndrome, and glomerulonephrosis (chronic).
Bat-wing distribution of microcalcifications in bilateral lungs. Mild shortness of breath. Spares the periphery. Most likely Dx? alveolar microlithiasis. Rare diffuse bilateral deposition of intra-alveolar microliths. Often asymptomatic (70%) in spite of radiographic abnormalities. No known Tx; lung transplant is considered for end stage.
What are some causes of L to R shunt? ASD, VSD, PAPVR, PDA, and endocardial cushion defect (CAVC). Reversal to R to L shunt is Eisenmenger syndrome.
What are the classifications of eosinophilic pneumonia? UNKNOWN cause (Löffler syndrome, acute/AEP, chronic/CEP, idiopathic hypereosinophilic syndrome-IHS) & KNOWN cause (ABPA, parasite infection, Churg-Strauss vasculitis, drug rxn). AEP mimics pulmonary edema. AEP & CEP show rapid response to corticosteroids.
What is Löffler syndrome? (also written Loeffler) Transient form of eosinophilic pna. Cough, blood eosinophilia, and radiographic shadowing related to parasitic/fungal infection or drug reaction.
What is the reversed halo sign? What is it classically associated with? aka atoll sign, a roundish groundglass/ST density with central lucency (not air/cyst), classically associated with COP/BOOP.
Triad of allergic history, peripheral blood eosinophilia, and systemic vasculitis. All have asthma. Most also have peripheral neuropathy. Most likely Dx? Churg-Strauss vasculitis. A granulomatous small vessel vasculitis.
What is the triad of symptoms with Horner syndrome? What causes it? Ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (loss of sweating). Involvement of the sympathetic chain and stellate ganglion, often by Pancoast tumor.
What is the current understanding of the differentiation between adenocarcinoma and bronchoalveolar carcinoma? True bronchoalveolar carcinoma is actually an adenocarcinoma in situ, which explains its more groundglass and interstitial appearance on CT. Any invasion makes it simply invasive adenocarcinoma. The term BAC or bronchoalveolar should not be used.
T/F: Among women with lung cancer around the world, half have no smoking history. True: 53%. It is even higher in Japan, where 80% of women with lung cancer are nonsmokers.
T/F: Squamous cell cancers in the lungs tend to be peripheral. False. SCC is more commonly central, as is small cell and carcinoid. AdenoCA is commonly peripheral.
What is the Golden “S” sign? distorted minor fissure (right lung): inferiorly concave lateral aspect and inferiorly convex medial aspect, due to central lung mass or lung collapse. Collapse of RUL, concerning for bronchogenic CA. Sometimes called the “reverse” S sign of Golden.
On CXR, there is complete opacity of the right apex, with a well defined inferiorly concave margin laterally and smooth convex line medially against the mediastinum. What is the top concern for Dx? Bronchogenic cancer in the right hilum. This is the Golden S sign from obstructive RUL collapse.
What is LEMS? Lambert–Eaton myasthenic syndrome. Autoimmune disorder, muscle weakness of the limbs due to antibodies against presynaptic voltage-gated calcium channels in the neuromuscular. 60% have underlying malignancy, most commonly small cell lung cancer.
What is Eaton-Lambert syndrome? More officially “Lambert–Eaton myasthenic syndrome (LEMS)”. Muscle weakness of the limbs due to antibodies against presynaptic voltage-gated calcium channels in the neuromuscular. 60% have underlying malignancy, most commonly small cell lung cancer.
What is the eponym given to the autoimmune paraneoplastic muscle weakness caused by antibodies against presynaptic voltage-gated calcium channels in the neuromuscular junction? What is the most common underlying neoplasm? Lambert–Eaton myasthenic syndrome (LEMS), aka Eaton-Lambert syndrome. Often associated with small cell lung cancer. Weakness improves with activity due to competitive loading of acetylcholine into the NMJ.
Name 3 paraneoplastic syndromes associated with small cell lung cancer. Cushing syndrome from ACTH-like hormone, SIADH from ADH-like hormone (hyponatremia, headache, muscle cramps, irritability, drowsiness, confusion, weakness, seizures, and coma), and Lambert–Eaton myasthenic syndrome (LEMS).
What are the two main divisions of small cancer therapy? Limited lung disease: dz only on one side of chest +/- central mediastinal nodes. Tx: Chemo/RT, maybe consider surgery if very limited/early. Extensive lung disease Tx: Chemo, maybe RT, never surgery.
T/F: Large cell lung cancer has a better prognosis than BAC and responds well to current therapies. False. Rapid growth, early mets, poor prognosis. Rarely cavitates.
Given a choice between cancer and abscess, what is the most likely cause of mass in the anterior lung? Cancer. Very unlikely an abscess if in the anterior lung. Difficult to aspirate anaerobic bacteria into the anterior lung while supine.
What is the most common cell type in NSCLC currently? What was it 50 years ago? Why? 50yrs ago, most common lung Ca was SCC, predominantly central. Filtered cigarettes & change in tobacco over last 40yrs, now more peripheral adenocarinomas. Filters remove large particles deposited in central airway where SCC preferentially develops.
Scleroderma is a subset of a disease that often is implied by the term scleroderma. What is this disease and what are its features? Systemic sclerosis (SSc): connective tissue dz affecting skin, lungs, heart, esophagus, & kidneys. Raynaud phenomenon (up to 90%), tendonitis, arthritis, and interstitial lung disease like UIP. 70% surv @5-yrs. COD commonly aspiration pna from esoph.
T/F: Scar carcinoma is lung adenoCa in response to a chronic lung scar. False. In scar carcinomas, the scar is usually a reaction to the malignancy. A localized scar is rarely the cause of malignancy.
T/F: 10% of lung adenoCa occur in the central airways. True, and they typically have solid architecture. The other 90% have more typical appearance and arise in the terminal respiratory unit (TRU). Precursors include atypical adenomatous hyperplasia (AAH) and adenoCa in situ (AIS aka BAC).
T/F: Many chronic lung diseases are associated with increased risk of adenoCa, but diffuse pulmonary fibrosis is NOT among them. False. It is.
Vessel convergence on a spiculated lung mass suggests what? fibrotic response. Commonly seen in adenoCa.
Which of the following is not a known risk factor for lung cancer? Smoking, secondhand smoke, family history, certain cooking practices, radon, air pollution, yearly chest CT scans.
What lung disease is characterized on histology by lepidic growth? Atypical adenomatous hyperplasia is characterized by lepidic growth of premalignant cells. Atypia falls short of BAC. Precursor/transition to BAC.
Discuss the 5-year survival of small or minimally invasive adenoCa of the lung (aka BAC). 100% 5-year survival if <5 mm localized fibrosis, regardless of invasion. 70% 5-year survival if 5–10 mm. 60% 5-year survival if >10 mm.
T/F: Shrinkage of groundglass tumor in the lung may be associated with progression of adenoCa. True. Adenocarcinomas of the lung may get smaller related to fibrosis and alveolar collapse.
What is invasive mucinous adenocarcinoma of the lung? Formerly “mucinous bronchioloalveolar carcinoma.” Alveolar spaces distended with mucin. Aerogenous spread common, leads to satellite tumors. Multifocal consolidation. No architectural distortion. 20%–25% of BACs. KRAS genetic mutation (75%).
Adult patient with wide-spread acinar micronodules in the lungs, miliary calcifications, recent exposure to child with illness and rash. Most likely Dx? varicella pneumonia
What is Friedlander pneumonia? Klebsiella pneumonia. Characterized by lobar expansion, massive necrosis, currant jelly sputum, pulmonary gangrene, association with hepatic abscesses in Asians.
What is Mendelson syndrome? Chemical pneumonitis caused by aspiration during anaesthesia, especially in conditions with high intra-abdominal pressures (pregnancy, ascites, mass, etc). Permeability edema, followed by acute inflammation. Rapidly clears, but may progress to ARDS.
What are some features of Nocardia pneumonia? Ubiquitous bug, risk in neutropenia, T-cell defects. Can be extrapulm (40-90% mortality): CNS, skin. AIDS pts get TMP-SMX prophylaxis for this.
T/F: Intracranial Cryptococcus gattii infections only occur in immunodeficient patients. False. Cryptococcus gattii is now recognized as a primary pulmonary pathogen, may occur in immunocompetent individuals.
Large well circumscribed cystic lesion in the lower lung with multiple smaller internal cysts. History of travel abroad. Most likely Dx? Pulmonary Echinococcus granulosus infection.
What is the “water lily sign” in Pulmonary Echinococcus infection? Sign of ruptured (host) pericyst. Impending rupture is implied by the crescent sign: air between pericyst and laminated membrane.
What parasitic disease do these features imply?: PTX and pleural infection during pleural penetration by juvenile worms. Transient patchy consolidation and linear tracts during larval migration. Peribronchial cysts associated with mature worm. paragonimiasis westermani. trematode (lung fluke), endemic to Asia, eating contaminated freshwater crab. Jejunum – peritoneal cavity – diaphragm – pleura – lung. Chronic granulomatous reaction.
What head and neck infection can lead to fulminant widespread streptococcal pneumonia? Lemierre syndrome. Complication of head and neck infection, especially streptococcal pharyngitis, with infectious thrombophlebitis and diffuse septic pulmonary emboli. Other bugs: MRSA, Bacteroides, Fusobacterium.
What disease does this describe?: Most common parasitic roundworm infection worldwide, 25%–95% prevalence, highest in children. Large ingestion associated with pneumonitis. Ascariasis lumbricoides. Small bowel – systemic circulation – alveoli – trachea – small bowel.
What lung disease is associated with HPV infection? recurring respiratory papillomatosis. Squamous papillomas. 1%–20% can have pulmonary lesions. Rare squamous cell carcinoma. Nodules +/- cavitation.
T/F: Bronchial carcinoid has a particularly high association with diarrhea and flushing. False. Carcinoid syndrome (which may also include CHF and bronchoconstriction) is rare in bronchial carcinoid, but may occur if liver metastases have occurred.
How do bronchial carcinoid and small cell carcinoma fit into the 1999 WHO criteria for neuroendocrine tumors? Largely d/t histologic mitotic rate and cell size. Typical carcinoid: <2 mitoses per 10 high power field (HPF). Atypical: 2–10 mit/10 HPF. Large cell neuroendocrine carcinoma: >/=11 mit/10 HPF (median=70). Small cell carcinoma: >/=11 mit/10 HPF (med=80).
T/F: Typical pulmonary carcinoid has a high 5-year survival and is not associated with smoking history. True. 95% survive to 5 years. Usually present as "iceberg lesion" -- central airway, partially endobronchial, mostly extends outside the airway, may calcify.
What is a Morel-Lavallée lesion? closed degloving shear injury associated with severe trauma which then presents as a seroma or hematoma
Formerly called “cylindroma.” adenoid cystic carcinoma (of the salivary glands or rests)
After SCC, what is the most common tracheal malignancy? adenoid cystic carcinoma (of the salivary rests). 80% of bronchial glandular tumors (remainder are low or high grade mucoepidermoid Ca). Local recurrence common. Rarely mets outside chest.
What is the name for rare aggressive central or periph lung neoplasm of elderly men with epithelial and mesenchymal components? carcinosarcoma (spindle cell, chondrosarc, osteosarc, rhabdomyosarc, SSC, adenoCa, undiff’d carcinoma). Poor progn: local inv, widespread mets. Rapid death.
What mixed-cell aggressive embryonal lung cancer affects children in the first decade? pulmonary blastoma. Large peripheral mass with central necrosis, hemorrhage. Nasty, but should not be the first thing on the differential for a solitary pediatric lung mass.
40yo male with history of mild hematemasis. CXR shows circumscribed 2.3 cm round mass in the perihilar LLL with speckled calcifications and areas of low density, -40 HU. Most likely Dx? hamartoma. No other DDx.
What is Carney triad? gastric smooth muscle tumors, pulmonary chondromas, and extra-adrenal paragangliomas. Occurs typically in women under age 20.
16yo F with hypertension, elevated urine catecholamines. CT C/A/P shows scattered smoothly round lung nodules and a round mass in the gastric wall. Biopsy of the gastric tumor reveals smooth muscle histology. Most likely for the underlying condition? Carney triad. Gastric smooth muscle tumors, pulmonary chondromas, and extra-adrenal paragangliomas. Occurs typically in women under age 20.
How do pulmonary chondromas differ from pulmonary hamartomas? Chondromas are seen in young women, and lack epithelials-lined clefts. Seen in Carney triad. Both pulmonary chondromas and pulmonary hamartomas are benign.
Who gets laryngeal papillomatosis? children ages 18 mo to 3 years, more often first-born infant to mother with (50%) HPV, spread transvaginally. May spread (5%), but usually localized and disappear spontaneously. 1% develop lung dz, mortality 37.5% from complications, SCC.
Plasma cell granuloma, histiocytoma, fibroxanthoma, xanthoma, myofibroblastic tumor, and mast cell granuloma are all synonyms for what benign pulmonary condition that represents the most common primary lung mass in both boys and girls? inflammatory pseudotumor. M=F, ages 1-77yrs. Aggressive-appearing fibroblastic/myofibroblastic/plasmacytic proliferation, but usually no/slow growth, may regress. 74% asymptomatic. Excellent prognosis after rsxn. Recurrence in 5%.
What is a juxtraphrenic peak? Small triangular opacity projecting upward from diaphragm on CXR related fluid collecting in small inferior accessory fissure, seen in upper or middle lobe atelectasis. Inferior accessory fissures are seen in 30%–45% of anatomic specimens.
What is a “pseudotumor” on CXR? lenticular opacity caused by fluid accumulation in the minor fissure in the setting of effusion
Buzzword: “split pleura sign”. Dx? empyema
What is empyema necessitatis? Empyema that has burrowed thru chest wall & presents as soft fluctuant mass expanding with cough. May break through skin and drain as a sinus. TB represents 73% of cases. BATMAN: Blastomyces, Actinomyces, Tuberculosis, Mucor, Aspergillus, & Nocardia.
Discuss the proper usage of the terminology for intervertebral disc disease: bulge, herniation, protrusion, extrusion, focal/broad-based. Bulge NOT= herniation, requires extension >50% of circumference (symmetric or asymmetric). Do NOT include osteophytes. Herniation is either protrusion (neck larger than herniated material) or extrusion (herniated material larger than neck). Focal<25%.
Buzzword: Comet tail on a lung mass against the pleura. Dx? round atelectasis. Look for thickened pleura, ovoid mass along the pleura, loss of lung volume, and comet tail from converging bronchovascular bundles.
What T-stage of NSMLC does a malignant pleural effusion define? T4 (Stage IIIB nonresectable). Next level of severity is IV in setting of distant mets.
What is “localized fibrous tumor” of the pleura? Rare usually-roundish pleural tumor of disordered spindle cells and collagen, can be large, malignant in 20%. Pedunculation with positional mobility is pathognomonic. M=F, not related to asbestos. Assoc’n with HPO.
50yo factory worker with incidental 8 cm roundish pleural-based mass in the RLL on screening CXR. Lateral decubitus reveals positional mobility. Appears pedunculated on CT, no calcs. Dx? localized fibrous tumor. Rare pleural tumor of disordered spindle cells and collagen, can be large, malignant in 20%. Pedunculation with positional mobility is pathognomonic. M=F, not related to asbestos. Assoc’n with HPO.
T/F: Mesothelioma usually presents bilaterally. False. If bilateral, think of pleural lymphoma or metastases. Only 10% of mesothelioma are present as bilateral disease.
What is Poland syndrome? congenital absence of the right pectoralis muscles, often with ipsilateral limb abnormalities such as syndactaly or adactyly. Thought to be due to in utero vascular insufficiency during limb development.
What is the term (eponym) for congenital absence of the right pectoralis muscles with ipsilateral limb abnormalities such as syndactaly or adactyly, thought to be due to in utero vascular insufficiency during limb development? Poland syndrome
What fungus-like higher bacterium is notorious for causing pleural fistula and chest wall draining sinus from lung infection? Actinomyces israelii (actinomycosis)
What is a chest wall desmoid? aka fibromatosis. Recurrent aggressive fibrous soft tissue mass w/ sparse fibroblasts. Not malignant, but can be difficult to tx d/t recurrence. May also occur in abd wall, more common in Gardner syndrome pts. Usually at sites of prior surgery or trauma.
Recurrent aggressive fibrous soft tissue mass with sparse fibroblasts, frequent recurrence after resection. What is the name for this condition? Desmoid tumor (aggressive fibromatosis). Not malignant, but can be difficult to treat due to recurrence. May also occur in abd wall, more common in Gardner syndrome pts. Usually at sites of prior surgery or trauma.
Classic causes of expansile rib lesion. FAME: Fibrous dysplasia. Aneurysmal bone cyst. Mets/Myeloma. Enchondroma. Consider also bone-destructive lesions: chondrosarcoma, lymphoma, Ewing sarcoma, neuroblastoma, Askin tumor (PNET).
What are the possible causes of rib notching? Renal osteodystrophy/secondary hyperparathyroidism (most common cause), neurofibromatosis (NF1), and coarctation.
12yo female with large destructive tumor in the right chest wall, eating through bone, with associated pleural effusion. Most likely (and worrisome) diagnosis? Askin tumor (PNET). Poor prognosis.
What attribute do the following tumors share?: Choriocarcinoma, osteosarcoma, testicular tumors, melanoma, Ewing sarcoma, thyroid carcinoma, and Kaposi sarcoma. They are the malignancies MOST HIGHLY PREDISPOSED to lung metastasis. MECK ThOT : mel, Ewing, choriocarc, Kaposi, thyroid, osteosarc, testicular
What is the DDx for noncalcified miliary pulmonary nodules? thyroid ca (papillary), choriocarcinoma, TB, viral pna, sarcoidosis.
What is Wilson-Mikity syndrome? In premature infants, very rare respiratory dz at 2-4 wks, air sacs injury, ?pre-HMD dz, ?virus, 50-70% survive.
What percentage of term deliveries are accompanied by meconium staining of the amnion? What percentage of these cases involve meconium aspiration? Of these, what percentage are symptomatic? 10%. 50%. 50%
T/F: Blood cultures are positive in only 50% of osteomyelitis cases. TRUE
What is a gibbus deformity? Focal kyphosis due to marked anterior collapse of vertebral body. Characteristic of MPS 1 (Hurler syndrome). Also can be seen in Pott disease (TB of spine), trauma, and osteoporosis (where it is aka dowager’s hump).
What type of population gets subperiosteal abscess in long bones? infants, children. Loose periosteum. Can occur in the sinuses/orbit of adults.
Who gets the “sequestrum/involucrum” response in osteomyelitis? children under 16yr. Uncommon in adults.
Typical organism involved in cat bite? Pasteurella multicida (not Bartonella henselae, which is responsible for cat SCRATCH dz)
T/F: Both epidermoid carcinoma and systemic amyloidosis are potential long term complications of osteomyelitis. True. Half a percent of osteomyelitis cases with long term (20-40yrs) draining sinus can develop epidermoid carcinoma, M>F. Mostly tibia/femur. Systemic amyloidosis is rare.
Leading organism implicated in septic arthritis in ages <2 yrs? H. influenza
What is the cause of joint destruction in septic arthritis? Collagenases released by stimulated WBCs. Also, fibrin deposits on the cartilage inhibit cartilage nutrition.
T/F: Slight narrowing of the 1st MTP joint in relation to MTPs 2-4 is a normal finding. TRUE
What is chronic granulomatous disease of childhood? WBCs cannot form superoxide, kill cat+Staph, nocardia, mycobact, Aspergillus. Skin lesions, Cx LAD, HSM, abscesses, PNA, chr osteo. Fatal in 40%. Bone destruction, limited sclerosis. Mostly X-linked recessive (affects males, carried by females).
What is chronic recurrent multifocal osteomyelitis (CRMO)? Indolent/recurrent 85%-symmetric plasmacytic osteomyelitis, may be sterile. F>M; 5-15yrs. SAPHO in young adults (Synovitis, Acne, Palmoplantar Pustulosis, Hyperostosis, Osteitis). Mostly affects metaph of LEs and axial skel.
10yo girl with chronic/recurrent symmetrical mixed lysis/sclerosis of bilateral tib and femur metaphyses and hips with edema on STIR, blood Cx consistently negative. This pattern is classic for what condition? CRMO (chronic recurrent multifocal osteomyelitis). Indolent/recurrent 85%-symmetric aseptic plasmacytic osteomyelitis. ages 5-15yrs. Mostly affects axial skeleton and metaphyses of LEs.
What is SAPHO? Synovitis, Acne, Palmoplantar Pustulosis, Hyperostosis, Osteitis. F>M for PPP, M>F for acne. Aseptic inflammatory condition, thought to be a collagen vascular disease related to psoriasis.
23yo woman with chronic recurrent acne, pustular rashes on the hands and feet, symmetrical joint synovitis, osteitis, and hyperostosis. Most likely Dx? SAPHO (Synovitis, Acne, Palmoplantar Pustulosis, Hyperostosis, Osteitis). F>M for PPP, M>F for acne. Aseptic inflammatory condition, thought to be a collagen vascular disease related to psoriasis.
IVDAs get septic arthritis in which joints most commonly? “S” joints: spine, sacroiliac, and sternal. Also acromioclavicular joint, symphysis pubis, ischial tuberosity. Most common bugs: Pseudomonas, Klebsiella, Serratia, and Candida in heroin addicts.
What is the eponym for the venous plexus connecting the spine, pelvis, and retroperitoneum? Batson plexus. During valsalva, venous blood can be pushed into this plexus, which may explain the propensity for tumors to seed these regions of the skeleton.
What is the Batson plexus? venous plexus connecting the spine, pelvis, and retroperitoneum. During valsalva, venous blood can be pushed into this plexus, which may explain the propensity for tumors to seed these regions of the skeleton.
What is amyloid arthropathy? Mostly in RA patients, mostly affects hips and shoulders. Classic "shoulder-pad" sign denotes end-stage amyloid deposits in the shoulder synovium and periarticular structures. Incidence reduced from 5% to less than 1% with newer Txs.
What is the link between RA and amyloid arthropathy? Increased serum levels of acute phase reaction proteins in RA lead to amyloid deposition (same/similar proteins) in tissues such as joints, kidneys, etc. Leads to arthropathy, ?renal failure. Common cause of death in ankylosing spondylitis patients.
What 4 intra-osseous tumors are notorious for crossing the intervertebral disc? chordoma, lymphoma, myeloma, giant cell tumor
What is the link between renal failure and amyloid arthropathy? Increased serum levels of β2-microglobulin, particularly in renal failure patients undergoing long-term haemodialysis, leads to amyloid deposition in the synovium, ligaments, and tendons around joints, leading to erosions, subchondral cysts.
cluster of grapes sign in GI tract pneumatosis cystoides intestinalis (PCI)
coffee bean sign sigmoid volvulus
What is Malta fever? aka undulant fever (as in “wave”), aka brucellosis. Brucella species. Ingested milk/meat. arthritis knee/SI/shoulder, prepatellar bursitis, L-spine L4, can mimic TB. “parrot beak” osteophyte, esp L4 region.
What is brucellosis? aka undulant fever (as in “wave”), aka Malta fever. Brucella species. Ingested milk/meat. arthritis knee/SI/shoulder, prepatellar bursitis, L-spine L4, can mimic TB. “parrot beak” osteophyte, esp L4 region.
What is undulant fever? aka Malta fever (as in “wave”), aka brucellosis. Brucella species. Ingested milk/meat. arthritis knee/SI/shoulder, prepatellar bursitis, L-spine L4, can mimic TB. “parrot beak” osteophyte, esp L4 region.
Buzzword: parrot beak osteophyte (at L-spine). Dx? brucellosis, aka undulant fever, aka Malta fever
Describe brucellosis. MSK infxn 30–85%: septic arthritis knee/SI/shoulder, prepatellar bursitis, L-spine L4, can mimic TB. Focal: subchondral ant/sup endplate (“parrot beak” o.phyte). Diffuse: vert body preserv, less disc/paravert involvemt, disc gas (25%–30%). Malta/undul fev
“Teardrop” paraspinal calcification (calcific mass) can be seen in what disorder? tuberculous paraspinal abscess, related to spondylodiscitis
What is the primary pathology of joint destruction in TB arthritis? fibrin deposits cover synovium, starve cartilage of nutrients/O2. Slow process; no proteases as in pyogenic septic arthritis. Granulation tissue erodes cartilage and bone. Synovial thickening, joint effusion, marrow edema, myositis.
What is the Phemister triad? (1) Juxtaarticular osteopenia, (2) Slow joint space loss, and (3) Peripheral erosions, as seen in tuberculous arthritis. Synovial thickening, joint effusion, marrow edema, and myositis may also be seen. Periostitis is not part of the triad.
In what major ways does atypical mycobacterium arthritis present differently from TB (classic Phemister triad)? more rapid growers, more frequently multiple lesions, hand/wrist, lysis/sclerosis, abscess/draining sinus common. May cause thick tenosynovitis.
Classic MSK findings in leprosy are ______. lattice-like osseous destruction of phalanges and nasal bone on x-ray. Long bone fractures with erosion/resorption (“licked candy stick” appearance). Multifocal masslike inflammatory changes in peripheral nerves on MR.
Lattice-like osseous destruction of phalanges and nasal bone on x-ray is specific for what disease? leprosy
What is actinomycosis? infection from Actinomyces israelii (or Nocardia asteroids?), both? are higher-bacteria anaerobe, “acid-fast-like”. Normal flora in mouth, usually imm(-).
What is Wimberger sign (NOT ring) and what is it associated with? bilat focal destruction of medial aspect of proximal tibial metaphyses, pathognomonic for congenital syphilis
What is Hutchinson triad? Hutchinson teeth, corneal interstitial keratitis, sensorineural deafness, as seen in kids with late-diagnosis of congenital syphilis (75% are dx’d after age 10)
What are Hutchinson teeth? _____ , as seen in kids with late-diagnosis of congenital syphilis (75% are dx’d after age 10)
What are Clutton joints? painless knee effusions, as seen in kids with late-diagnosis of congenital syphilis (75% are dx’d after age 10)
What is Wimberger ring (NOT sign) and what is it associated with? dense white cortical margin relative to osteoporotic centers of epiphyses in SCURVY
Buzzword: saber shin. Dx? congenital syphilis. Prolypherative periostitis crossing the metaphyses, usually solid or laminated. Occurs in 20% of pts, may occur as early as 6 weeks.
Buzzword: saddle nose. Dx? congenital syphilis, from nasal bone collapse. Osteomyelitis/osteitis/septic arthritis is much less common than prolypherative periostitis. Look for aggressive lysis affecting the outer table of the skull.
In terms of spirochetic diseases, what is a gumma? any bone caseous necrosis r/t degenerating spirochete in late-stage congenital syphilis. Look for bone lysis/reactive sclerosis. Arthritis is uncommon. 5-10% may get neuropathic joints at the knee, hip, ankle, spine.
Borrelia bergdorferi causes what disease? Lyme disease. Vector: Ixodes tick. Imaging findings can look a lot like JIA/JRA. Affects knee (80%), shoulder, elbow, temporomandibular, ankle, wrist, hip, hand/foot. Swelling, effusion, synovitis on MRI. Also adenopathy, myositis, ABSENCE of SQ edema.
48yo male with chronic osteopenia, joint loss (25%), erosions, and carcinoma. What chronic disease should be considered? Don’t forget Lyme disease can show these findings in 10% of cases.
Fungal infection associated with gardening, especially roses. sporotrichosis. Sporothrix schenckii. Dissemination from skin/resp inoculation can lead to septic monoarthritis, may progress to osteomyelitis. Knee is most common, then hand/wrist.
Created by: dudall
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