Thoracic Imaging 2003 - Society of Thoracic Radiology

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orrhagic lesions. In patients with CMV pneumonia and poorly defined nodules or nodules with an associated “halo” of ground glass attenuation, histologic correlation showed the nodular opacities to represent focal areas of inflammation or hemorrhage. Herpes simplex virus type 1 Herpes simplex virus type 1 pneumonia is an unusual infection that typically affects immunocompromised patients. It is also common in patients with severe burns. The CT findings include multiple nodular opacities, patchy segmental or subsegmental consolidation, and ground-glass attenuation. Pathologically, the nodular lesions contain central necrosis as the virus spreads peripherally from the hematogenously seeded foci. Varicella-zoster virus In adults, disseminated varicella-zoster infection tends to cause significant complications such as varicella-zoster virus pneumonia. The characteristic radiographic pattern consists of multiple 5- to 10-mm nodular opacities. Progression to extensive air-space consolidation can occur rapidly. The histologic findings parallel the clinical severity. Histologically, lesions vary from tiny microscopic foci of parenchymal necrosis and inflammation to large zones to necrosis and findings suggestive of diffuse alveolar damage. Measles virus infection Although measles pneumonia is rare among adults, immunocompromised patients who have lymphoreticular malignancy or congenital immunodeficiency may die as a result of measles pneumonia. Histologically, measles virus pneumonia is characterized by multinucleated giant cells containing up to 50 nuclei in the alveolar spaces and within bronchiolar epithelium. CT findings include ground-glass attenuation, air-space consolidation, and small centrilobular nodules Adenovirus infection Adenovirus is a common cause of bronchiolitis and atypical pneumonia in children and young adults, and may cause a fulminant pneumonia in immunocompromised patients. Pathologically, the lungs are large and heavy and show patchy areas of hemorrhagic consolidation. Nuclear inclusion bodies, most prominent in alveolar lining cells but also found in the airway epithelium, may be identified in infected cells. The bronchiolitis may be necrotizing and results in a necrotizing bronchopneumonia similar to that seen in severe herpes simplex infection. The most frequent radiographic findings of adenovirus pneumonia are unilateral or bilateral bronchopneumonia. REFERENCES: 1. Kim EA, Lee KS, Primack SL et al. Viral pneumonias in adults: radiologic and pathologic findings. RadioGraphics 2002;22:S137-S149 2. Kang EY, Patz Jr EF, Müller NL. Cytomegalovirus pneumonia in transplant patients: CT findings. J Comput Assist Tomogr 1996; 20:295-299 3. Franquet T, Lee KS, Müller NL. Cytomegalovirus pneumonia: thin-section CT findings in 32 immunocompromised non-AIDS patients. (submitted) 4. Worthy SA, Flint JD, Müller NL. Pulmonary complications after bone marrow transplantation: high-resolution CT and pathologic findings. RadioGraphics 1997;17:1359-1371 257 THURSDAY
THURSDAY 258 Imaging of Coccidioidomycosis William Berger, M.D. Objective: To illustrate the various imaging findings related to thoracic Coccidioides immitis infection. Coccidioidomycosis is an infection caused by Coccidioides immitis, a dimorphic soil-inhabiting fungus. The disease occurs in endemic areas, essentially confined to the Western Hemisphere, particularly the southwestern United States. Approximately 100,000 new cases of coccidioidomycosis occur in endemic regions each year. Knowledge of the various imaging findings related to coccidioidomycosis is important for radiologists outside of endemic regions as the southwestern United States is a popular tourism destination, and consequently patients with coccidioidomycosis may seek medical attention in nonendemic regions. Pulmonary manifestations are particularly common, as 99% of coccidioidomycosis infections are acquired by inhalation of arthrospores contained in dust. Approximately 30-40% of patients will develop symptoms following a 1-3 week incubation period, usually mild respiratory illness characterized by pleuritic chest pain and dry cough. Systemic manifestations may occur and include fever, night sweats, and myalgia. “Valley” or “Desert” fever usually implies primary disease combined with characteristic skin lesions such as erythema nodosum. Resolution of the infection usually occurs over 2-6 weeks, after which immunocompetent patients develop immunity. About three quarters of patients with primary coccidioidal pneumonia will go on to complete recovery. Persistent primary or chronic pulmonary Coccidioidomycosis occurs in about 5% of patients. Approximately 0.5% of white and 10-15% of African American and Philipino patients develop disseminated disease. A diagnosis of Coccidioidomycosis in endemic areas may be established if typical clinical or radiographic findings are present. In nonendemic areas, a travel history is of great importance as the diagnosis may be delayed without knowledge of previous travel to an endemic region. Serolgic tests for C. immitis are of benefit in establishing the diagnosis of avute or primary coccidioidomycosis, as they are accurate, and generally considered to be the most reliable among currently available serologic markers for mycoses. Occasionally, bronchoscopy, or biopsy of a lymph node, skin lesion, or pulmonary nodule is needed to establish the diagnosis. Treatment with antifungal medication is usually not necessary, but is often indicated for immunocompromised patients and in those with severe primary or disseminated coccidioidomycosis. Antifungal medication is usually not required for treatment of a nodule or cavity, or following resection of a lung lesion. Symptomatic patients with cavities may be treated with oral azole therapy. Further, cavities that are large, persist, or are subpleural (predisposing to rupture into the pleural space) are usually treated operatively. Chronic coccidioidal fibrocavitary disease is usually treated with azole antifungal therapy. Primary Coccidioidomycosis occurs after inhalation of the arthrospores, which induce an exudative reaction, producing a typical bronchopneumonia, which eventually is accompanied by a granulomatous reaction. The pneumonia usually remains relatively localized, and frequently completely resolves. Radiographic findings in primary coccidioidomycosis vary from no abnormalities to areas of air space consolidation, which are usually unilateral (80%) and often confined to the parahilar and basal regions. Consolidation is the most common radiographic abnormality and may be dense or hazy and ill defined. Occasionally, areas of consolidation may resolve in one area and develop in another, producing so-called “phantom infiltrates”. Mediastinal (5%) and hilar (15%) adenopathy may occur, and small effusions (typically ipsilateral to consolidations) occur in about 10%. Large effusions are rare. Less commonly, a cavity or one or more nodules may be present during the primary phase of the disease. Chronic Coccidioidomycosis is typically defined when clinical and radiographic manifestations last for longer than 6 weeks. Most commonly, a single nodule develops, frequently in the same area as a pre-existing consolidation, a finding that is particularly suggestive of Coccidioidomycosis. The nodules are usually less than 4 cm, frequently occur in mid to apical portions of the lung (including the anterior segments of the upper lobes in contrast to tuberculosis), and almost never calcify. These nodules may spontaneously cavitate and resolve, remain stable, or enlarge slowly. Less frequently multiple nodules may develop. Multiple nodules are almost always randomly distributed, small, and occasionally show microcavitation. Marked contrast enhancement of Coccidioidal nodules has been reported. Most patients with nodules are asymptomatic and frequently serum coccidioidal antibodies are negative. Occasionally biopsy of a nodule may be necessary to exclude a malignant etiology if a previous pneumonia in the same location can not be documented. Cavities are usually the result of cavitation of a nodule or excavation of a pneumonia. The cavities are also usually less than 4 cm and frequently have thin-walled “grape skin” morphology, though thick or irregular cavity wall morphology may also be observed. They are well circumscribed and rarely contain air-fluid levels. They also have a propensity for the upper lungs and frequently resolve spontaneously. About half of patients with cavities are asymptomatic, 25% have hemoptysis or respiratory complaints. Subpleural cavities may rupture into the pleural space producing pneumothorax and associated empyema. The most serious form of chronic Coccidioidomycosis is progressive and persistent pneumonia, which may ultimately prove fatal, especially in immunocompromised patients. Chronic progressive coccidioidal pneumonia occurs in less than 1% of patients, and may simulate chronic pulmonary tuberculosis or histoplasmosis due to presence of apical fibronodular changes, cavities, and volume loss. Disseminated Coccidioidomycosis usually occurs early in the course of the disease, but may develop from chronic progressive pneumonia or extrathoracic coccidioidomycosis. Disseminated disease, is more common in African American and Filipino patients, as well as the immunocompromised. Disseminated coccidioidomycosis has been documented in immunocompetent patients, though is more commonly fatal in immunocompromised patients. Disseminated thoracic coccidioidomycosis usually produces a miliary pattern. Associated mediastinal or hilar adenopathy is common. Extrathoracic disease is also frequently present, usually related to basal meningitis, meningoencephalitis, or vertebral osteomyelitis. .
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The Society of Thoracic Radiology T
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Dear Friends, Welcome to Miami Beac
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Continuing Medical Education Credit
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Warren B. Gefter, MD University of
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Ernest M. Scalzetti, MD SUNY Upstat
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Registration Hours Saturday, March
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Program Committee Ella A. Kazerooni
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Small Airway Disease Americana 3 Mo
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Benjamin Felson Memorial Lecture Am
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Session 2-B Concurrent Session Clin
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Workshops (choose 1) 1:00 - 1:45 D1
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Sunday
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March 2, 2003 General Session Sunda
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SUNDAY 46 One type of direct-readou
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CT-PET Imaging Suzanne Aquino, M.D.
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SUNDAY 58 an accompanying decreased
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SUNDAY 60 Radiofrequency Ablation i
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SUNDAY 62 17. Sewell PE, Vance RB.
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SUNDAY 64 cal ventilation will be r
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SUNDAY 66 radiologic, and histopath
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SUNDAY 68 application. The untreate
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SUNDAY 70 The Expanded Spectrum of
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SUNDAY 72 Hypersensitivity Pneumoni
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SUNDAY 74 Small Airway Diseases Mic
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SUNDAY 76 The “Head-cheese Sign
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SUNDAY 78 “Holes” in the Lung:
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SUNDAY 80 Pleural Effusions Gerald
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SUNDAY 82 Asbestos Related Pleural
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SUNDAY 84 Other Pleural Neoplasms S
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SUNDAY 86 Image-Guided Therapy of M
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Notes 88
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March 3, 2003 General Session 7:00
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Cardiac MRI: Established Indication
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Cardiac MRI: New Developments Gauth
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5. The volume of contrast medium re
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Acute Aortic Syndrome Ernest M. Sca
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as well as separation of the cusps
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Pulmonary Veins: Imaging for Radiof
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Imaging of Cardiopulmonary Support
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plied to the hollow fibers by an ex
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swelling of the entire leg, calf sw
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Multi-channel Pulmonary CTA: New Te
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terminate scintigrams, CT correctly
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CT Strucural and Functional Imaging
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curves (TDCs) are generated by manu
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7. Crawford T, Yoon C, Wolfson K, e
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80. Fleischmann D, Rubin GD, Bankie
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127 MONDAY
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129 MONDAY
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REFERENCES Bergin CJ, Rios G, King
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Notes 134
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March 4, 2003 General Session 7:00
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Adult Manifestations of Congenital
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will usually display the limbs of t
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Imaging of the Pericardium Paul L.
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Cardiomyopathy Martin J. Lipton, M.
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TUESDAY 150 Nuclear Cardiology Upda
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TUESDAY 152 ties. The predominant 1
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TUESDAY 154 Imaging protocols: Util
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Manpower Shortage in Radiology: Sol
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159 TUESDAY
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161 TUESDAY
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163 TUESDAY
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NIBIB Update for Thoracic Radiology
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vertically along the right atrium t
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Multidetector Pediatric Chest CT: P
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The Spectrum of Pulmonary Infection
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Immune deficiency occurs frequently
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TUESDAY 180 The Internet and the Pr
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Page 141 and 142: TUESDAY 184 Digital Images: Camera
Page 143 and 144: TUESDAY 186 Analysis of Mediastinal
Page 145 and 146: Unusual Manifestations of Lung Canc
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Page 149 and 150: March 5, 2003 General Session Wedne
Page 151 and 152: WEDNESDAY 208 principle is that “
Page 153 and 154: WEDNESDAY 210 years and a current o
Page 155 and 156: WEDNESDAY 212 lesions generally mim
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Page 159 and 160: WEDNESDAY 216 Small T1 Lung Cancer:
Page 161 and 162: WEDNESDAY 218 REFERENCES Seely JM,
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Page 167 and 168: WEDNESDAY 224 Lung Cancer Staging A
Page 169 and 170: Metastatic Disease to Lung Gordon L
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Page 177 and 178: WEDNESDAY 236 Pulmonary Arterial Hy
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Page 183 and 184: THURSDAY 250 Pulmonary Tuberculosis
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Page 195 and 196: THURSDAY 262 Inflammatory Diseases
Page 197 and 198: Virtual Endoscopy in the Thorax: Pr
Page 199 and 200: Notes 269 THURSDAY
Page 201: SECOND LEVEL THIRD LEVEL
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