Category Archives: Morning Report

Morning Report 8/3/22 – Cavitary Lung Diseases

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Wednesday’s Morning Report featured first year Emily Olson (@EmilyOlsonMD) leading a discussion of cavitary lung disease. Let’s review some of her learning points together!

First off, how much better of a mnemonic can you get for cavitary lung diseases than “CAVITY”?

 

It’s always helpful to look at previous chest imaging, and this is especially true in cavitary lung diseases! An important early diagnostic branch point is chronicity of process (12 weeks as the cutoff for a chronic process)

 

 

Histoplasmosis is one differential consideration for subacute/chronic cavitary lung disease which we commonly test for non-invasively.

We learned that the performance characteristics of testing depends on stage of disease.

 

 

Thanks for leading a great discussion, Emily!

 

Sources cited

  1. Chest. 2018 Jun;153(6):1443-1465. doi: 10.1016/j.chest.2018.02.026 
  2. J Clinical Microbiology.2017 Jun;55(6):1612-1620. doi: 10.1128/JCM.02430-16

Pulmonary Report 8/1/22 – Diffuse pleural thickening

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Today’s Morning Report featured a case of restrictive lung disease related to diffuse pleural thickening. Below are some of the points I hope you take away from the discussion:

I. Differential diagnosis of diffuse pleural thickening (DPT)

History is essential for differential diagnosis. 2 general categories:

  • Pleuritis-related
    • Recurrent PNA, empyema
    • Asbestos-related
    • TB
    • Connective tissue disease
    • Drugs
    • Post-radiation
    • Post-CABG
    • Post-traumatic
    • Fibrosing pleuritis
  • Pleural thickening mimickers
    • Pleural plaques
    • Mesothelioma
    • Other pleural-based malignancies

II. Timeline of asbestos-related pulmonary disease

Legend – BAPE (Benign Asbestos-related Pleural Effusion), DPT (Diffuse Pleural Thickening) Clockwise from top left: DPT, pleural plaques, mesothelioma, ILD/asbestosis, BAPE

Remember that timeline is fluid, not absolute!

III. 3 distinct benign responses to asbestos exposure

Asbestos plaques involve parietal pleura only – lung sliding remains intact

 

Asbestosis – pulmonary fibrosis does not involve the pleura; septal thickening, reticulations (left) & honeycombing (center) are observed.

 

Diffuse pleural thickening involves inflammation at the visceral pleural border. Several findings associated with this, clockwise from top left; parenchymal bands “crow’s feet” associated with volume loss, a prominent parenchymal band, rounded atelectasis

 

IV. PET-CT may have utility in diagnostic evaluation of pleural thickening

 

 

Sources cited:

  1. Radiopaedia
  2. Journal of Occupational Medicine and Toxicology 2008, 3:20
  3. Eur Respir J 1998; 11: 1021–1027
  4. J Nucl Med 2004; 45:995–998

Morning Report 7/13/22 – Air Trapping

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Today’s Morning Report from second-year fellow Elen Gusman featured a case of dyspnea with HRCT and PFT findings of air trapping without other parenchymal abnormalities. Below are some of the take-away points from her engaging discussion.

Air trapping – areas of lung parenchyma with less than normal increase in attenuation and lack of volume reduction with expiration (Fleischner Society, 2008)

Image – isolated air trapping due to bronchiolitis obliterans Source: Annals ATS 2014; 11(6):874-881

Expiratory findings:

  • Heterogenous hypoattenuation (air trapped) alongside hyperattenuation (normal ventilation)
  • Areas of air trapping do not decrease in volume like adjacent normal lung

Morning Report 6/28 – Chylothorax

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Some highlights about chylothorax from Amy’s great morning report case.

Chest x-ray chylothorax

Chylothorax (picture from StatPearls:https://www.ncbi.nlm.nih.gov/books/NBK459206/)

 

  • Equal incidence of traumatic (during surgery in chest) vs non-traumatic (malignancy causing compression or lymphoma, also lots of idiopathic/misc causes)
  • Gold standard: chylomicrons in fluid – lipoprotein electrophoresis but this is often not available
  • Cutoff: using triglycerides as surrogate, TG>110 mg/dL very likely chylothorax, TG<50 very unlikely to be chylothorax
  • Gross appearance of fluid not that sensitive for diagnosis, less than half of cases have the classic milky appearance
  • IR lymphagiogram – injecting lipophilic contrast agent into a lymph node and watching it ascend into the abdomen to identify the cisterna chyli
  • Recommendations: special diet ultra-low in middle chain fatty acids (<10g per day, aka less than one piece of pizza, 3 pieces of bacon, and dove chocolate bar) – decreased chylomicrons > decreased chyle
  • Other options include thoracic duct embolization, ligation (especially for high-volume chyle leak from thoracic duct injury), pleurodesis, pleuroperitoneal shunt, octreotide, somastatin etc

Sources:

Amy Ludwig’s Morning Report

StatPearls: Chylothorax