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(Unit-5)

Vinod Kumar.R

• Mrs Prasanna 48 years of age• C/O Exertional breathlessness –20 days NYHA Class 4 Dyspnoea – 1 week-Fever -Anorexia -Hemoptysis few episodes

Clinical summary

Patient was tachypnoeicRR – 30/min Grade 2 ClubbingCentral Cyanosis, HR -112/min, SpO2- 76% RA and improved to 98% with 6L/min O2

CVS - S1, S2 heard RS – Bilateral Coarse Biphasic crackles, Scattered Rhonchi

But the patient did not respond to treatment and succumbed to her illness within 2 hours after admission

OnExamination

CXR PA View..... First X Ray

CXR:

PA ViewAdequate Penetration , Non – Rotated Film in full Inspiration Trachea Midline Cardio-Thoracic Ratio: - Normal, Costo-phrenic , Cardio-Phrenic Angles freeMultiple diffuse ,Parenchymal, not well defined, Non-

Calcified nodular opacities seen in both lungs in all the zones ,more on the right side than on the left varying in size.

Differentials Of Multiple Pulmonary Nodules :

NeoplasticMetastases

Malignant lymphoma/lymphoproliferative disorders

InflammatoryGranulomas

Fungal and opportunistic infectionsSeptic emboli

Rheumatoid nodulesWegener granulomatosis

SarcoidosisLangerhan cell histiocytosis

CongenitalArteriovenous malformations (Osler-Weber-Rendu Syndrome)

MiscellaneousHematomas

Pulmonary infarctsOccupational (silicosis)

• In more than 95% of patients with multiple pulmonary nodules, the etiology of the nodules is (a) metastases or (b) tuberculous or fungal granulomas

• Pt has had menstrual irregularities for more than 1 year –visited doctor 5 months back found to have mass descending PV advised Surgery but she refused and took native treatment.

• Past Gynaecological hx – Per Vaginal Exm: showed hard mass involving the vaginal vault and extending from the uterine Cervix.

Cx Tissue biopsy : Uterine leiomyosarcoma identified

FINAL Diagnosis

• LEIOMYOSARCOMA WITH MULTIPLE PULMONARY SECONDARIES (Cannon ball Metastasis )

CT THORAX

CAUSES OF CAVITARY PULMONARY NODULES

Carcinoma (bronchogenic, metastases especially squamous cell)

Autoimmune (Wegener granulomatosis, rheumatoid nodules)

Vascular (bland and septic emboli)

Infection (especially mycobacterial and fungal)

Trauma (pneumatocele)

Young i.e., congenital (sequestration, diaphragmatic hernia, bronchogenic cyst)

SOURCE OF METASTASIS

• breast, colon kidney, uterus, prostate, head, and neck (M.C).

• choriocarcinoma, osteosarcoma, Ewing sarcoma, testicular tumors melanoma, and thyroid carcinoma(L.C)

• Calcification most commonly with osteosarcoma and chondrosarcoma or after successful treatment of metastases.

• A miliary nodular pattern of metastases is seen most commonly with thyroid or renal carcinoma, bone sarcoma, trophoblastic disease, or melanoma.

Neoplastic: MalignantBronchogenic carcinomaSolitary metastasisLymphomaCarcinoid tumor

Neoplastic: BenignHamartomaBenign connective tissue and neural tumors (e.g., lipoma, fibroma, neurofibroma)

InflammatoryGranulomaLung abscessRheumatoid noduleInflammatory pseudotumor (plasma cell granuloma)

CongenitalArteriovenous malformationLung cystBronchial atresia with mucoid impaction

MiscellaneousPulmonary infarctIntrapulmonary lymph nodeMucoid impactionHematomaAmyloidosisNormal confluence of pulmonary veins

Mimics of SPNNipple shadowCutaneous lesion (e.g., wart, mole)Rib fracture or other bone lesion

CAUSES OF SOLITARY PULMONARY NODULES

Thank you