1. Differential Diagnosis of CXRs
David Kirk

2. How to Learn Personally look at every film every day.
Examine every film the same way.
Write down your opinion *before* you compare to the radiologist opinion.
Re-examine the film *after* reading the radiology opinion.
Force your doc to read the film with you.

3. My Pattern Outside to Inside Date / Patient External / Hardware
ABCDE -- Airway, Bones (ribs/clavicles), Cardiac, diaphragm, everything else
Borders
Parenchyma

4. http://cdn. lifeinthefastlane. com/wp-content/uploads/2012/08/CXR-AP

5. http://cdn. lifeinthefastlane. com/wp-content/uploads/2012/08/CXR-AP

8. Rules Bunch of cases… thus we will move quickly
Guessing, shouting, participation required
Average computer monitor has 3 times less resolution than film. Projection decreases resolution even more…

9. First Case
51 year old male currently receiving treatment for hepatocellular carcinoma presents with several months of cough (+/- productive) and progressive DOE.
PFTs:
FVC is 94% predicted
FEV1 is 64% predicted
FEV1/FVC and FEF percent are both markedly reduced

12. What’s the Call?
Based on the CXR findings including bilateral bullous changes in the bases, you make the diagnosis…

13. Alpha-1-Antitrypsin
3 hints that a patient’s obstructive disease is alpha-1-antitrypsin deficiency and not COPD.
Presents earlier (Median ages: 46 vs 52)
Bullous changes at bases instead of apex
Liver disease
Cirrhosis in 12 percent and hepatocellular carcinoma in 3 percent

16. Everybody else…
COPD CXRs

24. Case 2
39 year old female with long history of sinusitis presents with SOB, DOE, and months of productive cough.
PMHx significant for congenital heart defect and recent pacemaker placement.

26. Situs Inversus What’s the syndrome? What is Kartagener’s triad?
Primary ciliary dyskinesia
What is Kartagener’s triad?
Chronic sinusitis
Bronchiectasis
Situs inversus
What percentage of PCD have situs inversus?
50%
What percentage of situs inversus patients also have PCD?
20-25%

27. Case 3
65 year old WF presents to you with DOE/SOB, orthopnea, and diffuse muscle weakness. Worse when sleeping flat.
PMHx: Polio as a child requiring braces for ambulation.
You send the patient for inspiratory and expiratory CXRs.

29. Inspiratory Muscle Weakness
What should the patient’s Aa gradient be?
Normal. (No impairment in diffusion…)
What’s the differential diagnosis of inspiratory muscle weakness? (12)
ALS MS
Tetanus
Polio / Post-Polio Syndrome
Guillian Barre’
Lyme Disease
Myasthenia Gravis
Botulism
Lambert-Eaton
Muscular dystrophy
Polymyositis / Dermatomyositis

30. Case 5
42 year old female presents with SOB, wt loss, joint tenderness, and chest pain.
Serial CXRs have shown diffuse, migratory infiltrates.
She has been treated in the ER for atypical pneumonia on several occasions.

32. DDx of “Migratory” Infiltrates (10)
Asthma with mucus plugging
Allergic brochopulmonary aspergillosis
BOOP
Recurrent Aspiration
Allergic alveolitis
Pulmonary Edema
Eosinophilic infiltrates
Alveolar hemorrhage syndromes
Vasculitis
Collagen Vascular Diseases

33. Pulmonary Hemorrhage Bronchoscopy -> pulmonary hemorrhage
UA -> Active sediment with RBCs
Differential… (3)
Vasculitis (particularly Wegener's)
Usually C-ANCA/PR3-ANCA positive
Lupus
Goodpasture’s

34. Case 6
28 year old F presents with encephalitis. As pt sits in the ER her MS continues to decline. Pt becomes hypoxic with increased WOB and is intubated.
Her initial CXR was normal.
Her current CXR is…

37. Where’d that Lung go? Differential Diagnosis (3)
Massive Effusion
Bronchial Occlusion -> atelectasis
Bronchial Torsion
How do you tell effusion vs atelectasis?
Effusions shift the heart away
Atelectasis shift the heart toward
Subsequent CXR post-bronchoscopy…

39. Atelectasis vs Effusion

44. Case 7
81 yo WM presents with URI and persistent cough for two weeks. His wife is in the hospital and the nurses on the floor convince him to go to the ED.
CXR obtained in the ED shows…

46. What’s that big honkin’ thang?
Thoracic Aorta Aneurysm

48. Case 8
24 year old college student presents with inguinal discomfort, fatigue, and cough.
Palpation discovers an inguinal mass. Mild scrotal swelling is noticed.
CXR…

51. Nodules on CXR Differential Diagnosis (6+) Old granulomas Infections
Abscess, TB, MAI, nocardia, aspergillus, cryptococcus
Neoplasms
BOOP
Infarcts
Sarcoid

53. Case 9
64 year old man with a long hx of RA presents with a nagging cough for two months.
Recently his arthritis has been poorly controlled and he has been receiving increasing doses of prednisone.
You send him for a CXR

56. BUL infiltrates Differential Diagnosis (9) TB Histoplasmosis
Sporotrichosis
Ankylosing spondylitis
Rheumatoid Arthritis
Rhodococcus equi
Radiation pneumonia
Sarcoid
Eosinophilic granuloma

57. Case 10
61 year old women is referred to you for “abnormal CXR” after she was seen in the ED for URI.
Patient has recovered nicely from the URI and is healthy.

59. Differential Diagnosis of Ipsilateral Raised Hemidiaphragm
Reduced lung volumes
Paralysis
60% idiopathic
Lung Ca
Trauma/Surgery
Cervical Disc Surgery
Primary Neurological Disease
Herpes/Polio
Mononeuritis multiplex
Mediastinal Disease
Diaphragmatic eventration
congenital absence of part of diaphragm
Abdominal Process
Pseudodiaphragmatic
Tumors
Ruptured diaphragm

60. Work-up? 50% of people are asymptomatic Tests CXR/CT
PFTs (decreased VC when supine)
Ultrasound can show lack of thickening on inspiration
Sniff test where upward paradoxical motion of the diaphragm is seen under fluro in 90%
EMG response to phrenic stimulation

61. Case 11 24 year old AAM with chronic cough and SOB.
No past medical history.
CXR…

67. Differential Diagnosis of Bilateral Hilar Fullness (12)
Pulmonary Hypertension
Left->Right Shunt
Mitral Valve Disease
Left Heart Failure
Sarcoid
Lymphoma
Metastatic Cancer
TB (primary)
Fungus
Viral Infections
Silicosis
Berylliosis

68. Clues to Sarcoid vs Malignancy
Majority of cases
No hx of prior malignancy
Uteitis
Erythema nodosum
Anemia rare
Malignancy
Lymphoma always symptomatic
Often history of remote cancer
Anemia is common

69. Stages of Sarcoidosis Stage I Presence of bilateral hilar adenopathy
Fifty percent of affected patients exhibit bilateral hilar adenopathy as the first expression of sarcoidosis.
Regression of hilar nodes within one to three years occurs in 75 percent of such patients
Stage II
Bilateral hilar adenopathy and interstitial infiltrates
Present at initial diagnosis in 25 percent of patients
Two-thirds of such patients undergo spontaneous resolution, while the remainder either have progressive disease or display little change over time.
Patients with stage II disease usually have mild to moderate symptoms
Stage III
Interstitial disease with shrinking hilar nodes
Interstitial opacities are commonly present and are predominantly distributed in the upper lung zones.
Stage IV – Stage IV disease is defined by advanced fibrosis

71. Ipsilateral Hilar Fullness
No Case… Just here for comparison

74. Case 12
79 year old male professor presents with increasing DOE, orthopnea, and dry cough.
PMHx:
COPD
CAD with hx of VT
Meds
ECASA, B-blocker, ACEI, Statins, Nitrates
Amiodarone for 4-5 months
PE: Crackles B lung fields

78. Amiodarone Lung? Amiodarone Lung
Chronic fibrosis vs hypersensitivity (BOOP-like)
Risk Factors
Drug dosage of greater than 400 mg/day
Duration of therapy exceeding two months
Increasing patient age
Preexisting lung disease
Pulmonary angiography

79. Amiodarone Lung? Clinical Clues… Treatment
New or worsening symptoms or signs
New abnormalities on chest CXR
A decline in TLC >15% or in DLCO >20 percent%
Improvement following withdrawal of the drug
Chest CT
Interstitial and/or alveolar changes
Accumulation of the drug is rarely helpful Bx
Treatment
Stop the drug. 75% will eventually improve although some initial progression may continue due to the long half life of the drug.

80. Case 14
53 year old female presents with fevers, cough with purulent sputum, and progressive SOB.
PMHx for multiple admissions for pneumonia
Oxygen dependent at home now

85. What does she have?
Bronchiectasis

86. Causes of Bronchiectasis
Cystic fibrosis
Lack of natural defenses
Ciliary dyskinesia
HIV
Hypogammaglobulinemia
Young's syndrome
Dyskinetic cilia
Rheumatic RA
Sjogren's syndrome
IBD (UC > Crohn’s)
Infections
Inability to clear / impaired host defenses
MAI
Immunocompromised
Female smokers with primary infection
Aspiration
Obstruction
Lymph nodes
Foreign bodies
Allergic bronchopulmonary aspergillosis
Idiopathic (approx. 50%)

87. What’s this?

93. The End References: UpToDate
Zackon, Harold. Pulmonary Differential Diagnosis