Focal Lung Disease Research Articles

Community-acquired pneumonia: antibiotic therapy approach after the COVID-19 pandemic. A review

Pneumonia is clearly differentiated from other focal inflammatory lung diseases of non-infectious origin. A patient with community-acquired pneumonia (CAP) should receive antibacterial drugs no later than 4 hours after the diagnosis. Initial antibacterial therapy in CAP should be based on factors affecting the potential causative agents and the risk of drug-resistant microorganisms. Rational use of amoxicillin in terms of dose and frequency in CAP patients without severe comorbidities and risk factors for PES pathogens, the use of -lactam in combination with a macrolide or moxifloxacin monotherapy in high-risk groups of patients is the most effective strategy of empirical antibacterial therapy.

Comparison of conventional chest x ray with a novel projection technique for ultra-low dose CT.

To compare a novel thick-slab projection technique for ultra-low dose computed tomography (CT; thoracic tomogram) with conventional chest x ray with respect to 13 diagnostic categories. With the approval of the institutional ethics board, a dataset was retrospectively collected of 22 consecutive patients who had undergone a clinically requested emergency room conventional chest x ray (CXR) and a same-day standard-of-care non-contrast CT. Scanner specific noise was added to the CT images to simulate a target dose of 0.18mSv. A novel algorithm was used to post-process CT images as coronal isotropic reformats by applying a voxel-based, locally normalized weighted-intensity projection to generate 2cm thick slabs with 1cm overlap. Three chest radiologists with no prior training for the study reviewed the CXR and thoracic tomogram for each case and assessed each diagnostic category (pneumonic infiltrates, pulmonary edema, interstitial lung disease, nodules>5mm, nodules<5mm, pleural effusion, pericardial effusion, heart size, acute bone fractures, foreign bodies, pneumothorax, mediastinal vessel diameter, free abdominal air) on a Likert scale from -4 (definitely absent/normal) to +4 (definitely present/abnormal). MRMC ROC curves were generated for each category. Time for interpretation and subjective image quality score (0-10) were also assessed. For focal lung disease (pneumonic infiltrates, nodules<5mm, nodules>5mm), the area under the ROC curve (AUC) was significantly higher for thoracic tomograms than CXR (0.803 vs 0.648, respectively, P=0.02). For non-focal lung disease (pulmonary edema, interstitial lung disease) and effusions (pulmonary, pericardial), the AUC was larger for thoracic tomograms than CXR but the difference did not reach significance (0.870 vs 0.833, P=0.141; and 0.823 vs 0.752, P=0.296, respectively). For acute bone fractures and foreign bodies, the AUC was smaller for thoracic tomograms than CXR, the difference was however not significant (0.491 vs 0.532, P=0.42; and 0.871 vs 0.971, P=0.39, respectively). Other diagnostic categories had no true positive cases in the dataset. The mean time for interpretation for each was 36.9 and 24.0s with standard deviations of 0.857 and 5.977. The image quality score for each was 8.2 and 7.8 with standard deviations of 0.970 and 1.614. Thoracic tomograms were found to be diagnostically superior to CXR for focal lung disease, at no increased radiation dose. The thoracic tomogram presents an opportunity to improve the standard-of-care for patients who would otherwise receive a conventional CXR.

TB OR NOT TB: A CASE OF NONTB MYCOBACTERIAL LUNG DISEASE

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Nontuberculous mycobacteria (NTM) are naturally-occurring organisms found in water and soil. NTM lung infection occurs when a person inhales the organism from their environment. Most people do not become ill but some susceptible individuals develop progressive and destructive lung disease. CASE PRESENTATION: 80-year-old female with a past medical history of emphysema presented with complaints of malaise and fatigue for 3-4 months. She also complained of dry cough, shortness of breath, hoarseness of voice and right upper chest wall discomfort. She was a non-smoker and retired nurse by profession. Physical exam was notable for a thin, frail build, supraclavicular hollowing, along with increased vocal fremitus and vocal resonance in the right upper lung fields. Further history revealed that she had secondhand smoke exposure from her husband years ago as well as a history of suspected Tuberculosis when she was young. Chest X-Ray and follow up CT scan revealed a 7 cm cavity in her right upper lobe. Her vitals and labs were within normal limits and her Sputum Acid Fast Bacilli smear x 3 was negative. Sputum cultures grew out mycobacteria 6 weeks later. Rapid speciation via Mass spectrometry revealed Mycobacterium abscessus. The patient was started on a long course of a triple-drug regimen of parenteral Amikacin and Imipenem along with oral Clarithromycin for treatment. DISCUSSION: M. abscessus is 1 of the 3 clinically relevant species among Nontuberculous mycobacteria. It is the third most frequently recovered nontuberculous mycobacteria in the US and accounts for 80% of the rapidly growing mycobacteria respiratory disease isolates. The demographic affected by M. abscessus generally include white nonsmoking females over the age of 60 with no predisposing lung conditions and those who were less than 50 years of age usually had a recognized underlying lung disease. There are clinical and microbiological criteria required for diagnosing nontuberculous mycobacterial lung disease, and it is a diagnosis of exclusion. M. abscessus are uniformly resistant to the standard anti-tuberculous agents. As per current guidelines, the only predictable curative therapy for limited (focal) lung disease is surgical resection combined with multidrug therapy, including a macrolide and one or more parenteral agents over several months to help control symptoms and progression. The major drawback of therapy stems from the adverse drug reactions associated with long-term use of parenteral agents. CONCLUSIONS: In the United States, the incidence of nontuberculous mycobacterial lung disease is rising, particularly among the elder age groups and hence must be considered in the differential diagnosis once more common etiologies have been excluded. Unfortunately, at present there are recommendations but there is no reliable and dependable antibiotic regimen to produce a cure for extensive Mycobacterium abscessus lung disease. Reference #1: Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175:367–416. DOIPubMed Reference #2: Pillai SK, Beekmann SE, Santibanez S, Polgreen PM. The Infectious Diseases Society of America Emerging Infections Network: bridging the gap between clinical infectious diseases and public health.Clin Infect Dis. 2014;58:991–6. DOIPubMed Reference #3: Lyu J, Jang HJ, Song JW, Choi CM, Oh YM, Lee SD, Outcomes in patients with Mycobacterium abscessus pulmonary disease treated with long-term injectable drugs. Respir Med. 2011;105:781–7.DOIPubMed DISCLOSURES: No relevant relationships by Sneha Lakshman, source=Web Response

Spectrum of 18F-FDG Uptake in Bilateral Lung Parenchymal Diseases on PET/CT.

Bilateral lung parenchymal involvement is seen in infective as well as noninfective conditions, appearing as focal or diffuse lung disease. PET/CT with FDG helps in characterization (increased glucose utilization is seen by both inflammatory and neoplastic cells). In this article, we describe the spectrum of patterns of FDG uptake and associated CT changes involving bilateral lung parenchyma. Benign conditions described are aspiration pneumonia; pulmonary toxicity by bleomycin; infections, namely, sarcoidosis, miliary pulmonary tuberculosis, and pulmonary nocardiosis; and inflammatory conditions such as pulmonary Langerhans cell histiocytosis and pulmonary alveolar proteinosis. Neoplastic conditions described are bilateral pulmonary metastases and lymphangitic carcinomatosis.

POINT-OF-CARE ULTRASOUND HELPED DIAGNOSE PERSISTENT RIGHT UPPER LOBE INFILTRATE FROM ECENTRIC JET OF MITRAL INSUFFICIENCY

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Approximately 0.2% of all cardiogenic pulmonary edema is unilateral and almost always associated with severe mitral regurgitation. It is often mistaken as focal lung disease like pneumonia, infarction or aspiration. It may lead to misdiagnosis and delay in management (1). Use of bedside echocardiography in diagnosis and management of critical illness is continuously evolving. Here we present a case of persistent right upper lobe infiltrate secondary to mitral valve insufficiency diagnosed with bedside focused echocardiography. CASE PRESENTATION: A 78-year-old woman with history of Heart failure (preserved ejection fraction), atrial fibrillation, severe chronic obstructive pulmonary disease and left upper lobe lung cancer status-post lobectomy presented with worsening dyspnea and respiratory failure. She was intubated in the emergency room for hypoxic and hypercapnic respiratory failure. She was treated for pneumonia of right upper lobe three weeks prior to this presentation. Her vital signs were BP156/78 mmHg, HR 120 bpm, Temp 99.0 F and saturation 96% of 60% FiO2. Respiratory exam was notable for rhonchi on right lung field and diffuse wheezes bilaterally. Chest x-ray showed persistent right upper lobe infiltrate. CT scan chest confirmed airspace opacity of the right upper lobe. Patient was started on intravenous antibiotics and IV steroids for presumed pneumonia and COPD exacerbation. Her infectious and cardiac work up remained negative. She remained on mechanical ventilation because of rapid shallow breathing. Bedside echocardiography was performed and showed eccentric jet of mitral regurgitation around posterior mitral leaflet occupying less than 40% of left atrial area consistent with mild to moderate mitral insufficiency. This finding was confirmed with transthoracic Echo. Patient had aggressive diuresis and after load reduction. Her rapid shallow breathing index improved and she came off mechanical ventilation and discharged later. DISCUSSION: Goal directed echocardiography helps integrate data and images to answer clinical question. It has been shown that bedside echocardiography performed by trained intensivist gives information promptly otherwise not accessible by physical exam alone(2). American college of chest physician competence in basic and advanced critical care echocardiography requires cognitive skills in recognition of clinical syndrome associated with acute massive valvular regurgitation and to answer whether valvulopathy is clinically relevant respectively(3).Our case is an excellent example demonstrating the advanced use of critical care echocardiography to diagnose a rare clinical presentation of mild to moderate mitral insufficiency causing right upper lobe infiltrate. CONCLUSIONS: Persistent right upper lobe infiltrate should prompt the use of bedside echocardiography looking for eccentric jet of posterior mitral leaflet. Reference #1: Attias, David, et al. "Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.” Circulation 122.11 (2010): 1109-111 Reference #2: Beaulieu, Yanick. "Specific skill set and goals of focused echocardiography for critical care clinicians.” Critical care medicine 35.5 (2007): S144-S149. Reference #3: Mayo, Paul H., et al. "American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.” Chest 135.4 (2009): 1050-1060 DISCLOSURES: No relevant relationships by Mohammedumer Nagori, source=Web Response No relevant relationships by Muhammad Shafi, source=Web Response No relevant relationships by Ziad Shaman, source=Web Response No relevant relationships by Edward Warren, source=Web Response

Pulmonary quantitative CT imaging in focal and diffuse disease: current research and clinical applications.

The frenetic development of imaging technology-both hardware and software-provides exceptional potential for investigation of the lung. In the last two decades, CT was exploited for detailed characterization of pulmonary structures and description of respiratory disease. The introduction of volumetric acquisition allowed increasingly sophisticated analysis of CT data by means of computerized algorithm, namely quantitative CT (QCT). Hundreds of thousands of CTs have been analysed for characterization of focal and diffuse disease of the lung. Several QCT metrics were developed and tested against clinical, functional and prognostic descriptors. Computer-aided detection of nodules, textural analysis of focal lesions, densitometric analysis and airway segmentation in obstructive pulmonary disease and textural analysis in interstitial lung disease are the major chapters of this discipline. The validation of QCT metrics for specific clinical and investigational needs prompted the translation of such metrics from research field to patient care. The present review summarizes the state of the art of QCT in both focal and diffuse lung disease, including a dedicated discussion about application of QCT metrics as parameters for clinical care and outcomes in clinical trials.

Dendriform Pulmonary Ossification in the Absence of Usual Interstitial Pneumonia: CT Features and Possible Association With Recurrent Acid Aspiration.

Dendriform pulmonary ossification (DPO) is a rare lung disease in which mature bone is present in the peripheral interstitium of the lung. It typically occurs in patients with usual interstitial pneumonia (UIP). We assessed patients with CT findings of DPO without UIP to determine possible causative factors and to assess the clinical and CT course. We hypothesized that DPO without UIP would be a unique entity. We retrospectively reviewed CT reports for the word "ossification." Two observers reviewed each examination for micronodules 1-5 mm in diameter in the peripheral interstitium (subpleural and perifissural spaces and interlobular septa), some of which had high attenuation on mediastinal windows, presence of contiguous clusters of nodules resulting in a branching pattern, and lack of findings of UIP or focal lung disease. We reviewed the electronic medical records and follow-up CT and clinical information in all eligible patients. The study population consisted of 52 men with a median age of 79 years old. Seventy-five percent of the patients had gastroesophageal reflux disease, obstructive sleep apnea, or a chronic neurologic disorder. No progressive pulmonary symptoms were attributed directly to DPO, and no patient developed pulmonary fibrosis or suffered clinical decline from DPO. CT showed minimal progression or remained stable at follow-up (77% for at least 1 year, 25% for over 4 years). DPO in the absence of UIP occurs in elderly men and appears to be associated with chronic aspiration of gastric acid. The course is indolent.

The Sound of Lung – Ultrasound of the Lung and Mediastinum

The analysis of lung artefacts has gained increasing importance as markers of lung pathology. B-line artefact (BLA), caused by a reverberation phenomenon, is the most important lung artefact. In this presentation the current role of BLA in pneumology is discussed. The current literature about BLA is summarized in healthy subjects and patients with interstitial syndrome (pulmonary fibrosis and edema) including technical factors influencing BLA visualization. BLA imaging is influenced by more factors than recently assumed [(1, 2)]. When multiple BLA are visualized in the lung, they represent a sign of increased density due to the loss of aeration in the lung periphery. This condition may indicate different diseases including cardiogenic pulmonary edema, diffuse or focal interstitial lung diseases, infections and acute respiratory distress syndrome (ARDS). Correct interpretation of BLA in lung ultrasound is strongly influenced by associated sonographic signs and careful integration of all relevant clinical information. BLA are useful to monitor clinical response, and may become crucial in directing the diagnostic process [(3)].

Lung B-line artefacts and their use.

The analysis of lung artefacts has gained increasing importance as markers of lung pathology. B-line artefact (BLA), caused by a reverberation phenomenon, is the most important lung artefact. In this review, we discuss the current role of BLA in pneumology and explore open questions of the published consensus. We summarized current literature about BLA. Also, we presented observations on healthy subjects and patients with interstitial syndrome (pulmonary fibrosis and edema), to investigate technical factors influencing BLA visualization. BLA imaging is influenced by more factors than recently assumed. When multiple BLA is visualized in the lung, they represent a sign of increased density due to the loss of aeration in the lung periphery. This condition may indicate different diseases including cardiogenic pulmonary edema, diffuse or focal interstitial lung diseases (ILD), infections and acute respiratory distress syndrome (ARDS). Correct interpretation of BLA in lung ultrasound is strongly influenced by associated sonographic signs and careful integration of all relevant clinical information. BLA is useful to monitor clinical response, and may become crucial in directing the diagnostic process. Further research is warranted to clarify technical adjustments, different probe and machine factors that influence the visualization of BLA.

Parasitic infestation of lung: An unusual cause of interstitial pneumonitis

Parasite infections are increasing worldwide due to increasing migration and traveling. Parasitic infections can affect lungs and present as a focal or diffuse lung diseases. High index of suspicion and detailed history are most important. We present a case of interstitial pneumonitis caused by parasite infestation, which was diagnosed on transbronchial lung biopsy.

Imaging–Histologic Discordance at Percutaneous Biopsy of the Lung

The purpose of this study was to quantify the degree of imaging-histologic discordance in a cohort of patients undergoing computed tomography (CT)-guided lung biopsy for focal lung disease. A retrospective review was performed of 186 patients who underwent percutaneous lung biopsy of a parenchymal lesion at our institution between January and December 2009. Diagnostic radiology reports of CT or positron emission tomography-CTs performed before biopsy were used to classify the lesion as malignant or benign by five readers. Pathology reports of the biopsied lesions were classified by three readers. Inter-reader agreement and imaging-histologic concordance were quantified using kappa statistics. Discordant benign cases were then revisited to determine downstream effects. Inter-reader agreement on report content was substantial or almost perfect with kappas >0.783. Kappas for concordance were as follows: malignant (0.448), primary lung cancer (0.517), metastatic disease to lung (0.449), benign (0.510), and overall agreement (0.381). Of the twelve discordant benign cases that were revisited, four were found to be false negatives, resulting in a delay in diagnosis. Our study of imaging-histologic discordance in percutaneous biopsy of lung lesions supports the need for imaging report standardization and improved integration and communication between the fields of radiology and pathology.

Complicaciones de la Ventilación Mecánica en niños

La ventilación mecánica (VM) puede salvar la vida del niño con insuficiencia respiratoria, pero sus complicaciones pueden incrementar la morbimortalidad. Decidimos realizar un estudio para evaluar la frecuencia de las complicaciones de la VM. Durante un periodo de 17 meses, todos los pacientes admitidos a la UCI del Instituto de Salud del Niño y sometidos a VM fueron evaluados prospectivamente. Se registró edad, diagnóstico(s), estado nutricional, tamaño del tubo endotraqueal (TET), duración de la VM, parámetros ventilatorios y complicaciones: intubación endobronquial (lE), obstrucción del TET, atelectasias, barotrauma (BT), infección respiratoria y estridor postextubación. La edad promedio fue 37 meses (&amp;lt;1 día - 19 años). La duración promedio de la VM fue de 5.7 días. En los niños que presentaron alguna complicación, el tiempo de VM fue significativamente mayor (p&amp;lt; 0.05). Se registró 228 complicaciones en 142 (31.6%) pacientes; 97 (21.6%) pacientes fueron malnutridos; ellos tuvieron una mortalidad significativamente mayor (p&amp;lt; 0.001, chi cuadrado, corrección de Yates). Se observó lE en 47 (10.5%) pacientes; BT en 66 (14.7%): infección en 46 (10.2%); atelectasia en 44 (9.8%); estridor postextubación en 10 (2.2%) y obstrucción del TET en 4 (0.9%). Ocho pacientes fallecieron por causas relacionadas a alguna complicación. La edad menor de 1 mes se asoció a mayor frecuencia de atelectasias e lE (p&amp;lt; 0.001 y 0.003, respectivamente); y la enfermedad pulmonar focal se asoció a mayor frecuencia de BT, infección y atelectasia (p&amp;lt; 0.001). El enfisema pulmonar intersticial (EPI) fue la forma más común de barotrauma. Conclusiones: 1) Las complicaciones de la VM se incrementan conforme aumenta la duración de su empleo; 2) La mayoría de las muertes por VM son prevenibles; 3) Los neonatos y niños con enfermedades pulmonares focales tienen mayor riesgo de complicaciones; 4) El EPI es la forma más común de barotrauma en niños.

An unusual masquerade of community acquired pneumonia: Left-side unilateral pulmonary edema

The diagnosis of pneumonia is clinical, based on the history of lower respiratory tract symptoms, physical, and/or radiographic signs of consolidation. Several diseases such as congestive heart failure, pulmonary embolism, and chemical pneumonitis may present with similar symptoms, signs, and chest radiographs, thus delaying the definitive diagnosis and initiation of appropriate treatment. Unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed at first as a focal lung disease. We have presented an unusual case of left-sided UPE in a 76-year-old man who developed acute heart failure resulting from dietary and pharmacological noncompliance. The patient was successfully managed with decongestive therapy and non-invasive mechanical ventilation.

Improved detection of focal pneumonia by chest radiography with bone suppression imaging

To evaluate radiologists' ability to detect focal pneumonia by use of standard chest radiographs alone compared with standard plus bone-suppressed chest radiographs. Standard chest radiographs in 36 patients with 46 focal airspace opacities due to pneumonia (10 patients had bilateral opacities) and 20 patients without focal opacities were included in an observer study. A bone suppression image processing system was applied to the 56 radiographs to create corresponding bone suppression images. In the observer study, eight observers, including six attending radiologists and two radiology residents, indicated their confidence level regarding the presence of a focal opacity compatible with pneumonia for each lung, first by use of standard images, then with the addition of bone suppression images. Receiver operating characteristic (ROC) analysis was used to evaluate the observers' performance. The mean value of the area under the ROC curve (AUC) for eight observers was significantly improved from 0.844 with use of standard images alone to 0.880 with standard plus bone suppression images (P < 0.001) based on 46 positive lungs and 66 negative lungs. Use of bone suppression images improved radiologists' performance for detection of focal pneumonia on chest radiographs. Bone suppression image processing can be applied to conventional digital radiography systems. Bone suppression imaging (BSI) produces images that appear similar to dual-energy soft tissue images. BSI improves the conspicuity of focal lung disease by minimizing bone opacity. BSI can improve the accuracy of radiologists in detecting focal pneumonia.

Endomicroscopie confocale en pneumologie : de la bronche à l’alvéole

Fibred confocal fluorescence microscopy, also named probe based confocal laser endomicroscopy (pCLE), is a new endoscopic technique that can be applied for in-vivo microscopic imaging of both upper airways and distal lung structures during bronchoscopy.Two recent in-vivo human studies using pCLE at 488nm light excitation have described the normal fluorescence endomicroscopic features of the bronchial wall and the elastic framework of the alveolus. These studies have demonstrated that elastin, a major component of the bronchial basement membrane and of the acinar elastic framework, is the main endogenous fluorophore in the non-smoking population. In smoking subjects, the tobacco tar itself is highly fluorescent and, thereby, acts as an additional fluorophore, allowing study of the macrophage alveolitis associated with smoking. These studies have also confirmed the safety of this endoscopic procedure.In the near future, confocal endomicroscopy of the airways should make it possible to investigate the semiology of focal and diffuse distal lung diseases, to characterize cancerous and precancerous lesions of both upper and distal airways and to study the lung microcirculation. These studies may also use exogenous molecular fluorescent probes, which will enable functional imaging of the lung structures in-vivo.Confocal endomicroscopy has the potential to explore accurately the peripheral lung in-vivo and may become a useful tool to improve endoscopic diagnosis of many lung diseases.

Use and Yield of Chest Computed Tomography in the Diagnostic Evaluation of Pediatric Lung Disease

Computed tomography is commonly used in the diagnosis of pediatric lung disease. Although the radiation is not negligible, the yield has never been studied. Clinical and imaging data were collected for all children who underwent chest computed tomography, as part of the diagnostic process. Cases were grouped according to type of lung disease, based on clinical data and the question addressed to the radiologist. A positive yield was defined as computed tomography providing >or=1 of the following: (1) a diagnosis, (2) a clinically important new finding that had not been recognized previously, (3) alteration of the plan for further evaluation or treatment, or (4) exclusion of lung disease. No yield was defined when computed tomography did not add new information and did not affect evaluation or treatment. Ages ranged from 2 weeks to 16 years, and 59% were male. The overall positive yield was 61% (64 of 105 cases). Yields were relatively low, that is, 23% (8 of 35 cases) for the evaluation of diffuse lung disease, 46% (6 of 13 cases) for localized disease, 50% (6 of 12 cases) for pleural disease, and 98% (41 of 42 cases) for congenital malformations. The yield of chest computed tomography depends on the type of disease. Computed tomography has a significant yield for congenital anomalies. The yield is particularly low in the evaluation of acquired diffuse pulmonary disease and is relatively low in acquired focal lung disease. We suggest that chest computed tomography be used more judiciously.

Unilaterales rechtsseitiges Lungenödem bei Mitralinsuffizienz

Two patients were admitted with dyspnoea, the first after an infection, the second in association with an ischemic cardiomyopathy. Chest radiography displayed an interstitial infiltrate in the right upper lobe in the first patient and in the right lower lobe in the second one. In both patients the transthoracic echocardiogram (TEE) showed significant mitral regurgitation with systolic reversal of flow as far as the right superior and inferior pulmonary veins, respectively. Both patients had unilateral pulmonary edema associated with mitral regurgitation. Mitral valvuloplasty was performed in the first patient while the second one was treated medically. Unilateral pulmonary edema associated with mitral regurgitation is a distinct but unusual clinical entity, often misdiagnosed initially as being caused by one of the more common focal lung diseases. The TEE indicated the cause and provided the reason for the mechanism of the edema formation.

COMPARISON OF TWO‐ VS. THREE‐VIEW THORACIC RADIOGRAPHIC STUDIES ON CONSPICUITY OF STRUCTURED INTERSTITIAL PATTERNS IN DOGS

Three-view thoracic radiography is often used to evaluate patients for pulmonary metastatic disease. Although use of three views has been reported to be more sensitive than two views for focal lung disease, it also requires increased time, effort, and radiographic exposure of patients and personnel. This study was performed to evaluate the conspicuity of lesions on two-view vs. three-view radiographic procedures to determine the proportion of diagnoses that would change. One hundred three-view radiographic studies of the canine thorax were randomized, and four protocols were reviewed for each study: right lateral and ventrodorsal views, left lateral and ventrodorsal views, both lateral views, and all three views. Radiographs were interpreted as either positive or negative for structured interstitial pulmonary disease, and the certainty of the reading was recorded using a visual analog scale. There was 85-88% agreement between each two-view group and the three-view group, with the kapp statistic ranging from 0.698 to 0.758. There were no differences in certainty of diagnosis among the groups, though within each group there was more certainty for positive diagnoses than negative diagnoses. These findings indicate that three-view studies should be continued when evaluating for possible structured interstitial pulmonary disease, including metastatic disease, as eliminating one view from a three-view study would change the diagnosis in 12-15% of patients.

Localized persistent interstitial pulmonary emphysema presenting as a spontaneous tension pneumothorax in a full term infant

Persistent interstitial pulmonary emphysema (PIPE) is a syndrome characterized by air-leakage in the perivascular tissues of the lung, primarily affecting mechanically ventilated neonates. Reports in the literature of infants developing PIPE with no history of respiratory distress syndrome (RDS) or mechanical ventilation are scarce. Here, we present a case of a 3-month-old former full term male infant with no history of RDS or mechanical ventilation who presented with focal cystic lung disease associated with spontaneous tension pneumothorax. He was ultimately found to have PIPE based on pathologic evaluation of the resected cystic region. We believe that focal PIPE should be included in the differential diagnosis of cystic lung disease in a full term, unventilated infant, even when spontaneous pneumothorax is the presenting entity.

Diagnostic value of cytology of bronchoalveolar fluid for lung diseases of sheep

Bronchoalveolar lavage fluid was collected postmortem from the lungs of 113 sheep, and total and differential cell counts were analysed in relation to the presence of gross and microscopic lung...