Tiny Nodules Research Articles

Deep learning ensembles for detecting brain metastases in longitudinal multi-modal MRI studies

Metastatic brain cancer is a condition characterized by the migration of cancer cells to the brain from extracranial sites. Notably, metastatic brain tumors surpass primary brain tumors in prevalence by a significant factor, they exhibit an aggressive growth potential and have the capacity to spread across diverse cerebral locations simultaneously. Magnetic resonance imaging (MRI) scans of individuals afflicted with metastatic brain tumors unveil a wide spectrum of characteristics. These lesions vary in size and quantity, spanning from tiny nodules to substantial masses captured within MRI. Patients may present with a limited number of lesions or an extensive burden of hundreds of them. Moreover, longitudinal studies may depict surgical resection cavities, as well as areas of necrosis or edema. Thus, the manual analysis of such MRI scans is difficult, user-dependent and cost-inefficient, and – importantly – it lacks reproducibility. We address these challenges and propose a pipeline for detecting and analyzing brain metastases in longitudinal studies, which benefits from an ensemble of various deep learning architectures originally designed for different downstream tasks (detection and segmentation). The experiments, performed over 275 multi-modal MRI scans of 87 patients acquired in 53 sites, coupled with rigorously validated manual annotations, revealed that our pipeline, built upon open-source tools to ensure its reproducibility, offers high-quality detection, and allows for precisely tracking the disease progression. To objectively quantify the generalizability of models, we introduce a new data stratification approach that accommodates the heterogeneity of the dataset and is used to elaborate training-test splits in a data-robust manner, alongside a new set of quality metrics to objectively assess algorithms. Our system provides a fully automatic and quantitative approach that may support physicians in a laborious process of disease progression tracking and evaluation of treatment efficacy.

Unsuspected Isolated Peritoneal Metastasis of Prostate Cancer Detected with Digital F-18 PSMA PET/CT Scan.

We report the case of a prostate cancer (PC) patient referred to our center to perform F-18 prostate-specific membrane antigen (PSMA) digital positron emission tomography / computed tomography (PET/CT) scan for biochemical recurrence. PET/CT was unremarkable except for a tiny PSMA-expressing nodule on the right paracolic gutter, which increased in size and PSMA-expression on repeat imaging. Excision of the lesion was consistent with PC peritoneal metastasis. The isolated location of the lesion was atypical for PC metastasis. In the era of highly sensitive digital PET/CT detectors, it is always important to investigate abnormal uptake of F-18 PSMA regardless of the location.

Gene variants polymorphisms and uterine leiomyoma: an updated review.

Uterine leiomyoma, commonly referred to as fibroids, is a benign tumor that develops in the muscular wall of the uterus. These growths are non-cancerous and can vary in size, ranging from tiny nodules to larger masses. Uterine leiomyomas often occur during a woman's reproductive years and can lead to symptoms such as heavy menstrual bleeding, pelvic pain, and pressure on nearby organs. While the exact cause is not fully understood, hormonal factors, particularly estrogen and progesterone, are believed to play a role in their development. The exploration of connections between genetic variants and uterine leiomyoma has captivated scientific attention for numerous years. The results from investigations remain a subject of intrigue within the scientific community. To date, the findings regarding the relationships between single nucleotide polymorphisms (SNPs) and uterine leiomyoma have exhibited some inconsistencies. However, amidst these inconsistencies, several promising outcomes have emerged that hold the potential to shape future research endeavors. These promising leads could pave the way for the development of innovative targeted therapies and novel prognostic biomarkers. This review specifically centers on accentuating the existing literature data concerning genetic variants that have been explored for their potential connections to uterine leiomyoma. Additionally, it underscores the prospects of employing genetic variations as diagnostic and prognostic biomarkers for individuals diagnosed with uterine leiomyoma.

Pulmonary Haemosiderosis Secondary to Mitral Valve Stenosis-Known Association of Uncommon Entity: A Case Report

Pulmonary haemosiderosis is a rare lung disease characterised by haemosiderin deposition in the lungs due to recurrent intra-alveolar bleeding. It can be idiopathic or secondary due to mitral stenosis. Affected patients will have symptoms of cough, haemoptysis, and shortness of breath. Radiologically, it is characterised by widespread tiny alveolar nodular opacities with or without septal thickening. Therefore, in the case of mitral valve stenosis, this imaging pattern on High-resolution Computed Tomography (HRCT) should prompt suspicion of secondary pulmonary haemosiderosis. Here, the authors present the case of a 27-year-old male patient with mitral stenosis who presented with progressive shortness of breath, mild atypical chest pain for two months, and a cough with occasional haemoptysis in the last 10 days before the hospital visit, along with typical radiological findings of widespread tiny ground glass alveolar nodules on HRCT. The radiological knowledge of this rare entity is very important for confidently making the diagnosis in the proper clinical context, to avoid unnecessary investigations and treatment.

An Innovative Method for Lung Cancer Identification Using Machine Learning Algorithms

Biological community and the healthcare sector have greatly benefited from technological advancements in biomedical imaging. These advantages include early cancer identification and categorization, prognostication of patients' clinical outcomes following cancer surgery, and prognostication of survival for various cancer types. Medical professionals must spend a lot of time and effort gathering, analyzing, and evaluating enormous amounts of wellness data, such as scan results. Although radiologists spend a lot of time carefully reviewing several scans, tiny nodule diagnosis is incredibly prone to inaccuracy. Low dose computed tomography (LDCT) scans are used to categorize benign (Noncancerous) and malignant (Cancerous) nodules in order to study the issue of lung cancer (LC) diagnosis. Machine learning (ML), Deep learning (DL), and Artificial intelligence (AI) applications aid in the rapid identification of a number of infectious and malignant diseases, including lung cancer, using cutting-edge convolutional neural network (CNN) and Deep CNN architectures, we propose three unique detection models in this study: SEQUENTIAL 1 (Model-1), SEQUENTIAL 2 (Model-2), and transfer learning model Visual Geometry Group, VGG 16 (Model-3). The best accuracy model and methodology that are proposedas an effective and non-invasive diagnostic tool, outperforms other models trained with similar labels using lung CT scans to identify malignant nodules. Using a standard LIDC-IDRI data set that is freely available, the deep learning models are verified. The results of the experiment show a decrease in false positives while an increase in accuracy.

SAT558 Papillary Thyroid Carcinoma With Anaplastic Transformation in a Filipino Male Treated With Radioactive Iodine and Radiotherapy: A Case Report

Abstract Disclosure: A.A. Apa-ap: None. P. Abarquez: None. M.B. Sedurante: None. A. Ongbit: None. P. Carlos Miguel: None. F. Acenas: None. J. Gacula: None. V. Lee: None. S. Estreller: None. INTRODUCTION. Papillary thyroid carcinoma (PTC) is an epithelial malignancy showing follicular differentiation and distinctive nuclear features, with a generally excellent prognosis. On the other hand, anaplastic thyroid cancer (ATC) is rare and highly lethal, with an incidence of only 0.7% in the Philippines. CASE DESCRIPTION. This paper describes a 43year old Filipino male with a 3-year history of anterior neck mass with an initial fine needle aspiration biopsy read as probable PTC. He underwent total thyroidectomy and bilateral radical lymph node dissection and histopathology revealed conventional PTC, solid variant with 5% focal anaplastic transformation. Metastatic workup revealed multiple sub-centimeter pulmonary nodules and a tiny hypodense nodule on left adrenal gland on CT scan. Bone scintigraphy showed increased tracer uptake in the posterior 10th rib and the sphenoid's greater wing. While the multidisciplinary team wanted to proceed with Radiation therapy (RT) first to address the more aggressive histology, this was not possible logistically and thus RAI was performed first. This slight deviation from guidelines was deemed acceptable by Nuclear Medicine due to the possible decrease in iodine absorption from post radiation fibrosis. After a dose of 150 mci, 4 weeks after surgery, patient then completed 33 fractions of RT. Surveillance revealed stable pulmonary nodules and adrenal mass but increasing TSH-stimulated thyroglobulin and antithyroglobulin. Patient underwent another cycle RAI and is currently stable on his 16th month from diagnosis, 15th month post initial RAI, and 13th month post-RT. DISCUSSION. In several case series, patients with minor anaplastic component had 1- and 2-year survival rates of 88% and 43%, respectively with a median survival of 17 months. The overall prognosis of patients with PTC with minor ATC component points to the value of active surveillance compared to more aggressive treatment modalities in the setting of conventional ATC. Presentation Date: Saturday, June 17, 2023

Congenital umbilical epidermal inclusion cyst masquerading as raspberry tumor– A common cyst in rare site

Umbilical tumours or lesions are rare; therefore, it is of outmost importance to navigate every umbilical nodule or growth cautiously. Only 10 cases have been reported to date. The present case has been diagnosed as congenital EIC in the umbilicus, the first time this has been reported in the archives.A 5 year old female child with umbilical nodular swelling since birth presented to the surgery OPD.A clinical diagnosis of "umbilical adenoma" was made. An excisional biopsy with abdominoplasty was done under general anaesthesia, and the specimen was submitted for HPE. On gross examination, we received an umbilical stump measuring 1 x 1 x 0.4 cm. A raised, firm nodular swelling was noted on the umbilical knot along with keratin debris. On cut, it showed a well-circumscribed, tiny gray-white nodule measuring 0.5 x 0.4 cm. On microscopic examination, a diagnosis of “Umbilical Epidermal Inclusion Cyst”was given.: Umbilical EIC is a rare entity that may present as an umbilical nodule and is detected in every age group with a female preponderance. Underlying etiopathogenesis can be congenital, idiopathic, or post-iatrogenic. Over 80% of the umbilical EIC is located above the fascia. The histopathological examination is the only modality that leads to an exact diagnosis and is considered the “gold standard” for detection of commonest cyst occurring in the rare site.

Targeted Magnetic Resonance Imaging/Near‐Infrared Dual‐Modal Imaging and Ferroptosis/Starvation Therapy of Gastric Cancer with Peritoneal Metastasis

AbstractAccurate identification and visualization of peritoneal metastases (PM) are clinically essential to improving the prognosis for gastric cancer. However, owing to the multifocal spread of peritoneal metastasis nodules, small size, and close contact with adjacent organs, identifying and completely removing them during surgery is extremely challenging, resulting in cancer treatment failure and recurrence. This study develops a T1‐weighted magnetic resonance imaging (MRI) contrast agent (FeGdNP)‐loaded indocyanine green/glucose oxidase (ICG/GOx) with conjugation of an RGD dimer (RGD2) and acid‐labile polymer mPEG (FeGdNP‐ICG/GOx‐RGD2‐mPEG). Compared with commercial Magnevist, the proposed FeGdNP‐ICG/GOx‐RGD2‐mPEG shows a two to three‐fold higher tumor ΔSNR in MRI of peritoneal metastasis and subcutaneous animal models. Compared with free ICG, the increased fluorescent signal of FeGdNP‐ICG/GOx‐RGD2‐mPEG allows for the detection of tiny tumor metastatic nodules (<3 mm), and the removal of the peritoneum transplanted tumors. Abundant gluconic acid and H2O2 are generated during the GOx‐mediated glucose depletion process in cancer cells, thereby enhancing Fenton reaction efficiency. Accumulated toxic ·OH can damage the mitochondrial function and induce the release of mitochondrial reactive oxygen species, which activates the ferroptosis pathway. The data indicate the potential of the nanoparticles for MRI preoperative diagnosis, intraoperative fluorescence‐guided navigation, and ferroptosis tumor therapy.

Radiological and clinical features of multinodular and vacuolating neuronal tumor (MVNT)

BackgroundTo investigate the imaging findings and clinical features of multinodular and vacuolating neuronal tumor (MVNT).MethodsWe retrospectively sought for cases that have suspicious imaging findings for MVNT through the hospital information system. The patients’ demographics and clinical symptoms were extracted. All available images were re-examined.ResultsHeadache was the most common complaint (n = 7). Other complaints included seizure, stroke-like symptoms and numbness. Conventional MRI revealed that all lesions consisted of tiny, sharply marginated, round or ovoid nodules following the gyral contour. These nodules were hyperintense on T2 and FLAIR WI, hypointense on T1 WI. All lesions were characterized by a lack of enhancement and diffusion restriction. Mass effect and peripheral edema were not observed. MVNT presented as an incidental finding in one case who complained gynecomastia and had pituitary adenoma on pituitary MRI. All lesions were supratentorial—mostly on the right side (10/11)—and located in subcortical white matter. Follow-up MRI was available for 11 patients with a mean of 14.8 months (3–40 months). No change in lesion size and morphology was observed in these follow-up images.ConclusionsRadiological and clinical follow-up data suggest MVNT may exhibit indolent behavior. If asymptomatic, patients can be followed by imaging alone. Surgery should be considered for symptomatic patients.

A Novel Method of Segmentation and Analysis of CT Chest Images for Early Lung Cancer Detection

Lung Cancer is the most common cancer diagnosed worldwide. It causes a higher amount of deaths. For the survival of cancer patients, early detection and treatment are beneficial and effective. Computer-aided diagnosis (CAD) is one of the most effective techniques utilized for image processing for lung cancer detection. Also, it’s the best image-based method for locating tiny nodules which facilitate early diagnosis of lung cancer. In this paper, the authors implemented a proposed CAD model. The proposed model successfully detected a very small tumor sized between 500 -1000 sq mm and can detect a smaller lung tumor than 500 sq mm if present which will enable physicians to early detect and appropriately stage lung cancer.

Accurate classification of lung nodules on CT images using the TransUnet.

Computed tomography (CT) is an effective way to scan for lung cancer. The classification of lung nodules in CT screening is completely doctor dependent, which has drawbacks, including difficulty classifying tiny nodules, subjectivity, and high false-positive rates. In recent years, deep convolutional neural networks, a deep learning technology, have been shown to be effective in medical imaging diagnosis. Herein, we propose a deep convolutional neural network technique (TransUnet) to automatically classify lung nodules accurately. TransUnet consists of three parts: the transformer, the Unet, and global average pooling (GAP). The transformer encodes discriminative features via global self-attention modeling on CT image patches. The Unet, which collects context by constricting route, enables exact lunge nodule localization. The GAP categorizes CT images, assigning each sample a score. Python was employed to pre-process all CT images in the LIDI-IDRI, and the obtained 8,474 images (3,259 benign and 5,215 lung nodules) were used to evaluate the method's performance. The accuracies of TransUnet in the training and testing sets were 87.90 and 84.62%. The sensitivity, specificity, and AUC of the proposed TransUnet on the testing dataset were 70.92, 93.17, and 0.862%, respectively (0.844-0.879). We also compared TransUnet to three well-known methods, which outperformed these methods. The experimental results on LIDI-IDRI demonstrated that the proposed TransUnet has a great performance in classifying lung nodules and has a great potential application in diagnosing lung cancer.

Tuberculosis of the tongue

Introduction: Tuberculosis mostly affects the lungs, but may also affect the central nervous system, lymphatic system, circulatory system, genitourinary system, bones, joints, and skin. Extrapulmonary involvement in tuberculosis is rare, accounting for just 10 to 15% of cases. The lymph nodes are the second most common site of tuberculosis infection. Oral tuberculosis has long been thought to be an unusual phenomenon. Oral manifestations are thought to occur in just 0.05 to 5% of all tuberculosis cases. Surface ulcers, patches, papillomatous lesions, and indurated soft tissue lesions are the most common oral manifestations. Case Presentation: A 69-year-old man presented to the Department of Ear, Nose, Throat at MGM Hospital in Aurangabad, India, with a painful ulcer and tiny nodules on the tongue’s tip and lateral surface. The ulcer appeared 3–4 weeks ago without any obvious trigger with a prickling feeling and increased soreness over the area., Onintraoral inspection multiple small nodules is measuring about 0.1 cm and multiple circular ulcer measuring about 0.2 x 0.1 cm in diameter at the tip and lateral border of the tongue. A granulomatous center and a whitish, well-defined border with mild elevation characterized the ulcer. Conclusion: Despite the rarity of tuberculosis evidence in the oral cavity, oral tuberculosis should be included in the differential diagnosis of chronic oral lesions. To prevent ineffective oral therapy, accurate diagnosis is crucial for successful care by concentrating on the pathological source.

DISSEMINATED BLASTOMYCOSIS PRESENTED WITH ADRENAL MASS

DISSEMINATED BLASTOMYCOSIS PRESENTED WITH ADRENAL MASS

Tuberculosis of the Glans Penis: A Case Presentation with Review Literature

Background: Tuberculosis of the glans penis is a rare occurrence., even in developing nations. Aim and Object: To review the literature and case presentation of Tb of glans penis Methodology: Pakmedinet, Pubmed and google data were searched for Tb of glans penis. Literature Review: Tuberclosis of the penis can be primary or secondary, and it might look like penile cancer, penile ulcers (granulomatous), genital herpes simplex or HIV infection. Tb of the Penis can develop after a individual who had primary pulmonary Tb and can be spread through ejaculation, contamination of endometerium secretions or clothes, as a result of a previous pulmonary Tb or Tb somewhere else. Tb of the Penis is characterised by a tiny nodule on the penis that is either painless or painful, an ulcer, a mass that progressively increasing and be swelling. Palpation of inguinal lymph nodes and erection problems of the penis can or can not observed. Normally, the patient's voiding is normal. Biopsy or acid fast bacilli in penile discharge or positive Elisa serology or PCR for tuberculosis are used to confirm the diagnosis. Needs 6 months, pulmonary tuberculosis therapy. Conclusions: Tb of the glans penis is an uncommon occurrence. After a biopsy, antitubercular medications are the standard treatment, thus doctors should evaluate the potential of Tb of the penis in instances of penile lesions. Keywords: Tb, penis, presentatation management and review litrarature

AI in NSCLC: PET-CT & histology model.

e21044 Background: Almost 70% of cases of lung cancer are diagnosed at advanced stage, albeit with sophisticated imaging modalities available. Of these, 35% are tiny nodules that are often missed at initial radiological screening, owing to limitations of resolution of human vision.Dramatic shift in therapeutic paradigm in the management of lung cancer in the last decade has ushered an era of stratified medicine. In India, one-third population inhabits rural lands;lack of awareness for molecular medicine poses challenges to treating oncologists. AI-based cancer detection and prediction of potential oncogenic driver at diagnosis, will help alleviate patient anxiety caused due to diagnostic delays, aiding in prompt initiation of optimal therapy.Here, a comprehensive deep-CNN based diagnosis of lung adenocarcinoma (LUAD) was implemented using both PET/CT and histopathology images of 100 patients. Methods: Data collection: 143 whole-slide images were downloaded from Dartmouth Lung Cancer Histology Dataset from Biomedical Informatics Research and Data Science website and PET/CT dataset-A Large-Scale CT and PET/CT Dataset for Lung Cancer Diagnosis (Lung-PET-CT-Dx) from The Cancer Imaging Archive. This comprises 251,135 images from 355 participants across 436 studies. Creation of Deep-CNN model: Residual Neural Network - 18 was used for histopathlogic classification followed by Detectron2’s region-based deep-CNN for detection of presence of tumours in lung PET/CT images. Properties such as size, morphology, attenuation, malignancy, and spiculation were also measured. The 18-layer deep network, ResNet-18, detected the histologic patterns using whole-slide histopathology images. Results: Results for 100 patients whose PET/CT images, histopathology images, and mutational status of three genes (EGFR, ALK, ROS) were readily available. The histologic patterns of tumour cells appear to be related to the mutational status of genes. The ResNet-18 CNN could predict various histologic patterns (Acinar, Lepidic, Papillary, Micropapillary, and Solid patterns). Conclusions: CNN models can help in early diagnosis and prompt treatment of lung cancer, if fairly accurate. Larger datasets are needed to improve the same. The final validation of the model is underway and will be reported in near future.[Table: see text]

Clinical Presentation and VRT-CT Features in Pediatric Patients with COVID-19 Infection

Objective: The aim of this study is to discuss the clinical, laboratory, chest computed tomography (CT) and volumetric imaging technique (VRT) features in pediatric patients with novel coronavirus 2019 (COVID-19) infection. Material and Methods: The clinical, laboratory, and chest CT features of 17 pediatric patients with COVID?19 infection those confirmed by pharyngeal swab COVID?19 polymerase chain reaction(PCR) were evaulated. All clinical and laboratory data have been recorded and analyzed during march-february 2021 . Chest CT have been performed to all Covid 19 PCR confirmed patients and radiologicall view have been noted. Results: Seventeen pediatric patients with a history of close contact with COVID?19 diagnosed family members included to the study. Fever (10/17, 58%) and cough (13/17, 76%) were the most common symptoms. For laboratory findings, c reactive protein elevation (15/17, 88%) seem to be the most finding. A total of 4 patients presented with unilateral pulmonary lesions (4/17, 23%), 9 with bilateral pulmonary lesions (9/17, 52%) and 13 cases showed bilateral diffuse covid pattern on chest CT (13/17, 76%). Non-spesific consolidation with was observed in 8 patients (8/17, 47%), ground?glass opacities were observed in 11 patients (11/17, 64%), nodules were observed in 7 patients (7/17, 41%), and tiny nodules were observed in 2 patients (2/17, 11%). Conclusion: In pediatric patients before confimation positivitiy of COVID?19 nucleic acid test from pharyngeal swab samples; the early detection of lesions with chest CT especialy by VRT (volumetric rendering technique)-CT tecnique can be efficient; in management and early treatment for pediatric patients. More clinical trails can suggest about the primeline screening and treatment options in pediatric covid-19 infection in future.

Application of Highly Flexible Adaptive Image Receive Coil for Lung MR Imaging Using Zero TE Sequence: Comparison with Conventional Anterior Array Coil.

(1) Background: Highly flexible adaptive image receive (AIR) coil has become available for clinical use. The present study aimed to evaluate the performance of AIR anterior array coil in lung MR imaging using a zero echo time (ZTE) sequence compared with conventional anterior array (CAA) coil. (2) Methods: Sixty-six patients who underwent lung MR imaging using both AIR coil (ZTE-AIR) and CAA coil (ZTE-CAA) were enrolled. Image quality of ZTE-AIR and ZTE-CAA was quantified by calculating blur metric value, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) of lung parenchyma. Image quality was qualitatively assessed by two independent radiologists. Lesion detection capabilities for lung nodules and emphysema and/or lung cysts were evaluated. Patients’ comfort levels during examinations were assessed. (3) Results: SNR and CNR of lung parenchyma were higher (both p < 0.001) in ZTE-AIR than in ZTE-CAA. Image sharpness was superior in ZTE-AIR (p < 0.001). Subjective image quality assessed by two independent readers was superior (all p < 0.05) in ZTE-AIR. AIR coil was preferred by 64 of 66 patients. ZTE-AIR showed higher (all p < 0.05) sensitivity for sub-centimeter nodules than ZTE-CAA by both readers. ZTE-AIR showed higher (all p < 0.05) sensitivity and accuracy for detecting emphysema and/or cysts than ZTE-CAA by both readers. (4) Conclusions: The use of highly flexible AIR coil in ZTE lung MR imaging can improve image quality and patient comfort. Application of AIR coil in parenchymal imaging has potential for improving delineation of low-density parenchymal lesions and tiny nodules.

Occult pleural dissemination detected intraoperatively in patients with thymic tumors: a retrospective analysis

BackgroundThymic tumors usually present with adjacent organ invasion or pleural dissemination, but very few studies have reported on occult pleural dissemination detected intraoperatively. This study aimed to investigate the risk factors that can predict pleural dissemination preoperatively.MethodsConsecutive patients with thymic tumors who underwent surgery from January 2010 to January 2017 were reviewed. Only patients without pleural dissemination detected preoperatively were included in this study. Demographic, clinical, pathological, and survival data were collected for statistical analysis. Further analyses were performed to find the risk factors of occult pleural dissemination.ResultsA total of 352 patients with thymic tumors were included in this study. Seven patients had pleural dissemination detected intraoperatively. All pleural dissemination cases were in clinical Masaoka-Koga stage III, and most underwent the video-assisted thoracoscopic surgery (VATS) approach (or VATS exploration). Univariate analysis showed that positive squamous cell carcinoma (SCC) antigen was the only predictor of pleural dissemination (p = 0.009). Tiny nodules close to the diaphragm were detected in the computed tomography scans of 1 case after reviewing the imaging data. Tumor recurrence occurred in 5 patients during follow-up. The disease-free survival rates were better in patients with a solitary nodule than those with multiple nodules (p = 0.019). No significant difference was detected in terms of disease-free survival rates between SCC antigen positive and SCC antigen negative patients.ConclusionsPositive SCC antigen was the only detected risk factor for predicting pleural dissemination in thymic tumors preoperatively in this study. The VATS approach (including VATS exploration) is suggested for patients with clinical Masaoka-Koga stage III and SCC antigen positive thymic tumors, according to our experience.

THE FAULT IN OUR MOSAIC PATTERNS: PULMONARY HYPERTENSION MISSED AND TREATED AS HYPERSENSITIVITY PNEUMONITIS

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Mosaic Pattern refers to areas of variable lung attenuation seen on Computed Tomography (CT) of the chest. The pattern is a nonspecific finding and can be associated with airway, infiltrative lung, or pulmonary vascular diseases[1]. We present a case of exertional dyspnea with mosaic pattern on high resolution CT (HRCT) that was initially misdiagnosed and treated as hypersensitivity pneumonitis (HP) and found later to be caused by pulmonary arterial hypertension. CASE PRESENTATION: A 70-year-old Caucasian female presented with worsening exertional dyspnea after percutaneous coronary intervention. HRCT of the chest done at an outside office showed mosaic pattern and few tiny bilateral nodules with no fibrotic changes that was interpreted as possible chronic hypersensitivity pneumonitis. She was started on prednisone 40mg daily with minimal improvement in symptoms and referred to our Interstitial Lung Disease (ILD) Clinic for further work up and treatment. Upon interviewing the patient, she reported previous intake of anorexigenics (dextroamphetamine) in her 20's for 2 months. Review of the HRCT study showed parenchymal changes were not consistent with any specific ILD pattern and no exaggeration of mosaic pattern with expiratory cuts suggesting the presence of pulmonary hypertension and absence of significant air trapping. Prednisone was tapered off, and serologic work up showed no evidence of connective tissue disease. 6-minute walk test revealed severe reduction in exercise capacity with patient covering 38m which was 12% of predicted distance, and spirometry showed moderate-severe restrictive defect. Her echocardiography showed normal LV systolic function with ejection fraction (55-65%), and her ventilation-perfusion (VQ) scan was negative for any embolic disease. The patient was admitted to the hospital for hypervolemia and after adequate diuresis, a detailed hemodynamic study by right heart catheterization for the assessment of pulmonary hypertension was done. Results showed increased mean pulmonary artery pressure (mPAP) (31 mmHg) at rest; however, during limited exercise challenge which she could not complete, pulmonary artery occlusion pressure (PAOP) increased to 23 mmHg suggesting decreased left atrial/ventricular compliance. She was started on sildenafil and discharged with close follow up. DISCUSSION: Air-trapping in airway diseases causing relative hyperemia of healthy lungs, pulmonary vascular diseases causing relative oligemia in hypo-perfused lungs, and parenchymal disease presenting as patchy ground-glass opacities, all can give a mosaic pattern on CT[1]. Infiltrative diseases and airway diseases are reliably differentiated as the cause of mosaic attenuation on CT scan, but vascular diseases are often misinterpreted.[2] CONCLUSIONS: Careful review of HRCT with a chest radiologist in an advanced lung disease center is necessary to avoid misdiagnoses and unnecessary treatments. REFERENCE #1: Stern, Eric J., et al. "CT mosaic pattern of lung attenuation: distinguishing different causes.” AJR. American journal of roentgenology 165.4 (1995) REFERENCE #2: Worthy, Sylvia A., et al. "Mosaic attenuation pattern on thin-section CT scans of the lung: differentiation among infiltrative lung, airway, and vascular diseases as a cause.” Radiology205.2 (1997) DISCLOSURES: No relevant relationships by Roberto Bernardo, source=Web Response No relevant relationships by Salim Daouk, source=Web Response No relevant relationships by Ahmad Hassan, source=Web Response No relevant relationships by Abed Madanieh, source=Web Response No relevant relationships by Chirin Orabi, source=Web Response

English

Erdheim-Chester disease (ECD) is a rare, multisystem disorder with a constellation of clinical and radiological findings. We present a case of ECD who came with acute obstructive uropathy and chronic bone pain. Radiological work up in this patient led to a host of findings in various systems, the correlation of which led to narrowing of the differential diagnoses. A 44-year-old male presented with right loin pain and nausea for 1-day duration. A provisional diagnosis of right ureteric colic was made. Routine lab investigations revealed normal total counts and urine analysis. Additional laboratory investigations revealed a raised erythrocyte sedimentation rate (ESR) and Creactive protein (CRP). Radiological Investigations 1. Patient was referred for ultrasound of abdomen which revealed mild to moderate right hydronephrosis with a suspicious hypoechoic area (~ 0.7 x 1.2 cm) in the renal pelvis region raising possibility of a lesion. 2. Contrast computed tomography (CT) study of abdomen was performed which revealed enhancing soft tissue infiltration (+30 to +45 HU) around bilateral kidneys (giving ‘hairy kidney appearance’) (Figures 1, 2 &amp; 3) and adrenal glands with infiltration to renal sinus and constriction of bilateral renal pelves resulting in moderate right and mild left hydronephrosis. Thin streak of excreted contrast was traversing the narrowed segment of renal pelves (Figures 4 &amp; 5). 3. Soft tissue infiltration covering the visualized thoracic and abdominal aorta (giving ‘coated aorta appearance’) (Figures 6 &amp; 7), extending below renal arteries to aortic bifurcation and proximal bilateral common iliac arteries. 4. The adrenal glands were not separately visualized from the above mentioned perinephric soft tissue. 5. Both ureters were normal in course and caliber. No evidence of ureteric calculus. 6. No significant retroperitoneal lymphadenopathy. 7. Few tiny centriacinar nodules with patchy ground glass opacities in postero basal segment of both lungs (left &gt; right) (Figure 8).