section name header

Info


A. Diffuse Processes [1]

  1. Interstitial
    1. Viral
    2. Influenza, Adenovirus
      1. RSV, Measles, CMV, Herpes
    3. Bacterial (atypicals)
    4. Mycoplasma
      1. Miliary Tuberculosis
      2. Legionella
      3. Chlamydia (TWAR)
    5. Fungal - Pneumocystis carinii pneumonia
  2. Allergic - eosinophilic pneumonia
    1. Penicillin
    2. Gold (intramuscular)
    3. Nitrofurantoin
  3. Drug Reaction -Bleomycin, Methotrexate
  4. Occupational / Exposure
    1. Dusts (silica, beryllium, coal), Fumes
    2. Irradiation, Oxygen Toxicity
  5. Alveolar Filling Diseases
    1. Infection
    2. Neoplastic
    3. Edema
  6. Congenital - Lipoidosis, Hamartoma
  7. Neoplasm
    1. Bronchogenic CA more common than:
    2. Metastatic Ca more common than:
    3. Lymphoma
  8. Circulatory
    1. Pulmonary Hypertension
    2. Pulmonary Embolism
    3. Pulmonary Venous Occlusion
  9. Unknown Causes
    1. Sarcoidosis
    2. Idiopathic Pulmonary Hemosideridosis
    3. Idiopathic Pulmonary Fibrosis
    4. Usual interstitial pneumonitis
      1. Desquamative Pneumonitis
    5. Goodpasture's Syndrome
    6. Amyloidosis
    7. Microlithiasis
    8. Lymphangioleiomatosis (LAM)

B. Lung Mass

  1. Solitary Mass
    1. Abscess
    2. Neoplasm
    3. Cyst
    4. Silicosis, Asbestosis
    5. Fluid
    6. Rheumatoid Nodule
    7. Arteriovenous Malformation (AVM)
  2. Solitary Mass with Calcifications
    1. Tuberculosis
    2. Histoplasmosis,
    3. Papillary Thyroid Carcinoma
    4. Osteosarcoma
    5. Teratoma and Hamartoma
  3. Multiple Masses
    1. Metastatic Disease
    2. Miliary Tuberculosis
    3. Abscess Seeding
    4. Silicosis
    5. Rheumatoid Nodule

C. Solitary Pulmonary Nodule [2,3,4]

  1. Usually defined as <4cm opacity without atelectasis or hilar adenopathy
  2. Etiology
    1. Bronchogenic Ca (35-50%): non-small cell cancers were more common than SCLC
    2. Metastatic Cancer (breast, colon, renal, Kaposi's Sarcoma)
    3. Carcinoid Tumor (total 10%)
    4. Granulomatous Process: TB, Histoplasma, Coccidiomycosis, Cryptococcus, Aspergillus
    5. Other: Bronchial Cyst, AV Fistula, Fibroma, Rheumatoid Nodule, Hematoma, Sarcoid
    6. Rounded Atelectasis, Hamartoma
    7. Resolving pneumonia, infarction
  3. Factors Favoring Malignancy
    1. Older age of patient
    2. Smoker
    3. Margins Not Sharp
    4. Uncalcified, or Calcification NOT laminated, homogeneous or popcorn
    5. Change in size on Chest Radiograph over 2 years
    6. A very rapid doubling in size (<7 days) favors benign histology
    7. Size >2cm
  4. Evaluation
    1. Chest radiography is most common initial test
    2. Nodules <2cm require thin section CT study
    3. >2cm is nearly always a bronchogenic CA; staging with chest and abdominal CT
    4. Sputum Cytology: diagnostic 20% of malignancies (endobronchial tumors often exfoliate)
    5. Fiberoptic Bronchoscopy: Diagnostic yields 50-75%; drops off for lesions <2cm
    6. Transthoracic Aspiration: Diagnostic <2cm ~60%, >2cm ~85%
  5. Chest Radiographic (CXR) Results of Benign Lesions
    1. Calcification usually means benign (<1% malignancies appear calcified on CXR)
    2. Benign Calcifications: laminated (granuloma), popcorn (hamartoma), homogeneous
    3. No change in size over 2 years
    4. CT scan gives better assessment of size and calcification

D. Mediastinal Mass ("Terrible T's")

  1. Thymoma
  2. Teratoma (embryonal carcinoma)
  3. Terrible Lymphoma (Hodgkin's Disease)
  4. Thyroid Carcinoma
  5. Neurofibroma ("Tingle")
  6. Renal Cell Carcinoma ("Tinkle")

E. Hemoptysis

  1. Diseases
    1. Pulmonary Embolus
    2. Arterio-venous malformation (AVM)
    3. Pseudoaneurysm or Aneurysm [8]
    4. Goodpasture's (anti-basement membrane Antibodies) Syndrome
    5. Vasculitis
    6. Sarcoidosis
    7. Mitral Stenosis - with high pulmonary pressures; called "cardiac apoplexy"
  2. Infection (Bronchiectasis, bronchitis)
    1. Bacterial pneumonia
    2. Tuberculosis (most common world-wide)
    3. Nocardia
    4. Lung abscess
    5. Unusual: fungal balls, fungal infection (aspergillosis), parasitic infections
  3. Neoplastic
    1. Lung Carcinoma
    2. Lymphoma (unusual)
    3. Carcinoid Tumors

F. Pulmonary Embolism

  1. Myocardial Infarction
  2. Pneumonia
  3. Congestive Heart Failure
  4. Asthma
  5. COPD Exacerbation
  6. Intrathoracic Cancer
  7. Rib Fracture
  8. Pneumothorax
  9. Musculoskeletal Pain
  10. Patients present with pain and shortness of breath; A-a gradient usually present

G. Pulmonary Edema

  1. Acute Cardiac Decompensation
    1. Mitral Regurgitation
    2. Ischemia
    3. Arrhythmia
    4. Myocardial Infarction
    5. Heart Failure (Left Sided)
  2. ARDS
  3. Hypoproteinemia
    1. Liver Failure
    2. Nephrotic Syndrome
  4. Inflammatory Response
  5. Pulmonary Embolism and Infarction

H. Lung Cavitation (Cavitary Lesions) [6,7]

  1. Infection
    1. Tuberculosis
    2. Other Atypical Bacteria: actinomyces, rhodococcus
    3. Burkholderia pseudomallei
    4. Pyogenic (Bacterial) Abscess: anaerobic (mainly oral), mixed flora, S. pyogenes
    5. Fungus Histoplasmosis, Nocardia, Actinomyces, Aspergillus
    6. Parasitic: echinococcus, toxoplasma, entamoeba, paragonimus
  2. Aspiration Pneumonia with Abscess formation
  3. Neoplasms
    1. Bronchial adenoma
    2. Teratoma
    3. Pimary Lung Cancer: usually non-small cell carcinoma
    4. Lymphoma - usually non Hodgkin's
    5. Metastatic disease
  4. Pulmonary infarction
  5. Septic emboli (endocarditis, others)
  6. Mechanical Obstruction
    1. Tumor, foreign body, bronchostenosis
    2. infected bullae: chronic obstructive pulmonary disease / emphysema, irradiation
  7. Cystic Bronchiectasis
  8. Developmental (congenital) Cysts
  9. Parasitic Disease - hydatid, paragonimiasis
  10. Silicosis - very rarely cavitary

I. Pulmonary Cysts (Table 4 in reference [5])

  1. Infections
    1. Fungal: coccidioides, aspergillus, pneumocystis
    2. Bacterial: staphylococcus, mycobacterium
    3. Parasitic: paragonimus, echinococcus
  2. Embolic Disease
    1. Thromboembolism
    2. Septic embolism
  3. Malignant Cancers
    1. Primary or metastatic tumor
    2. Lymphoma
  4. Autoimmun Disease
    1. Vasculitis
    2. Systemic lupus erythematosus (SLE)
    3. Rheumatoid Arthritis
    4. Wegener's Granulomatosis
    5. Sjogren's Syndrome
  5. Interstitial Lung Disease
    1. Lymphocytic interstitial pneumonitis
    2. Eosinophilic granuloma
    3. Sarcoidosis
    4. Idiopathic pulmonary fibrosis
  6. Airway Disease
    1. Bullous emphysema
    2. Cystic bronchiectasis
  7. Congenital / Genetic Disease
    1. Congenital Cysts
    2. Cystic Fibrosis
    3. Alpha1-Antitrypsin Deficiency

References

  1. Elias AD and Mark EJ. 1997. NEJM. 337(7):
  2. Stoller JK, Ahmad M, Rice TW. 1988. Cleve Clin J Med. 55(1):68 abstract
  3. Libby DM, Henschke CI, Yankelevitz DF. 1995. Am J Med. 99(5):491 abstract
  4. Swensen SJ, Jett JR, Payne WS, et al. 1990. Mayo Clin Proc. 65(2):173 abstract
  5. Harris RS and Mark EJ. 2001. NEJM. 344(22):1701 (Case Record) abstract
  6. Baden LR and Elliott DD. 2003. NEJM. 348(5):447 abstract
  7. Cao AY, Munandar R, Ferrara SL, et al. 2005. NEJM. 352(25):2628 (Case Record) abstract
  8. Collard HR, Gruber MP, Weinberger SE, Saint S. 2003. NEJM. 349(10):987 (Case Discussion) abstract