64-year-old patient Breathless for 2 months three stone weight loss
What is the most likely diagnosis
ANSWAR/
Multiple pulmonary masses
There are multiple pulmonary masses of varying sizes seen in both lungs.
The commonest cause of this appearance in a patient of this age would be
multiple metastases. There are no bony lesions, no mastectomy and
no other clues to suggest a primary site. Old films would help to confirm
the nature of the nodules and rate of growth.
Comment
If pushed, this film is another situation where a surgical sieve will help to
recall causes of multiple pulmonary nodules masses
Tumour
Metastasis Breast, renal, thyroid, squamous carcinoma (head
and neck), gastrointestinal tumours, osteosarcoma
Lymphoma
Infection
Bacterial Abscesses, Staph. aureus, Pseudomonas, TB
Parasitic Hydatid
Infarction
Multiple pulmonary infarct
Vascular
Pulmonary avm
Granuloma
Wegeners
Rheumatoid nodule
AIDS
Kaposi sarcoma
Occupation
Caplans, PMF
Others
Amyloid
Papillomatosis of the lung
28-year-old male. This patient is breathless febrile and unwell. He has recently arrived from Africa.
Miliary nodules
There are multiple miliary nodules in both lungs
The patient is from Africa and is unwell making miliary TB the most likely
diagnosis. Barrier nursing in isolation should be undertaken.
TB is spread by the respiratory route, so precautions must be taken to
sterilise ventilation equipment following use. Disposable equipment should
be used where possible and bacterial filters should be used to protect
the ITU ventilator. Medical and nursing staff are at risk of infection, full
face masks and eye protection should be worn during procedures involving
the airway. If he was well, consider sarcoid or pneumoconiosis (old films
would help in this latter differential). Any history of primary malignancy is
important, thyroid malignancy, bone sarcoma and trophoblastic disease can
give rise to miliary metastases. Further less common possibilities include
acute extrinsic allergic alveolitis, nodular pulmonary fibrosis and histiocytosis X.
Haematogenous metastases tend to go to the bases and inhaled dusts to
the apices. Densely calcified tiny nodules have a different differential
diagnosis
miliary TB. There are innumerable tiny nodules distributed throughout both lungs. The clinical setting is important in making the diagnosis as dust inhalation, granulomatous diseases, infection and metastases can give a similar
appearance.
Miliary TB Sarcoid Dust inhalation/pneumoconiosis Extrinsic allergic alveolit Miliary metastases: thyroid, melan
Dense miliary nodules Haemosiderosis Silicosis Stannosis Chicken pox