Computed tomography findings in bronchial asthma: quantification of air trapping and correlation with pulmonary function tests.

BACKGROUND: High-resolution computed tomography (HRCT) scans can help identify subsets of asthma patients who show rapid decline in lung function. PURPOSE: To evaluate high-resolution computed tomography (HRCT) findings in adult patients with asthma, obtain quantitative measurements of air trapping on expiratory scans, and correlate the findings with pulmonary function tests (PFTs). MATERIAL AND METHODS: Thirty adults with asthma with persistent-mild, persistent-moderate, and persistent-severe categories as per standard clinical guidelines were evaluated with inspiratory and expiratory HRCT for various imaging features of bronchial asthma. Expiratory HRCT scan were used to quantify degree of air-trapping, and their values quantified as "pixel index," using a special "density' mask" software. Complete spirometry and body plethysmography were performed on each patient within 0-2 days of HRCT scans. HRCT findings were correlated with the clinical severity groups and the CT pixel indices (PI) were correlated with the PFT results using correlation coefficients and linear regression analysis. RESULTS: The inspiratory CT findings did not correlate with increase in disease severity. Expiratory scans accurately quantified areas of air trapping. CT-PI correlated well with PFT values indicative of airway obstruction and airflow limitation, which helped differentiate patients with asthma with increasing severity from those with milder forms of the disease. CONCLUSION: Expiratory thin-section CT is a useful objective method to quantify air-trapping in people with asthma. The air-trapping score measured in "pixel indices" correlates well with PFT results and can successfully identify patients with severe asthma. Further studies are needed to confirm if this parameter can serve as a potential marker for airway remodeling and declining lung function.

Congenital Left Atrial Aneurysms.

Online supplemental material is available for this article.

Expanding the spectrum of chronic necrotising (semi-invasive) aspergillosis: a series of eight cases presenting as radiologically solid lung nodules mimicking malignancy.

AIM: To clinicopathologically characterise a subset of aspergillosis cases characterised by radiologically solid lung nodules. METHODS AND RESULTS: We reviewed our archives for lung biopsies/resections with fungal hyphae on histology. Cases classifiable as a well-established form of aspergillosis were excluded. Unclassifiable cases with radiologically solid lung nodules and histological evidence of fungal hyphae consistent with Aspergillus were analysed in detail. Of 134 lung biopsies/resections with fungal hyphae, eight presented as a solid lung nodule on imaging and could not be classified as a well-recognised form of aspergillosis. All patients were non-immunocompromised/minimally immunocompromised adult smokers. Imaging showed solid, predominantly solitary, spiculated, subpleural, hypermetabolic upper lobe nodules in emphysematous lungs. Malignancy was suspected clinically in all cases. Histologically, the nodules were necrotising granulomas containing fungal hyphae consistent with Aspergillus. On follow-up, none of the nodules recurred or progressed to invasive disease. CONCLUSIONS: Aspergillosis can present as a radiologically solid, spiculated lung nodule suspicious for malignancy.

A review of endovascular stenting for superior vena cava syndrome in fibrosing mediastinitis.

Fibrosing mediastinitis (FM) is a rare disorder of inflammation and fibrosis involving the mediastinum. The formation of fibroinflammatory mass in the mediastinum can lead to obstruction of mediastinal structures and cause severe debilitating and life-threatening symptoms. Superior vena cava syndrome (SVCS) is a dreaded complication of FM with no medical therapy proven to be efficacious. Spiral vein grafting has long been utilized as first-line therapy for SVC syndrome due to FM. Endovascular repair with stents and angioplasty for malignant causes of SVC syndrome is well established. However, there are limited data on their utility in SVC syndrome due to FM. We present two cases of SVC syndrome due to FM treated with endovascular stenting and a detailed review of current literature on its utility in SVCS due to benign causes.

Imaging Evaluation of Airway Complications After Lung Transplant.

Airway complications (ACs) after lung transplant remain a challenge and include bronchial dehiscence, bronchial stenosis, tracheobronchomalacia, infections, and bronchial fistulas. The spectrum of complications may coexist along a continuum and can be classified as early (<1 month after transplant) or late (>1 month), and anastomotic or nonanastomotic. Bronchiolitis obliterans is the most common form of chronic lung allograft rejection. Airway compromise is seen in rare instances of lung torsion, and imaging may provide helpful diagnostic clues. Computed tomography (CT) and bronchoscopy play major roles in the diagnosis and treatment of ACs after lung transplant. Chest CT with advanced postprocessing techniques is a valuable tool in evaluating for airways complications, for initial bronchoscopic treatment planning and subsequent posttreatment assessment. Various bronchoscopic treatment options may be explored to maintain airway patency. The goal of this article is to review imaging findings of ACs after lung transplantation, with emphasis on chest CT and bronchoscopic correlation.

Association of Transthoracic Echocardiography Findings and Long-Term Outcomes in Patients Undergoing Workup of Stroke.

BACKGROUND: Transthoracic echocardiography (TTE) has become routine as part of initial stroke workup to assess for sources of emboli. Few studies have looked at other TTE findings such as ejection fraction, wall motion abnormalities, valve disease, pulmonary hypertension and left ventricular hypertrophy and their association with various subtypes of stroke, long-term outcomes of recurrent stroke, and all-cause mortality. METHODS AND RESULTS: Computed tomography and magnetic resonance imaging brain imaging and TTE reports were reviewed for 2464 consecutive patients referred for TTE as part of a workup for acute stroke between 1/1/01 and 9/30/07. Study patients were 67 ± 15years, 60% female, 75% minorities and had hypertension (76%), diabetes (41%), chronic kidney disease (27%) and atrial fibrillation (18%). On TTE, a mass, thrombus, or vegetation was identified in only 4 cases (0.2%), whereas a clinically significant abnormality (ejection fraction < 50%, left ventricle or right ventricle wall motion abnormalities, severe valve disease, pulmonary hypertension, or left ventricular hypertrophy) was identified in 16%. Those with an abnormal TTE had increased risk for death at 10years (hazard ratio [HR] 1.8; 95% confidence interval [CI]: 1.6, 2.0; P < .01), although risk for readmission with stroke was not increased. Abnormal TTE remained associated with increased risk of death at 10years after adjustment for age, sex, race, and cardiovascular risk factors (HR 1.4; 95% CI: 1.2, 1.7; P < .01). CONCLUSIONS: TTE performed as part of an initial workup for stroke had minimal yield for identifying sources of embolism. Clinically important abnormalities found on TTE were independently associated with increased long-term mortality, but not recurrent stroke.

Pathology of pulmonary tuberculosis and non-tuberculous mycobacterial lung disease: Facts, misconceptions, and practical tips for pathologists.

Most pathologists are familiar with the microscopic features of tuberculosis and the need to examine special stains for acid-fast bacteria (AFB) in cases of granulomatous lung disease. However, misconceptions do exist, including the concept that finding AFB in "caseating granulomas" confirms the diagnosis of tuberculosis. This dogma is attributable to the high prevalence of tuberculosis in many countries, as well as unfamiliarity with the microscopic spectrum of non-tuberculous mycobacterial lung disease. This review aims to provide surgical pathologists with practical tips to identify AFB, illustrate the histologic overlap between pulmonary tuberculosis and non-tuberculous mycobacterial lung disease, and highlight the importance of cultures in this setting. M. tuberculosis and non-tuberculous mycobacteria cannot be reliably differentiated either on the basis of the tissue reaction or by bacterial morphology on acid-fast stains. Although a presumptive clinical diagnosis of tuberculosis can be made without culture-confirmation, the only definitive means to determine the true identity of AFB is by cultures or molecular methods. Making this distinction is most critical when AFB are found in incidentally detected lung nodules in geographic locations where the incidence of tuberculosis is low, because in such settings AFB in necrotizing granulomas of the lung are more likely to be non-tuberculous mycobacteria than M. tuberculosis.

CT Gray-Level Texture Analysis as a Quantitative Imaging Biomarker of Epidermal Growth Factor Receptor Mutation Status in Adenocarcinoma of the Lung.

OBJECTIVE: The purpose of this study was to investigate the radiogenomic correlation between CT gray-level texture features and epidermal growth factor receptor (EGFR) mutation status in adenocarcinoma of the lung. MATERIALS AND METHODS: This retrospective study included 25 patients with exon 19 short inframe deletion (exon 19) and 21 patients with exon 21 L858R point (exon 21) EGFR mutations among 125 patients with EGFR mutant adenocarcinoma of the lung. The randomly formed control group consisted of 20 patients selected from 126 patients with EGFR mutation-negative (wild-type) adenocarcinomas. Five gray-level texture features (contrast, correlation, inverse difference moment, angular second moment, and entropy) were analyzed. RESULTS: Contrast differentiated both exon 19 (p = 0.00027) and exon 21 (p = 0.00001) mutants from the wild type. Wild-type adenocarcinomas had high scores for contrast (mean, 1598.547) compared with EGFR mutants (mean, 679.463). Correlation differentiated both exon 19 (p = 0.017) and exon 21 (p = 0.0015) mutants from wild-type adenocarcinomas. Inverse difference moment differentiated exon 19 mutants from exon 21 mutants (p = 0.019) and both exon 19 (p = 0.044) and exon 21 (p = 0.00001) mutants from wild-type adenocarcinomas. Angular second moment and entropy were not associated with statistically significant differences between mutation statuses. CONCLUSION: Contrast, correlation, and inverse difference moment texture features correlate with EGFR mutation status in adenocarcinoma of the lung. Further investigation with larger prospective studies is needed to validate the role of CT gray-level texture analysis as a quantitative imaging biomarker.

Radiographic Distribution as a Diagnostic Clue in Pulmonary Disease.

Because some disease processes produce radiographic abnormalities that occur in characteristic distributions in the chest, classifying the position and appearance of these suggestive features and the underlying diseases provides a tool by which diagnostic accuracy might be improved. The goal of this review is to offer to the chest clinician a taxonomy of these disease entities that can produce characteristic chest radiographic distributions. These radiographic distributions often reflect anatomic or physiologic conditions that drive the radiographic appearance; for example, foramen of Morgagni diaphragmatic hernias most commonly present in the right ventral chest, consistent with the anatomic location of the diaphragmatic foramen. This taxonomy includes 3 distributional categories: (1) upper versus lower lung zone-predominant processes, (2) central versus peripheral processes, and (3) processes with distinctive focal locations, eg, "photonegative appearance" as in chronic eosinophilic pneumonia. It is hoped that this taxonomy aids the chest clinician in generating and streamlining a differential diagnosis and in ascertaining the specific cause of diseases with radiographic abnormalities.

A confounding bronchopulmonary situs abnormality after bilateral lung transplantation.

A 36-year-old female with a past medical history of primary ciliary dyskinesia and bilateral lung transplantation was noted to have a rare and confounding postsurgical anatomy acquired as a result of transplantation. Bronchoscopy and computed tomography showed isomeric main bronchi with a tri-lobed right lung, a bi-lobed left lung and dextrocardia. This rare phenomenon can be observed in lung transplant recipients with situs ambiguous morphology of their native lungs, who receive donor lungs with normal situs solitus morphology. To the best of our knowledge, ours is the first reported case of such a composite bronchopulmonary situs abnormality. Careful review of bronchial anatomy should be done with the help of CT imaging prior to undertaking any bronchial interventions in these subset of patients with bronchial isomerism and bilateral lung transplantation.

Acute Dyspnea After Lung Transplantation: A Twisted Tale.

CASE PRESENTATION: A 67-year-old woman developed sudden-onset severe dyspnea 24 h after a bilateral sequential lung transplant for COPD. She had an uneventful surgery performed on cardiopulmonary bypass support. She required two units of packed RBCs as well as fresh frozen plasma during the surgery. She was successfully extubated within 12 h of surgery. Her primary graft dysfunction score was grade 2, 1, and 1 at 0, 12, and 24 h, respectively. Approximately 24 h after the procedure, she complained of increasing shortness of breath without fever, chills, cough, or pleuritic chest pain.

Recurrence of primary disease following lung transplantation.

Lung transplant has become definitive treatment for patients with several end-stage lung diseases. Since the first attempted lung transplantation in 1963, survival has significantly improved due to advancement in immunosuppression, organ procurement, ex vivo lung perfusion, surgical techniques, prevention of chronic lung allograft dysfunction and bridging to transplant using extracorporeal membrane oxygenation. Despite a steady increase in number of lung transplantations each year, there is still a huge gap between demand and supply of organs available, and work continues to select recipients with potential for best outcomes. According to review of the literature, there are some rare primary diseases that may recur following transplantation. As the number of lung transplants increase, we continue to identify disease processes at highest risk for recurrence, thus shaping our future approaches. While the aim of lung transplantation is improving survival and quality of life, choosing the best recipients is crucial due to a shortage of donated organs. Here we discuss the common disease processes that recur and highlight its impact on overall outcome following lung transplantation.

Recycling plastic: diagnosis and management of plastic bronchitis among adults.

Plastic bronchitis is a rare, underdiagnosed and potentially fatal condition. It is characterised by the formation and expectoration of branching gelatinous plugs that assume the shape of the airways. These airway plugs differ from the allergic mucin that characterises allergic bronchopulmonary aspergillosis and mucoid impaction of the bronchi. Plastic bronchitis is most often encountered in the paediatric population following corrective cardiac surgery, such as the Fontan procedure. It also occurs in adults. Plastic bronchitis in adults is rare, heterogeneous in its aetiology, and can lead to respiratory distress or even life-threatening airway obstruction. Plastic bronchitis in adulthood should not be overlooked, particularly in patients with chronic inflammatory lung diseases. This review presents current understanding of the presentation, aetiology, pathogenesis, pathology and management of plastic bronchitis in adults.

A case of hypereosinophilic syndrome with STAT5b N642H mutation.

Hypereosinophilia is defined as persistent eosinophilia (>1.5 × 109/L). Hypereosinophilic syndrome (HES) is a term used to describe a group of disorders characterized by sustained hypereosinophilia associated with end-organ damage. Based on underlying molecular mechanism of eosinophilia, there are different subtypes of HES. Diagnosis of HES subtype can be challenging, especially in the absence of overt lymphoid/myeloid neoplasms or discernable secondary causes. Long-term outpatient follow-up with periodic complete blood count and repeated bone marrow biopsy may be needed to monitor disease activity. Somatic signal transducer and activation transcription 5b (STAT5b) N642H mutation was recently found to be associated with myeloid neoplasms with eosinophilia. We report a case of HES who presented with pulmonary embolism and acute eosinophilic pneumonia, found to have recurrent STAT5b N642H mutation by next-generation sequencing, suggesting possible underlying myeloid neoplasm.

Imaging algorithm for COVID-19: A practical approach.

The global pandemic of COVID-19 pneumonia caused by the novel coronavirus (SARS-CoV-2) has strained healthcare resources across the world with emerging challenges of mass testing, resource allocation and management. While reverse transcriptase-polymerase chain reaction (RT-PCR) test is the most commonly utilized test and considered the current gold standard for diagnosis, the role of chest imaging has been highlighted by several studies demonstrating high sensitivity of computed tomography (CT). Many have suggested using CT chest as a first-line screening tool for the diagnosis of COVID-19. However, with advancement of laboratory testing and challenges in obtaining a CT scan without significant risk to healthcare providers, the role of imaging in diagnosis has been questioned. Several imaging societies have released consensus statements and guidelines on utilizing imaging resources and optimal reporting. In this review, we highlight the current evidence on various modalities in thoracic imaging for the diagnosis of COVID-19 and describe an algorithm on how to use these resources in an optimal fashion in accordance with the guidelines and statements released by major imaging societies.

A Unique Case of Combined Nodular and Tracheobronchial Amyloidosis.

Amyloidosis is a heterogeneous group of diseases characterized by the extracellular deposition of misfolded proteins that can affect either systemically or locally confined to one system. Pulmonary amyloidosis is rare and can be classified into three forms according to the anatomic site of involvement: nodular pulmonary amyloidosis, tracheobronchial amyloidosis and diffuse alveolar-septal amyloidosis. The former two usually represent localized amyloid disease and the latter represents systemic disease. Typically lung parenchymal and tracheobronchial amyloidosis do not present together in localized forms of pulmonary amyloidosis. Here we report a unique case of localized pulmonary immunoglobulin light-chain amyloidosis, manifested as both parenchymal nodules and tracheobronchial amyloid deposition.