Radiology Rounds – 8/22/23

Time for #RadiologyRounds! This week we have a man in his 70s with CLL s/p treatment now in remission. He had fevers, a dry cough, and malaise that initially improved outpatient with antibiotics but have now recurred.

Check out the video of his CT scan here

The CT had multiple findings including small nodules, consolidations, and bands of fibrosis around the secondary pulmonary nodules. This is known as Arcade-Like Sign and has classically been described with COP. While it can make you think COP, it has a low sensitivity

The patient underwent bronchoscopy with Tbbx given the suspicion for OP. The BAL was negative for bacterial, viral, fungal, or mycobacterial infection. The histopathology revealed organizing pneumonia. The patient was started on glucocorticoids and all symptoms improved

Radiology Rounds – 5/30/2023

A middle-aged man with metastatic esophageal cancer presents with 2 weeks of low-grade fevers and more recently progressive dyspnea. His exam is notable for late inspiratory crackles throughout the right lung.

A bronchoscopy was performed and an expanded infectious panel was sent and all were negative, as were serum infectious studies (e.g. histoplasmosis ag, urine legionella etc). A trans bronchial biopsy showed plugs of granulation tissue filling the alveolar spaces

He was treated with steroids but her hypoxemia progressed and she was ultimately intubated. What is your treatment of choice for refractory ICI pneumonitis?

Severe ICI is rare and the treatment for steroid refractory disease is still based on small series and case reports This patient was treated with high-dose steroids (2mg/kg), IVIG, MMF, and tocilizumab. With that, he improved after 10 days intubated and was weaned to room air.

40. Pulm PEEPs and ATS RCMB Assembly: Short Telomeres and Interstitial Lung Disease

This week on Pulm PEEPs we are thrilled to share a collaboration with the American Thoracic Society Assembly on Respiratory Cell & Molecular Biology. We are joined by two expert members of the ATS RCMB Assembly who have done basic and translational research in respiratory biology and lung disease. We explore the topic of Short Telomeres and their role in lung disease. With the annual ATS Conference just around the corner, this is a great intro episode for everyone from aspiring researchers and clinical pulmonologists.

Meet The Guests

Mark Snyder is an Assistant Professor of Medicine at the University of Pittsburgh Medical Center, and a member of the Graduate Program in Microbiology and Immunology there. He does research on the role of the adaptive immune system’s role in chronic rejection after lung transplantation and has received both a Parker B Francis Foundation award and an NIH K23 grant for this work.

Jonathan Alder is an Assistant Professor of Medicine at the University of Pittsburgh. His research focuses on telomeres and their role in human health and disease. He is an accomplished researcher, was a Parker B Francis fellow, and now has an NIH RO1 studying Telomere-mediated Lung disease.

Further Reading and References

Alder JK, Armanios M. Telomere-mediated lung disease. Physiol Rev. 2022 Oct 1;102(4):1703-1720. doi: 10.1152/physrev.00046.2021. Epub 2022 May 9. PMID: 35532056; PMCID: PMC9306791.

Alder JK, Chen JJ, Lancaster L, Danoff S, Su SC, Cogan JD, Vulto I, Xie M, Qi X, Tuder RM, Phillips JA 3rd, Lansdorp PM, Loyd JE, Armanios MY. Short telomeres are a risk factor for idiopathic pulmonary fibrosis. Proc Natl Acad Sci U S A. 2008 Sep 2;105(35):13051-6. doi: 10.1073/pnas.0804280105. Epub 2008 Aug 27. PMID: 18753630; PMCID: PMC2529100.

Armanios MY, Chen JJ, Cogan JD, Alder JK, Ingersoll RG, Markin C, Lawson WE, Xie M, Vulto I, Phillips JA 3rd, Lansdorp PM, Greider CW, Loyd JE. Telomerase mutations in families with idiopathic pulmonary fibrosis. N Engl J Med. 2007 Mar 29;356(13):1317-26. doi: 10.1056/NEJMoa066157. PMID: 17392301.

Radiology Rounds – 4/25/2023

Today’s #RadiologyRounds is a reminder that pulmonary care extends beyond the lungs! Although we’ll have a CT chest too

A 70-year-old woman with a diagnosis of seronegative RA presents with progressive dyspnea. PFTs show a moderate restrictive defect and moderately reduced DLCO. Here is the CT scan:

The CT was interpreted as indeterminate for UIP / fibrosing NSIP. The basilar and subpleural fibrosis and honeycombing are consistent with UIP, but with reticular nodular infiltrates and pleural effusions that are less consistent. In reviewing her history: RF, CCP, and anti-SCL70 were all negative. On hand exam, she had MCP enlargement, some PIP synovitis, and slight R hand ulnar deviation. She did not have clear telangiectasias. She had a history of GERD. She denied Raynauds. She had significant skin thickening over her legs and limited ankle mobility. X-rays were obtained:

This showed severe dystrophic calcifications and no bony erosions. This degree of extensive dystrophic calcifications is consistent with scleroderma and the patient was felt to have limited scleroderma, and possibly an overlap syndrome

The patient was started on MMF as the initial agent based on the Scleroderma Lung Study II (SLSII): Glucocorticoids were avoided given the risk of scleroderma renal crisis with steroids. An anti-fibrotic was also considered but not started as 1st line.

Radiology Rounds – 10/11/22

For #RadiologyRounds this week we have a mystery case from the pulmonary clinic complete with imaging and exploration of PFTs. Follow along for some great clinical pearls and teaching points about lung function tests. Graphics made with the help of outstanding educator Kaitlin Seitz.

What imaging views would you get next?

A) Supine and prone

B) Inspiratory and expiratory

C) High resolution

D) With contrast

What test would you get next?

A) Bronchoscopy



D) Lung US

What do these PFTs show?

A) Restriction concerning for ILD

B) Restriction concerning for obesity

C) Restriction concerning for weakness

D) Mixed obstruction and restriction

The patient was referred to neurology and ultimately diagnosed with severe mixed sensory and motor chronic axonal polyneuropathy.

Radiology Rounds – 6/14/22

This week on #RadiologyRounds we are extremely excited to share a case brought to you by one of our new Associate Editors, Leon Mirson! Enjoy, and follow us on Twitter and Instagram for content delivered to you weekly!

What abnormalities do you see on this CXR to help explain the patient’s presentation?

The CT scan has reticular changes consistent with interstitial lung disease and there are multiple features that help us define the pattern of the ILD. His CT notably has very few ground-glass opacities, there is traction bronchiectasis, and honeycombing with a basilar and peripheral / sub-pleural predominance.

Taking all these features together, the patient’s radiographic presentation is consistent with Usual Interstitial Pneumonia (UIP)

This patient had a thorough history taken and he had no prior smoking and no occupational or environmental exposures of significance. He had no family history of interstitial lung disease. A broad history was taken regarding symptoms of connective tissue disease and a broad serologic workup was sent, all of which were unremarkable. What would you want to do next diagnostically?

If you want to learn more about diagnosing interstitial lung disease, listen to our prior Top Consults episode on diagnosing ILD with experts in the field and see these prior #RadiologyRounds on Fibrotic NSIP and Sarcoidosis.

Radiology Rounds – 4/5/22

We have another #RadiologyRounds for you today! You are seeing a new patient in the clinic with dyspnea who brings in prior CT chest imaging. A representative coronal image is shown.

In addition to bullous disease, you see bilateral honeycombing with evidence of fibrosis primarily in the upper lung fields.

As part of your evaluation, an EBUS is performed showing the following representative lymph node tissue pathology.

We had evidence of noncaseating granulomas, evidence of fibrocystic changes on chest imaging, and we excluded other causes of granulomatous disease. Given his symptoms and clinical context, we were concerned about Stage IV pulmonary sarcoidosis which can be categorized below.

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