Radiological Category Pulmonary Principal Modality 1 Radiography Principal

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Radiological Category: Pulmonary Principal Modality (1): Radiography Principal Modality (2): CT Case Report #

Radiological Category: Pulmonary Principal Modality (1): Radiography Principal Modality (2): CT Case Report # 0841 Submitted by: Heng-Hsiao Liu, M. D. Faculty reviewer: Emma Ferguson, M. D. Date accepted: August 31, 2011

Case History 25 year old African American female with history of chronic cough and

Case History 25 year old African American female with history of chronic cough and occasional hemoptysis over the past year with increasing hemoptysis over the past few days.

Radiological Presentations Frontal view of the chest

Radiological Presentations Frontal view of the chest

Radiological Presentations Axial enhanced CT images of the chest

Radiological Presentations Axial enhanced CT images of the chest

Radiological Presentations Axial enhanced CT images of the chest

Radiological Presentations Axial enhanced CT images of the chest

Radiological Presentations Coronal enhanced CT images of the chest in soft tissue and lung

Radiological Presentations Coronal enhanced CT images of the chest in soft tissue and lung windows

Test Your Diagnosis Which of the following best characterizes the patient’s underlying heart disease?

Test Your Diagnosis Which of the following best characterizes the patient’s underlying heart disease? After your selection, go to next page. • Bacterial pneumonia • Tuberculosis • Lymphoma • Bronchioalveolar carcinoma

Findings and Differentials Findings: Radiograph of the chest reveals a right upper lobe opacity

Findings and Differentials Findings: Radiograph of the chest reveals a right upper lobe opacity with air bronchograms, upward displacement of the minor fissure and ill-defined faint right basilar opacities. CT shows masslike homogenous consolidation involving the central region of the right upper lobe but also with involvement of the right middle lobe. Although there is mild volume loss of the right upper lobe, a bulging fissure is seen along the posterior aspect of the right upper lobe. Bronchial artery collaterals are seen. Diffuse centrilobular opacities are seen within the remainder of the right lung and debris is noted along the right major bronchi consistent with hemorrhage (given the patient’s history of hemoptysis). Additionally, there is a homogenous, bilobed anterior mediastinal mass. Differentials: • Bacterial pneumonia • Tuberculosis • Bronchioalveolar carcinoma

Findings Central consolidation of the right upper lobe with upward displacement of the minor

Findings Central consolidation of the right upper lobe with upward displacement of the minor fissure (consistent with volume loss) and illdefined opacities of the right lung base.

Findings Homogenous consolidation of the right upper lobe without displacement of the vessels or

Findings Homogenous consolidation of the right upper lobe without displacement of the vessels or bronchi but with a bulging posterior fissure. Homogenous, bilobed, anterior mediastinal mass. Also note the presence of bronchial artery collaterals.

Findings Homogenous consolidation of the central right upper and middle lobes with ill-defined centrilobular

Findings Homogenous consolidation of the central right upper and middle lobes with ill-defined centrilobular ground glass opacities in the remainder of the right lung and debris in the right major bronchi.

Pathology The low power view (leftmost image) of the resected mediastinal mass demonstrates the

Pathology The low power view (leftmost image) of the resected mediastinal mass demonstrates the nodular pattern with intervening sclerosis which is typical of nodular sclerosing Hodgkin’s lymphoma. The medium power view (middle image) shows a close-up of the same pattern. The high power view (right small image) shows a classic binucleated Reed Sternberg cell.

Discussion A bulging fissure is classically associated with bacterial pneumonia, with the most common

Discussion A bulging fissure is classically associated with bacterial pneumonia, with the most common underlying infectious agents being Klebsiella pneumoniae and Pseudomonas aeruginosa, and less commonly with Streptococcus pneumoniae and Staphylococcus aureus. More rarely, this has been seen in association with tuberculosis and bronchioalveolar carcinoma. However, in our patient, this consolidation was seen with the additional finding of an anterior mediastinal mass. Given the young age of this patient and the homogenous soft tissue attenuation of the mass, lymphoma was the most likely possibility. Due to the patient’s repeated bouts of hemoptysis in the ICU, the patient was taken to the OR where her right middle and upper lobes as well as her anterior mediastinal mass were resected, all of which revealed Hodgkin’s disease. Pulmonary parenchymal involvement by Hodgkin’s disease is rare, accounting for 5 -11% of cases, seen bilaterally in 4%. It is more commonly seen in secondary or recurrent disease rather than primary disease, and is usually associated with mediastinal or nodal disease. There is an upper lobe predilection, and radiologic patterns include poorly defined nodules with or without cavitation, masslike consolidation, and atelectasis from an endobronchial or nodal disease.

Diagnosis Hodgkin’s lymphoma presenting as both an anterior mediastinal mass and mass-like consolidation

Diagnosis Hodgkin’s lymphoma presenting as both an anterior mediastinal mass and mass-like consolidation

References Francis JB, Francis PB. Bulging (sagging) fissure sign in Hemophilus influenzae lobar pneumonia.

References Francis JB, Francis PB. Bulging (sagging) fissure sign in Hemophilus influenzae lobar pneumonia. South Med J. 1978 Nov; 71(11): 1452 -3. Jung JI, Kim H, Park SH, Kim HH, Ahn MI, Kim HS, Kim KJ, Chung MH, Choi BG. CT differentiation of pneumonic-type bronchioloalveolar cell carcinoma and infectious pneumonia. Br J Radiol. 2001 Jun; 74(882): 490 -4. Guermazi A, Brice P, de Kerviler E E, Fermé C, Hennequin C, Meignin V, Frija J. Extranodal Hodgkin disease: spectrum of disease. Radiographics. 2001 Jan. Feb; 21(1): 161 -79.