Case of

Case of
Cavitary
Cavitary
Lung Lesions
Lung Lesions
Following
Following
Pharyngitis
Pharyngitis
Courtney L. Lockhart, HMS III
Courtney L. Lockhart, HMS III
Harvard Medical School
Harvard Medical School
Gillian Lieberman, MD
Gillian Lieberman, MD
Our Patient: Initial Presentation
Our Patient: Initial Presentation
17
17
yo
yo
M presents with one
M presents with one
-
-
week
week
history of
history of
pleuritic
pleuritic
chest pain,
chest pain,
worse with inspiration
worse with inspiration
Our Patient: Cavitations on CXR
Our Patient: Cavitations on CXR
Two lung lesions in the anterior lung fields suggestive of cavitations (yellow). Mild
blunting of the costophrenic angles (blue) consistent with atelectasis or acute
pleural effusion.
PACS Childrens Hospital Boston
Cavitary
Cavitary
Lung Lesion
Lung Lesion

Pulmonary
Pulmonary
cavitary
cavitary
lesion
lesion

Air
Air
-
-
containing area surrounded by definitive wall
containing area surrounded by definitive wall

Wall thickness of at least 4mm

Wall thickness of at least 4mm

Sometimes mistaken for cysts which are thin

Sometimes mistaken for cysts which are thin
-
-
walled air
walled air
-
-
containing lesions
containing lesions

Cavity may also contain blood, pus, fluid, or

Cavity may also contain blood, pus, fluid, or
debris
debris
Cavitary
Cavitary
Lung Lesions on CXR and CT
Lung Lesions on CXR and CT

Imaging
Imaging

CXR
CXR

Initial test of choice for all cardiopulmonary
Initial test of choice for all cardiopulmonary
complaints
complaints

Defined area of increased
Defined area of increased
lucency
lucency
surrounded by
surrounded by
rim of density
rim of density

Limitations: small lesions may be missed, limited
Limitations: small lesions may be missed, limited
characterization
characterization

Chest CT
Chest CT

10
10
-
-
20 times more sensitive for evaluation of lung
20 times more sensitive for evaluation of lung
nodules of all types
nodules of all types

Provides more detail of lung parenchyma
Provides more detail of lung parenchyma

Provides better characterization and localization of
Provides better characterization and localization of
lesions
lesions
Our Patient: Nodular Lesions on
Our Patient: Nodular Lesions on
Axial Chest CT
Axial Chest CT

Axial Chest
Axial Chest
CT
CT

Non
Non
-
-
cavitary
cavitary
peripheral
peripheral
lung nodule
lung nodule
in right
in right
upper lobe
upper lobe

Evolving
Evolving
cavitation
cavitation
within
within
nodule
nodule
along left
along left
major
major
fissure
fissure
PACS Childrens Hospital Boston

Axial Chest
Axial Chest
CT
CT

Peripheral
Peripheral
cavitary
cavitary
lung
lung
lesion in
lesion in
the left
the left
lobe
lobe
Our Patient:
Our Patient:
Cavitary
Cavitary
Lesions on
Lesions on
Axial Chest CT
Axial Chest CT
PACS Childrens Hospital Boston
Our Patient:
Our Patient:
Cavitary
Cavitary
Lesion on
Lesion on
Coronal Chest CT
Coronal Chest CT

Coronal CT
Coronal CT

Peripheral
Peripheral
cavitary
cavitary
lung lesion
lung lesion
in the left
in the left
upper lobe
upper lobe
PACS Childrens Hospital Boston
Differential Diagnosis
Differential Diagnosis

Differential
Differential
Dx
Dx
for
for
cavitary
cavitary
nodules
nodules

C
C

Carcinoma
Carcinoma

typically
typically
squamous
squamous
,
,
mets
mets
,
,
lymphomas
lymphomas

A
A

Autoimmune
Autoimmune

Wegener
Wegener

s
s
granulomatosis
granulomatosis
,
,
rheumatoid nodules
rheumatoid nodules

V
V

Vascular
Vascular

emboli (septic or bland)
emboli (septic or bland)

I
I

Infection
Infection

lung abscess, bacterial pneumonia,
lung abscess, bacterial pneumonia,
fungal pneumonia, TB,
fungal pneumonia, TB,
hydatid
hydatid
cysts (parasitic
cysts (parasitic
infections)
infections)

T
T

Trauma
Trauma

lung laceration
lung laceration

Y
Y

Young (congenital)
Young (congenital)

cystic
cystic
adenomatoid
adenomatoid
malformation, sequestration,
malformation, sequestration,
bronchogenic
bronchogenic
cyst
cyst
MedPix Medical Image Database
Narrowing the Differential of
Narrowing the Differential of
Cavitary
Cavitary
Lung Lesions
Lung Lesions

Characterization of
Characterization of
cavitary
cavitary
lung lesions
lung lesions

Focal or multifocal v. diffuse

Focal or multifocal v. diffuse

Wall thickness
Wall thickness

Contour of inner lining (irregular or smooth)

Contour of inner lining (irregular or smooth)

Nature of contents
Nature of contents

Location
Location

Clinical parameters
Clinical parameters

Rapidity of disease process

Rapidity of disease process

Clinical context
Clinical context
Ryu Ryu, Jay, et al. Mayo , Jay, et al. Mayo Clin Clin Proc. 2003; 78:744 Proc. 2003; 78:744- -752 752
Our Patient: History and Physical Exam
Our Patient: History and Physical Exam

HPI Continued
HPI Continued

1 week of sore throat, fever, pain, rigors
1 week of sore throat, fever, pain, rigors

Throbbing HA,
Throbbing HA,
hematuria
hematuria
,
,
n/v/d
n/v/d

Right flank pain
Right flank pain

Bilateral knee pain
Bilateral knee pain

Physical Exam
Physical Exam

VS: T 37.1 BP 124/68 P 80 RR 20 O2Sat 95%RA
VS: T 37.1 BP 124/68 P 80 RR 20 O2Sat 95%RA

Erythematous
Erythematous
,
,
exudative
exudative
oropharynx
oropharynx
,
,
shotty
shotty
LAD
LAD

Diminished breath sounds over right lung base
Diminished breath sounds over right lung base

CVA tenderness bilaterally
CVA tenderness bilaterally
Our Patient:
Our Patient:
Lymphadenopathy
Lymphadenopathy
on
on
Coronal Chest CT
Coronal Chest CT

Coronal Chest
Coronal Chest
CT
CT

Peribronchial
Peribronchial
lymph node in
lymph node in
the
the
mediastinum
mediastinum
PACS Childrens Hospital Boston
Our Patient:
Our Patient:
Cavitary
Cavitary
Lung Lesion
Lung Lesion
on Axial Chest CT
on Axial Chest CT

Axial Chest
Axial Chest
CT
CT

Medial
Medial
cavitary
cavitary
lung
lung
lesion in
lesion in
right lobe
right lobe
anterior to
anterior to
pericardium
pericardium
PACS Childrens Hospital Boston
Our Patient:
Our Patient:
Cavitary
Cavitary
Lung Lesion
Lung Lesion
on Axial Chest CT Lung Window
on Axial Chest CT Lung Window

Axial Chest
Axial Chest
CT
CT

Medial
Medial
cavitary
cavitary
lung
lung
lesion
lesion
anterior to
anterior to
pericardium
pericardium
at the end of
at the end of
pulmonary
pulmonary
vessel
vessel
PACS Childrens Hospital Boston
Our Patient:
Our Patient:
Cavitary
Cavitary
Lung Lesion
Lung Lesion
on Axial and
on Axial and
Sagittal
Sagittal
Chest CT
Chest CT


Chest CT
Chest CT
Same medial lung Same medial lung cavitation cavitation
anterior to the pericardium anterior to the pericardium
Inferior section showing intact Inferior section showing intact
pericardium pericardium
PACS Childrens Hospital Boston
PACS Childrens Hospital Boston
Our Patient: Lab Results
Our Patient: Lab Results

CBC
CBC

WBC 9.14, RBC 4.28 (

WBC 9.14, RBC 4.28 (
Hct
Hct
36.7%),
36.7%),
Plt
Plt
452
452

Urine
Urine

Turbid, pH 7.0, 2+ blood, 10

Turbid, pH 7.0, 2+ blood, 10
-
-
20 RBC/
20 RBC/
hpf
hpf

Blood culture
Blood culture

Positive for gram negative rods

Positive for gram negative rods
Diagnosis????
Diagnosis????
Lemierre
Lemierre

s
s
Disease
Disease

Also known as post
Also known as post
-
-
anginal
anginal
sepsis
sepsis
characterized internal jugular vein septic
characterized internal jugular vein septic
thrombophlebitis
thrombophlebitis

Characteristically seen in adolescents or
Characteristically seen in adolescents or
young adults
young adults

Sepsis following a
Sepsis following a
tonsillar
tonsillar
or
or
peritonsillar
peritonsillar
infection
infection

May also be preceded by
May also be preceded by
mastoiditis
mastoiditis
,
,
cellulitis
cellulitis
or
or
odontogenic
odontogenic
infection
infection

Spread via lymphatic and venous systems
Spread via lymphatic and venous systems
into the lateral pharyngeal space
into the lateral pharyngeal space
Lemierre
Lemierre

s
s
Disease Continued
Disease Continued

Classically caused by
Classically caused by
Fusobacterium
Fusobacterium
necroporum
necroporum

Staph, Strep,
Staph, Strep,
Eikinella
Eikinella
,
,
Bacteroides
Bacteroides
are other
are other
causative organisms
causative organisms

Sore throat, fever, rigors, productive cough w/
Sore throat, fever, rigors, productive cough w/
blood
blood
-
-
tinged sputum, neck swelling along the
tinged sputum, neck swelling along the
sternocleidmastoid
sternocleidmastoid
m.
m.

Reports of carotid rupture,
Reports of carotid rupture,
dysphagia
dysphagia
, Horner
, Horner

s
s
syndrome, and
syndrome, and
trapezius
trapezius
paralysis during initial
paralysis during initial
spread to the internal jugular vein
spread to the internal jugular vein

Metastatic abscesses to the lungs, pleura, joints, and
Metastatic abscesses to the lungs, pleura, joints, and
soft tissues
soft tissues

Pleuritic
Pleuritic
chest pain,
chest pain,
dyspnea
dyspnea
,
,
hepatomegaly
hepatomegaly
,
,
jaundice, joint pain, encephalopathy,
jaundice, joint pain, encephalopathy,
hematuria
hematuria
Head and Neck Anatomy
Head and Neck Anatomy
Peritonsillar
Peritonsillar
Abscess on Head CT
Abscess on Head CT

Head and Neck CT with
Head and Neck CT with
contrast
contrast

Low
Low
-
-
attenuation mass
attenuation mass
with a minimally
with a minimally
enhancing wall in the
enhancing wall in the
right
right
peritonsillar
peritonsillar
region
region

Associated edema, mild
Associated edema, mild
compression of the
compression of the
internal carotid and
internal carotid and
internal jugular vein, and
internal jugular vein, and
deviation of the airway
deviation of the airway
are present.
are present.
*
Emerg Med 37(5):18-47, 2005
Examination of Internal Jugular Vein
Examination of Internal Jugular Vein

Ultrasound
Ultrasound

Test of choice: Cost effective, easily accessible,

Test of choice: Cost effective, easily accessible,
real
real
-
-
time evaluation, no radiation
time evaluation, no radiation

Lumenal
Lumenal
for dilatation, filling defect and flow
for dilatation, filling defect and flow

Thrombophlebitis
Thrombophlebitis
:
:
Echogenicity
Echogenicity
within a
within a
dilated lumen; decreased
dilated lumen; decreased
compressibilty
compressibilty

CT
CT

Rapid test, more sensitive in the evaluation of

Rapid test, more sensitive in the evaluation of
fresh thrombus and additional pathology
fresh thrombus and additional pathology

Better visualization of anatomy

Better visualization of anatomy

Thrombophlebitis
Thrombophlebitis
: Low
: Low
attentuation
attentuation
of filling
of filling
defect with soft tissue swelling
defect with soft tissue swelling
Our Patient: Internal Jugular Vein
Our Patient: Internal Jugular Vein
Ultrasound
Ultrasound
IJV Ultrasound
- IJV lumen with and without
compression
- Normal lumenal diameter
- Full compression with probe
- IJV flow for stasis or filling defect
- Normal flow with no filling defects
PACS Childrens Hospital Boston
PACS Childrens Hospital Boston
Companion Patient:
Companion Patient:
Thrombosed
Thrombosed
Internal Jugular Vein Ultrasound
Internal Jugular Vein Ultrasound

IJV Ultrasound
IJV examination for
stasis or filling defect

Filling defect with
disruption of flow

IJV Ultrasound
IJV lumen

Increased lumenal diameter

Echogenic foci within the
lumen
Courtesy of Dr. D. Ferris, PACS Childrens Hospital Boston
Courtesy of Dr. D. Ferris, PACS
Childrens Hospital Boston
Our Patient: Treatment and Outcome
Our Patient: Treatment and Outcome
Patient treated with long course of
Patient treated with long course of
high dose antibiotic
high dose antibiotic
Follow
Follow
-
-
up CXR was normal
up CXR was normal
Take Home Points
Take Home Points

Lemierre
Lemierre

s
s
disease is an easily forgotten
disease is an easily forgotten
DDx
DDx
even when characteristic signs and
even when characteristic signs and
symptoms are present
symptoms are present

Blood cultures and radiological
Blood cultures and radiological
examination of IJV and effected organs are
examination of IJV and effected organs are
essential to confirm diagnosis and assess
essential to confirm diagnosis and assess
the extent of disease
the extent of disease

Our patient had a good outcome but most
Our patient had a good outcome but most
are fatal, though mortality has decreased
are fatal, though mortality has decreased
in the era of antibiotic use
in the era of antibiotic use
Take Home Points Continued
Take Home Points Continued

CT is the best imaging modality for
CT is the best imaging modality for
characterizing cystic or
characterizing cystic or
cavitary
cavitary
lung
lung
lesions
lesions

US is the most convenient, cost effective,
US is the most convenient, cost effective,
and rapid imaging modality for evaluation
and rapid imaging modality for evaluation
of thrombus in vessels of the neck,
of thrombus in vessels of the neck,
especially in the pediatric population
especially in the pediatric population

Neck CT is the test of choice when neck
Neck CT is the test of choice when neck
pathology such as abscess or tumor is
pathology such as abscess or tumor is
suspected
suspected
Acknowledgments
Acknowledgments

Dr. Diane Ferris, BIDMC Radiology
Dr. Diane Ferris, BIDMC Radiology
Resident
Resident

Dr. Katie Taylor, CHB PGYI
Dr. Katie Taylor, CHB PGYI

Dr. Amanda
Dr. Amanda
Growdon
Growdon
, CHB Attending
, CHB Attending

Dr. Lieberman, Radiology Clerkship
Dr. Lieberman, Radiology Clerkship
Director
Director
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