Chest differentials
Terms
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- Alveolar disease
-
Common
--pneumonia
--aspiration
--pulmonary edema
--pulmonary hemorrhage
less common
* TB, fungus, sarcoid
* BAC, lymphoma
* Alveolar proteinosis
* COP, eosinophilic PNA - Peripheral consolidation
-
BOOP
eosinophilic PNA
pulmonary infarcts
vasculitis
septic emboli and mets - Pulmonary hemorrhage
-
anticoagulation, hemophilia
contusion, PE
vasculitis (Goodpasture’s, Wegener’s), CVD
infectious (TB, GNB, Aspergillus, Mucor)
drugs
bronchiectasis
tumor - Interstitial
-
Edema
Infection (viral/Mycop, TB, fungi, PCP)
Pulm fibrosis
Sarcoid
*lymphangitic spread of CA
*EG
*AS, CVD, hypersens pneumonitis
*drugs
*silicosis, asbestos, talc
*LAM, RTx, KS, LIP, BOOP, eosinophilic PNA, NF - Interstitial upper lung zone
-
* CF (not interstitial dz)
* Ankylosing spondylitis
* sarcoid
* silicosis
* EG
* TB
* PCP
chronic hypersensitivity pneumonitis, radiation fibrosis, chronic fungal infection - Interstitial dz lower lung zone
-
BADASS –
Bronchiectasis
Aspiration (chronic)
Drugs
Asbestosis
Scleroderma/rheumatoid lung
Sarcoid
IPF, neurofibromatosis - Kerley B lines
-
CHF
lymphangitic spread of CA
less common – viral, asbestos, sarcoid, lymphoma - Pulmonary fibrosis
-
IPF
Sarcoid
Pneumoconiosis, talc
Histiocytosis
CVD
Radiation
Drugs
Chronic hypersens pneumonitis -
Lymphangitic carcinomatosis
What are the common primaries? -
Lung
Breast
Stomach
Pancreas
Prostate
Thyroid - Hematogenous pulmonary mets
-
lung
breast
kidney
thyroid
colon
uterus
head&neck
testes
melanoma
lymphoma
osteosarcoma - Solitary pulmonary nodule
-
Inflamm - Granuloma/abscess/scar
Neoplasm- lung or mets
hamartoma
AVM, hematoma, infarct
chest wall lesion, nipple shadow
bronchial adenoma, bronchogenic cyst
rheum nodule, plasma cell granuloma
fissural pseudotumor
rounded atelectasis, round PNA
carcinoid
sequestration - Multiple nodules
-
Mets, lymphoma (usu NHL)
Granuloma (TB, fungi, sarcoid)
AVMs
Nocardia, parasite, septic emboli (S aureus)/ abscesses
Rheumatoid nodules, Wegener’s
Trauma-hematoma/healed rib fxs
Silicosis
KS, Langerhans, PTLD -
Miliary nodules
(3-5mm) -
*TB, fungi (esp histo)
*mets (melanoma, RCC, chorioCA, thyroid)
*sarcoid, histiocytosis X
*varicella
*silicosis, talc, alveolar microlith (1mm) - Calcified nodules
-
*Mets (thyroid, mucinous, osteogenic)
*varicella, TB, histo, cocci
*silicosis, alveolar microlith - Peribronchovascular nodules
-
sarcoid
LC
KS
lymphoma - Large thoracic mass
-
tumor (bronchogenic CA, lymphoma, mets)
infection (abscess, round PNA)
rounded atelectasis
sequestration
hematoma
extrapulmonary – fibrous tumor of pleura, loculated effusion, chest wall mass, mediast mass, AAA - Adenopathy
-
LOW DENSITY –
TB / fungal infx esp in AIDS, necrotic mets, lymphoma, seminoma
VASCULAR –
Castleman’s, vascular mets (carcinoid, small cell, KS, RCC, thyroid, melanoma, chorioCA)
CALCIFIED-
TB, fungal, sarcoid, silicosis, lymphoma post RTx
intrathoracic nodal mets –
GU (renal, test), head/neck (skin, larynx, thyroid), breast, melanoma, KS - Eggshell calcifications in hilar nodes
-
silicosis
Coal workers' pneumoconiosis
Treated lymphoma
Granulomatous dz [Sarcoid (rare)] - Conglomerate masses
-
silicosis
CA
TB
fungus
sarcoid
berylliosis - Mediastinal widening
-
enlarged thyroid
malignant adenopathy
tortuous brachiocephalic vessels or aorta
mediastinal hemorrhage
fatty deposition (mediastinal lipomatosis)
mediastinitis
lymphoma, lung CA, thymic lesion, teratoma - Hilar mass
-
-TB / fungal / sarcoid
-mets / lymphoma
-PA enlargement
UNILATERAL
-Castleman’s
-bronchogenic cyst
BILATERAL
-silicosis - Superior mediastinal mass
-
* Thyroid or parathyroid
* Adenopathy
* Cystic hygroma
* Lymphoma, mets
* Vascular - Anterior mediastinal mass
-
thymic lesion (thymoma)
lymphoma (Hodgkin’s)
germ cell tumor (teratoma)
thyroid (intrathoracic goiter)
vascular (aneurysm), bronchogenic cyst, lymphangioma, hemangioma - Middle mediastinal mass
-
thyroid (intrathor goiter)
esophageal lz (leiomyoma, duplic cyst)
bronchogenic cyst
pericardial cyst
vascular (aneurysm, aberrant vessel)
mets (head/neck, GU, breast, melanoma)
lung CA (small cell)
lymphoma / leukemia
KS
TB, fungus, sarcoid
hiatal hernia
Castleman’s disease - Posterior mediastinal mass
-
NEUROGENIC (neurofibroma, schwannoma, ganglioneuroma, neuroblastoma, pheo, paraganglioma)
*ant or lat thoracic meningocele
*bronchogenic, gastroenteric, neuroenteric cyst
TB spine
paraspinal lymphoma
vascular, hematoma
extramedullary hematopoeisis
Bochdalak hernia
sequestration
mets, sarcoid - Fatty mediastinal mass
-
mediastinal lipomatosis
hernia
lipoma, liposarcoma
thymolipoma
teratoma - Densely enhancing mediastinal mass
- vascular, hypervascular tumors, goiters, Castleman’s
- Cardiophrenic angle mass
-
* Fat pad (most common)
* Pericardial cyst
* Morgagni hernia
* Lymphoma, mets, lung CA, - Cyst
-
traumatic cyst, hematoma cyst, bronchogenic cyst, hydatid cyst, emphysematous bullae, bronchiectasis, end-stage interstitial disease, sequestration, CAM, pneumatocele
small cystic dz – EG, LAM, cystic PCP, honeycombing, emphysema - Cavity
-
*abscess (Staph, Klebs, E coli, Pseudomonas, anaerobes)
*lung CA (usu sq cell)
*TB, fungus (blasto, cocci, histo)
*Nocardia, 2ary Aspergillus infxn of cavity
*septic emboli (Staph aureus), lymphoma (Hodgkin’s), rheumatoid nodule, Wegener’s, large hiatal hernia, silicosis, lymphomatoid granulomatosis, parasites - Air crescent sign in cavity
-
Aspergillus
Mucor
Actinomycosis
septic emboli
Klebsiella
TB
tumors (KS) - Endobronchial
-
tumor (usu sq cell > small cell, carcinoid)
mets
TB
hamartoma, papilloma, hemangioma
foreign body, mucus plug, trauma - Bronchiectasis
-
-postinfectious (most common)
-obstruction (CA, FB),
-congenital (CF, Kartageners, immotile cilia syndr)
upper lobe – CF, TB, RTX, ABPA - Mucoid (bronchial) impaction
-
CF
asthma
ABPA
congenital bronchial atresia - Tracheal lumen
-
BIG - tracheobronchomegaly, pulm fibrosis, tracheomalacia
SMALL – saber-sheath (COPD), tracheomalacia, relapsing polychondritis, sarcoid, amyloid, Wegener’s, TB and fungal stenosis, tracheopathia osteochondroplastica - Scarring
- prior TB, prior pneumonia, prior PE, prior trauma, prior surgery, radiation, fibrosis
- Calcification
- granuloma (TB, fungus), hamartoma, lung CA, vascular, pleural (asbestos exposure, prior pyothorax or hemothorax), sarcoid, silicosis, varicella, mitral stenosis, mets (bone tumor, mucinous tumors, post-chemotherapy), alveolar microlithiasis, parasites
- Air fluid level
-
lung (abscess, tumor, cyst)
mediastinum (esophageal lesion, bronchogenic cyst)
pleural (hydroPTX, hemoPTX, pyoPTX)
hiatal hernia
achalasia - Atelectasis
-
*poor diaphragm movmt, hypoventilation, PE
*central obstruction
– endobronchial (CA, mucus plug, forn body)
- extrinsic (large LNs, heart, aneurysm, mediast mass)
*periph obstr – PNA, post-op (LLL after cardiac surg)
*compression – pleural fluid, PTX
*contraction – scarring - chronic TB, pulm fibrosis - Complete opacification of one hemithorax
-
- complete atelectasis (broncho CA, muc plug, lo ETT)
- large effusion (mets, lymphoma)
- prior pneumonectomy
- mesothelioma
- unilateral PNA or pulm edema - PTX
-
- emphysema (ruptured bulla)
- trauma (rib fx, rupt bronch)
- iatrogenic / ventilator
- chronic interstitial lung dz or pneumoconiosis
- spontaneous
- bronchopleural fistula
- infection (Staph, PCP)
- neoplasm (met osteosarc)
- LAM
- EG
- asthma
- catamenial - Pneumomediastinum
-
asthma
trauma
alveolar rupture
ruptured bronchus or esophagus
post endoscopy
Boerhaave syndrome
pos pressure ventilation
chest tube placement
ruptured abdominal viscus
post surgical
pneumo(retro)peritoneum - Chylothorax
-
tumor (esp lymphoma)
trauma
LAM
filariasis
iatrogenic
idiopathic - Pleural mass
-
mesothelioma
benign fibrous tumor
malignant thymoma/lymphoma
mets (esp lung CA)
lipoma
rib tumors (kids–EG, ABC, Ewing’s, neuroblast;
adults– mets>myel>Paget’s, FD)
infection (TB, fungus, Actino)
asbestos-related
trauma / surgery - Calcified pleural plaques
-
TB
asbestos exposure
fluid (empyema, hematoma)
talc - Pleural thickening + calcification
-
old infection or trauma
asbestos exposure
loculated effusion /empyema
pleural mets
mesothelioma
talc - Extrapleural lesions
-
*CA (mets, myeloma, esp rib mets)
*infection (TB, fung, Actino)
*trauma (hematoma)
*diaphr rupture or paralysis
*pectus excavatum
*kyphoscoliosis
*cervical ribs /congen fusion of ribs - Elevated diaphragm
-
localized eventration
atelectasis
subpulmonic effusion
diaphragmatic paralysis
hernia (hiatal, Morgagni, Bochdalek)
ascites
subphrenic mass
pleural mass - Oligemia and/or overinflation
-
infection (TB, Staph pneumatocele, viral, parasite)
pulmonary HTN
asthma, emphysema, bullae
lobar atelect w/compensatory hyperinfl
Swyer-James syn (unilat lucent small lung)
PE (Westermark’s sign)
foreign body or mucus plug (air trapping)
lung hypoplasia
scimitar syndrome
mastectomy
congenital bronchial atresia
congenital lobar emphysema
Poland’s syn (cong absence of pec muscle)
PA stenosis/hypoplasia - Bronchiolitis obliterans
-
postinfectious
CVD (esp RA)
toxic fumes
post transplant (BMT)
lymphoma
lung CA
idiopathic - Mosaic attenuation (air trapping)
-
BO
sarcoid
hypersensitivity pneumonitis
chronic PE
asthma
emphysema - Small lung
-
hypogenetic lung syndrome
PA agenesis
chronic atelectasis
BO - Small hilum
-
PA compression/invasion/hypoplasia
lobar atelectasis/resection
emphysema - Enlarged cardiac silhouette
-
cardiomegaly
pericardial effusion - SVC syndrome
-
bronchogenic CA (#1)
lymphoma, mets
long term IV devices
fibrosing mediastinitis - Chronic airspace disease
-
bronchioloalveolar CA
lymphoma
alveolar proteinosis
alveolar sarcoid
lipoid PNA
BOOP
eosinophilic PNA - ground glass opacity on HRCT
-
Edema
Infection (PCP, bacterial alveolitis, viral pneumonitis)
hypersensitivity pneumonitis
BOOP
eosinophilic PNA
alveolar proteinosis
hemorrhage
lupus - reticulonodular pattern on HRCT
-
pulmonary edema
viral, mycoplasma, PCP
lymphangitic spread
fibrosis (IPF/drugs/RTx/CVD)
asbestosis - nodular pattern on HRCT
-
hematogenous infection or mets
sarcoid
pneumoconiosis (silicas, CWP)
EG - Cystic pattern on HRCT
-
LAM
cystic PCP
EG
honeycombing (IPF, any end-stage ILD) - interlobular septal thickening on HRCT
-
CHF
lymphangitic spread
alveolar proteinosis
sarcoid - centrilobular nodules on HRCT
-
endobronchial spread of infection or tumor (TB, MAI, bronchoPNA)
airways disease (CF, bronchiectasis, TB, MAI)
hypersensitivity pneumonitis
silicosis
histiocytosis
BOOP
pulmonary edema
talc - tree-in-bud on HRCT
-
endobronchial spread of infection
airways disease - perilymphatic nodules on HRCT
-
sarcoid
silicosis
lymphangitic spread - diffuse random nodules on HRCT
-
miliary TB
fungus
mets -
Ddx -
Bilateral ground glass opacity emanating from hila at bases -
PCP
Hypersensitivity
COP
Hemorrhage - freve
- frvf