0:00

Moving on to another case and this reminds

0:03

me of something I heard from my Radiology teachers

0:06

a while ago.

0:08

I was always taught your eyes do not see what your mind

0:11

does not know. So hopefully we'll open our minds to

0:14

another abnormality that we can identify or

0:17

we can encounter in clinical practice.

0:20

This was a Caucasian female had chronic pain and was

0:23

a total power internal nutrition within indwelling line.

0:27

And she was suffering from shortness of

0:30

breath and hypoxia.

0:31

So let me show you these CT images.

0:35

And let's try and run it from the beginning.

0:41

Hopefully this will work.

0:46

Right. Okay. There we go.

0:49

So here we starting from the Apex and we are

0:52

scrolling down.

0:54

And you can see what is the main finding that you

0:57

are seeing. Just try to try to capture.

1:01

the most pertinent abnormality you're seeing

1:04

on these CT images

1:06

I'm sure a lot of you might have picked up. There is

1:09

a fair amount of notillarity in the lungs and

1:12

it has this very tree input appearance.

1:15

So we have this tree in but not larity in the

1:18

lungs.

1:19

As you come more inferiorly you can start seeing there

1:22

is slightly more focal changes, which seem

1:25

to have the appearance of atelectasis.

1:28

So really the main finding here was treeing but

1:31

not a literally and we think about it the big things that

1:34

come to mind are infection and aspirations. So that's indeed what

1:37

was considered initially?

1:39

The patient had bronchoscopy, which was negative did not improve

1:42

over time.

1:43

Got to repeat CT this time of pect and

1:46

there were no embley, but the pulmonary arteries

1:49

were dilated.

1:51

So here are the long windows from the pect again,

1:54

you see that extensive tree, but not larity. This is

1:57

the mips scan or a map image and you can see that

2:00

all those tiny nodules are hard to pick up

2:03

but there are lots and lots of those in a tree and what distribution

2:07

so I want you to think about this question and let's bring up the question for

2:10

the poll.

2:11

We have negative bronchoscopies. We have this persistent

2:14

stream, but not a rarity. What do you think is the

2:17

most likely cause

2:18

is it infection aspiration some kind

2:21

of an airway process like diffuse band bronchiolitis obliterative

2:24

bronchiolitis, or is it a

2:27

vascular abnormality?

2:30

you

2:33

So, let's see we can get the results of the poll now.

2:41

Excellent. So everybody thinks it's vascular and that is

2:44

indeed the point of the case. I wanted to make sure

2:47

that we think about vascular tree

2:50

and bought in our differential when we see this kind of a pattern.

2:53

So like I said infection aspiration

2:56

a common causes of tree in bond, but in

2:59

this particular case the Persistence of these abnormalities, nothing

3:02

found clinically in terms of infection didn't

3:05

really go with these two findings.

3:08

among the every processes also things like diffuse band

3:11

bronchitis and obliterative bronchitis do

3:14

not do not make sense given the clinical setting they

3:17

are in

3:18

So really the answer is vascular and in fact,

3:21

if you pay attention to this, you can see a lot of these are indeed

3:24

along the vascular structures all of these tiny little

3:27

nodules.

3:28

And the point of this case is again to reiterate

3:31

the importance of considering vascularine, but not

3:34

literary.

3:36

So what are the various vascular causes of training

3:39

button? Let's think about it. You could have some kind of

3:42

vasculitis. So Grand lomatosis with polyangitis, you could

3:45

have pulmonary tumor embolism pulmonary capillary

3:48

hemantromatosis or excipient lung disease.

3:52

In this particular case the diagnosis was excipient lung disease

3:55

and let's use the process of elimination to get

3:58

rid of the other possibilities.

4:01

So if you think about vasculitis with granulomatosis and

4:04

polyangitis previously known as Wagner's you can

4:07

understand that those nodules that typically larger with Cavalry

4:10

Focus. So that doesn't really make sense in the scenario.

4:14

The patient doesn't have any prior or preexisting malignancy

4:17

to tell us about a pulmonary tumor embolism.

4:22

Pulmonary capillary hematomitosis is again a form of

4:25

pulmonary hypertension. However, in that case the

4:28

nodules are typically Central they're not so much as vascular training,

4:31

but they tend to be centrally lobular ground glass and

4:34

slightly larger nodules.

4:37

So here is in fact just to show you a companion case. This is a patient

4:40

with pulmonary capillary humanitosis. All of these are very

4:43

ground glass nodules distributed throughout the

4:46

lungs.

4:47

So going back what we are really talking about right now is

4:50

excipient lung disease.

4:52

And the idea behind this is the

4:55

patients will often take oral tablets that are

4:58

meant for oral ingestion. They will crush them and

5:01

use an IV injection.

5:04

And the problem is that whenever we have these oral

5:07

form of drugs. They often have some kind

5:10

of particulate materials which make it

5:13

easier for them to swallow and stuff like that. They're not meant

5:16

to be injected into a system into our IV system.

5:20

So once we do that it basically this

5:23

excipient material or this binder or

5:26

filler which could be talc or starch or cellulose. It

5:29

goes through the IV route

5:32

lodges in the pulmonary arterials and capillaries insights are

5:36

reaction and leads to pulmonary hypertension and that explains why

5:39

we have those dilated pulmonary arteries in this particular patient.

5:43

So the findings of central

5:46

lobular entry but nodules as he was seeing this was a vascular Tree

5:49

in but appearance along with the dilated pulmonary

5:52

arteries really helps us Clue Into excipient

5:55

lung disease.

5:56

Not to mention another factor that is really important to

5:59

recognize. This was a chronically ill patient

6:02

who had an interwelling line and these are the patients who are

6:05

most likely to do this who are most likely to crush

6:08

these tablets and do this.

6:10

And why would people actually inject this drugs

6:13

into their system? Well initially it

6:16

was seen in heroin addicts on methadone where

6:19

they found that they got a more intense effect if they

6:22

injected methadone tablets rather than consuming them

6:25

orally.

6:26

But then this practice kind of expanded to other

6:29

medications as well. It's a very very difficult condition to

6:32

diagnose. But again thinking about

6:35

the settings where the patients might do it and looking for

6:38

those Imaging findings we discussed about the tree but not

6:41

a rarity and dilated pulmonary arteries is really

6:44

is really key.

6:46

Again, definitive diagnosis is really lung

6:49

biopsy.