0:00

So let's talk about random nodules again, I talked about

0:03

before, these are tropic nodules, hematogenous.

0:06

And so again,

0:07

they do not respect the secondary pulmonary lo anatomy.

0:11

So here is a diagram of the right lower lobe,

0:14

which I don't know whether it'd be proud or ashamed of this.

0:16

You know, I, I created this myself.

0:18

Uh, this was a little bit while ago, uh, when I thought

0:21

that maybe I could be an artist,

0:22

but as you can tell, I should probably stick to my day job.

0:24

But here's my diagrammatic

0:26

representation on the right lower lobe.

0:27

So these random nodules, again, they don't care.

0:29

They don't care what the in lab or SEP are.

0:31

They don't care what the subpleural lung is.

0:33

They're just gonna go wherever they want.

0:35

And so when these random nodules are profuse enough,

0:38

they will involve the subpleural lung

0:40

because again, even subpleural lung needs blood.

0:42

And so blood goes there.

0:43

Random nodules will go there

0:45

because random nodules are from hematogenous spread.

0:48

And so here's a real life example here.

0:50

This is a MIP of the right upper lobe.

0:52

We see beautiful examples of these random nodules.

0:55

Some are closer together, some are further apart.

0:58

So these are truly entropic.

1:00

There's no rhyme

1:01

or reason why these nodules are where they are.

1:04

And very commonly with hematogenous metastases,

1:07

and I'm sure you you guys remember this, some

1:09

of these nodules can be bigger than others.

1:10

So some are, there are variable sizes.

1:12

'cause presumably those mets have gone

1:13

there at variable times.

1:15

They're growing perhaps even at different rates.

1:17

Differential diagnosis, again,

1:19

it's dichotomous hematogenous infection

1:21

or hemat autogenous metastases very commonly.

1:24

Here's an example of someone with histoplasmosis coronal

1:27

plane on the right lung.

1:29

This is why you use MIPS on mips.

1:31

Very easy to see that these nodules are in tropic.

1:34

They are, some are closer together, some are further apart.

1:37

These random nodules will involve a subpleural lung.

1:39

'cause again, subpleural lung needs blood to survive.

1:41

So you'll see random nodules there.

1:43

This, this patient with disseminated histo histoplasmosis.

1:46

Another patient here. This patient has thyroid

1:48

cancer, thyroid metastases.

1:49

We see these nodules, they look random there,

1:51

but don't stop there.

1:53

Look at the mips. MIPS are so, so much easier.

1:56

So these are truly tropics.

1:57

Some are closer together, some are very far apart.

1:59

They're all over the place.

2:00

Variable sizes, obviously the kicker would be if the patient

2:03

had a history of something that spreads to the lungs.

2:06

And this patient had thyroid cancer, as I alluded to

2:08

before, again, use mips.

2:10

Quite helpful. Another example here,

2:14

this patient had ary tuberculosis.

2:16

I think you can see the fine

2:17

nodularity all throughout the lungs.

2:19

Let's go ahead and blow that up.

2:21

This fine nodularity along the fissures.

2:23

Truly a random pattern here.

2:24

They're all throughout the lungs.

2:27

Another example here, this patient also looks very similar,

2:30

looks to have a ary pattern.

2:32

Here's the MIB in that patient. Beautiful pattern here.

2:35

This is actually a nice little story here.

2:36

This, um, so Miller tuberculosis, we all know

2:39

how you get tuberculosis,

2:40

but this is actually something else.

2:43

So this patient actually had history of bladder cancer.

2:47

And this is a case, this case I was shared with me by Dr.

2:49

Sak PVA from University

2:51

of Washington when actually when I was a resident,

2:53

which now seems like eons ago.

2:55

And so this patient had bladder cancer.

2:57

And one of the things that they do

2:58

For, for superficial bladder cancers is

3:00

that they will actually inject, um, a solution of m bovis,

3:04

microbacterial bovis into the bladder.

3:07

'cause it causes a local superficial inflammatory

3:12

reaction within the bladder wall.

3:13

And so it's like, it's probably like the first,

3:16

maybe not the first, but one of the earliest, uh,

3:18

utilization of like, almost like an immunotherapy.

3:20

You're making the body inflame

3:23

so it attacks cancer cells, right?

3:25

So right now in that setting, it's maybe a little bit more,

3:28

uh, indiscriminate because it's just attacking the whole

3:30

superficial lining causing that inflammation.

3:32

But you're trying to activate the, the inflammatory system

3:35

of the body, the immune system of the body

3:37

to attack those cancer cells in,

3:39

in early superficial bladder cancer.

3:42

And so in this patient,

3:43

what happened was when they're putting the catheter in, uh,

3:46

through the urethra, they got a little bit of blood back.

3:48

So it was probably a, a little bit, uh, traumatic there.

3:50

So they may have hurt the mucosa,

3:53

but they had already injected that solution.

3:56

If this patient came into the ED like a week

3:58

or two later, short of breath, they got a CT scan

4:00

and they had all these random

4:02

nodules all throughout the lungs.

4:03

So this is disseminated hematogenous m bovis infection.

4:08

So, um, I, this is probably the third case I've seen.

4:11

So I think it does happen from time to time.

4:13

I don't know how common that is still to use m bovis

4:17

for these superficial, uh, bladder cancers or,

4:20

or, or treatment of that.

4:21

But bottom line, this,

4:23

that just just proves the point hematogenous infection can

4:26

spread with this random diffuse nodule lung disease

4:29

morphology.