Oral Boards Review Chest Differentials

Chest Differentials Page 1

LUNG VOLUMES AND GLOBAL PATTERNS

~ Increased Lung Volumes ~ Diffuse unilateral disease
¾ Emphysema ¾ Pneumonia
¾ CF ¾ Effusion
¾ LCH / LAM ¾ BAC, lymphangitic carcinomatosis
~ Reduced lung volumes ¾ Hemorrhage, trauma
¾ Fibrosis – IPF, CTD ¾ XRT
~ Unilateral small lung ~ Perihilar lung disease
¾ Lobar atelectasis or collapse ¾ Edema
¾ Surgery or paralysis ¾ PCP
¾ Hypoplastic lung ¾ Bronchiectasis
¾ Swyer-James ~ Peripheral lung disease
~ Unilateral large lung ¾ Eosinophilic pneumonia
¾ Asymmetric emphysema ¾ BOOP – patchy peripheral consolidation
¾ Tension pneumothorax ¾ Hypersensitivity pneumonitis
¾ Airway obstruction ¾ Fibrosis
~ Hyperlucent hemithorax ~ Upper lung disease
¾ Asymmetric chest wall – mastectomy, Poland’s syndrome ¾ Sarcoid / Silicosis
¾ Pneumothorax ¾ TB
¾ q aeration – asymmetric emphysema, compensatory ¾ LCH
hyperinflation, endobronchial obstruction, ipsilateral BO w/air ~ Lower lung zones
trapping ¾ Aspiration pneumonia
¾ r vascularity – PE, hypoplasia ¾ Fibrosis – idiopathic, CVD, asbestosis, drugs
~ Hyperlucent lungs ~ Posterior lung disease
¾ Over penetrated ¾ Fibrosis – idiopathic, CVD, asbestosis, drugs
¾ Emphysema ¾ Silicosis
¾ Air trapping ¾ Edema / dependent atelectasis
¾ r vascularity – RpL shunt, PAH
~ Diffuse lung disease
¾ Edema
¾ Pneumonia
¾ ARDS
¾ Fibrosis
¾ Sarcoid
¾ Pneumoconiosis
¾ Hemorrhage
¾ Aspiration
¾ Drugs or inhalation injury
¾ BAC
¾ Mets

PULMONARY NODULES AND MASSES

~ Solitary pulmonary nodule ~ Ill-defined pulmonary nodules
¾ TOP 3 – Granuloma, carcinoma, hamartoma, AVM ¾ Granulomatous
¾ Mimics – pseudotumor, pleural plaque ¾ Mets
¾ Inflammatory – granuloma, scar, abscess ¾ BAC
¾ Neoplasm – bronchogenic carcinoma, solitary met, hamartoma, ¾ Wegner’s
fibrous tumor of pleura ¾ Septic emboli
¾ Vascular – prominent vessel, AVM, infarct ¾ LCH
¾ Other – round atelectasis, mucoid impaction ~ Tiny nodules
~ Peripheral pulmonary mass ¾ Granulomatous
¾ Adenocarcinoma ¾ Miliary TB
¾ Round atelectasis ¾ Mets / lymphangitic carcinomatosis
¾ Organized pneumonia ¾ Sarcoid / silicosis / CWP
¾ Loculated effusion ¾ Varicella pneumonia
¾ Infarct ~ Calcified pulmonary nodules
~ Pulmonary nodules with adenopathy ¾ Granulomatous disease
¾ Sarcoid / silicosis ¾ Silicosis
¾ Mets ¾ Healed varicella
¾ Granulomatous infection ¾ Calcified mets (osteosarcoma, mucinous tumor)
¾ NHL
~ Well defined pulmonary nodules
¾ Granulomatous
¾ Mets
¾ BAC
¾ Wegner’s
¾ AVM
¾ Sarcoid / silicosis
Chest Differentials Page 2

CAVITIES AND LUCENT LESIONS

~ Localized pulmonary lucency ~ Cavitary nodule or mass
¾ Bulla / bleb ¾ Abscess
¾ Pneumatocele ¾ Bronchogenic carcinoma (1° SCC, also others)
¾ Loculated pneumothorax ¾ Mets
¾ Current or healed abscess ¾ Infarct
~ Cystic lesions with lobar enlargement ¾ Wegener’s
¾ Large bullous emphysema ~ Multiple cavitary nodules
¾ CCAM ¾ Septic emboli, Fungal, TB
¾ CLE ¾ Mets
~ Multiple lucent lesions or cysts ¾ Progressive massive fibrosis
¾ Emphysema ¾ Wegener’s
¾ LCH
¾ LAM
¾ Cystic bronchiectasis
¾ Honeycombing

AIRWAY, ATELECTASIS AND COLLAPSE

~ Tracheal wall thickening ~ Tracheal mass
¾ Relapsing polychondritis ¾ SCC, adenoid cystic
¾ Tracheopathia osteochondroplastica ¾ Mets
¾ Sarcoid ¾ Direct invasion (esophageal, lung, thyroid)
~ Tracheal enlargement ¾ Papilloma
¾ Tracheomalacia ¾ FB
¾ Tracheobronchomegaly (Mounier-Kuhn) ~ Endobronchial lesion
¾ Relapsing polychondritis ¾ Bronchogenic carcinoma
¾ Adjacent fibrosis ¾ Mucus plug
~ Tracheal narrowing ¾ Met (RCC, breast, colon, melanoma)
¾ Extrinsic ~ Atelectasis and pulmonary collapse
ƒ Mass ¾ Endobronchial lesion, bronchogenic carcinoma, mucus plug
ƒ Adenopathy ¾ Effusion, pneumothorax
ƒ XRT fibrosis ~ Bronchiectasis
ƒ Fibrosing mediastinitis ¾ Recurrent pneumonias, aspirations
¾ Intrinsic ¾ Fibrosis
ƒ Burn / chemical ¾ Kartagener’s
ƒ Cartilage deficiency ¾ CF
ƒ Tracheal thickening ¾ ABPA
ƒ Prior trach
~ TEF
¾ Congenital
¾ Cancer
¾ Trauma
¾ XRT
¾ Infection
Chest Differentials Page 3

CONSOLIDATION AND AIRSPACE DISEASE

~ Acute diffuse or patch consolidation ~ Localized consolidation
¾ Edema ¾ Pneumonia
¾ Pneumonia ¾ Atelectasis or collapse
¾ Hemorrhage ¾ Hemorrhage
¾ ARDS ¾ Infarct
~ Chronic diffuse airspace disease and consolidation ¾ BAC / Lymphoma
¾ Pneumonia (atypical, lipoid) ¾ PMF
¾ PAP ~ Consolidation with lobar enlargement
¾ Sarcoid ¾ Pneumonia
¾ BAC / lymphoma ¾ 1° TB
¾ ARDS ¾ BAC
~ Unilateral airspace disease ~ Chronic lobar consolidation
¾ Pneumonia ¾ BAC / lymphoma
¾ Unilateral edema ¾ Postobstructive pneumonia
ƒ Lateral decubitis position ¾ BOOP
ƒ Reexpansion edema (s/p thoracentesis) ¾ Lipoid pneumonia
¾ BAC ~ Recurrent pneumonia
¾ Contusion ¾ Bronchial narrowing or obstruction
¾ Hemorrhage ¾ Bronchiectasis / CF
~ Hemorrhage ¾ Repeated aspiration
¾ Bronchiectasis ¾ Sequestration
¾ Contusion
¾ Coagulopathy
¾ Wegner’s
¾ Aspergillus
¾ PE

INTERSTITIAL LUNG DISEASE

~ Acute diffuse interstitial lung disease ~ Migratory infiltrates
¾ Edema ¾ Edema
¾ Pneumonia – PCP, atypical, mycobacterial ¾ Eosinophilic pneumonia
¾ Hypersensitivity pneumonitis ~ Focal reticulonodular pattern
~ Chronic diffuse interstitial (not nodular) ¾ Fibrosis – prior pneumonia, XRT
¾ Infection ¾ Lymphangitic carcinomatosis
¾ Fibrosis ~ Diffuse reticulonodular pattern
¾ Hypersensitivity pneumonitis ¾ Fibrosis (honeycombing)
¾ Leukemia / lymphoma ƒ Idiopathic
~ Chronic nodular interstitial disease ƒ Drugs
¾ Fibrosis ƒ CTD
¾ Infection – fungal, PCP ƒ Sarcoid
¾ Lymphangitic carcinomatosis ƒ ARDS
¾ Hypersensitivity pneumonitis ƒ Pneumoconiosis
¾ Leukemia / lymphoma ¾ Other
¾ Silicosis / sarcoid ƒ Lymphangitic carcinomatosis
~ Diffuse interstitial disease with effusions ƒ Chronic PVH
¾ Edema ƒ Lymphoma
¾ CVD ƒ Hypersensitivity pneumonitis
¾ Pneumonia ~ Peripheral reticulonodular pattern (fibrosis)
~ Diffuse interstitial disease with adenopathy ¾ Idiopathic
¾ Sarcoid ¾ Drugs
¾ Lymphoma / leukemia ¾ CTD
¾ Lymphangitic carcinomatosis ¾ Asbestosis
¾ Infection – fungal, TB ¾ Hypersensitivity pneumonitis
~ Diffuse disease with increased lung volumes ~ Upper lung reticulonodular pattern
¾ ILD with superimposed emphysema ¾ Granulomatous
¾ CF ¾ Sarcoid
¾ LCH ¾ 2° TB
¾ LAM ¾ Silicosis
~ Peripheral infiltrates ¾ Ankylosing spondylitis
¾ Pneumonia – bacterial, BOOP, eosinophilic ~ Lower lung reticulonodular pattern
¾ Fibrosis ¾ IPF
¾ Hypersensitivity pneumonitis ¾ CTD
~ Unilateral interstitial disease ¾ Asbestosis
¾ Unilateral pulmonary edema ¾ Chronic aspiration
ƒ Lateral decubitis position
ƒ Reexpansion edema
¾ Aspiration
¾ Pneumonia
¾ Local lymphangitic spread
Chest Differentials Page 4

HRCT
~ Ground glass opacities ~ Cystic lesions
¾ Edema ¾ Emphysema
¾ Fibrosing alveolitis – inflammatory phase of IPF ¾ Bronchiectasis
¾ Hemorrhage, lupus ¾ Fibrosis
¾ PAP ¾ LCH
¾ Infection – PCP, hypersensitivity pneumonitis, BOOP ¾ LAM
~ Interlobular septal thickening – Kerley lines ~ Interstitial nodules
¾ Edema ¾ Infection
¾ Lymphangitic carcinomatosis (typically nodular) ƒ Bronchopneumonia
¾ Sarcoid (often nodular) ƒ Granulomatous
¾ Fibrosis ƒ BO
¾ Hypersensitivity pneumonitis ƒ Hematogenous spread of TB
~ Intralobular septal thickening ¾ Tumor – Mets, lymphangitic carcinomatosis
¾ Fibrosis ¾ Other – Silicosis / CWP / sarcoid; LCH
¾ Hypersensitivity pneumonitis ~ Small perilymphatic nodules
¾ Sarcoid (often nodular) ¾ Sarcoid / silicosis / CWP
¾ PAP ¾ Lymphangitic carcinomatosis
~ Peribronchovascular interstitial thickening ~ Small randomly distributed nodules
¾ Edema ¾ Granulomatous disease
¾ Lymphangitic carcinomatosis (typically nodular) ¾ Mets
¾ Lymphoma ¾ Miliary TB
¾ Sarcoid (irregular) ¾ Fungal
¾ Fibrosing alveolitis ~ Centrilobular nodules
~ Honeycombing ¾ BO
¾ IPF ¾ Endobronchial spread of TB – tree in bud
¾ CTD ¾ Bronchopneumonia
¾ ESLD ¾ BAC
¾ Asbestosis ¾ Hypersensitivity pneumonitis
¾ ARDS ¾ LCH
¾ Drug-related
¾ Pneumoconiosis

PLEURA
~ Spontaneous pneumothorax with diffuse lung disease ~ Pleural thickening
¾ CF ¾ Asbestos exposure
¾ PCP ¾ Prior empyema
¾ Emphysema ¾ Fibrosis
¾ LAM ¾ Organized effusion
¾ LCH ¾ Metastatic disease
~ Unilateral effusion ¾ Mesothelioma
¾ Cardiovascular – CHF, PE, Dressler’s (L >R) ~ Plural calcifications
¾ Inflammatory – Parapneumonic effusion, abscess, pancreatitis ¾ Asbestos exposure
¾ Malignancy – pleural mets, bronchogenic carcinoma, ¾ Prior empyema / hemothorax
mesothelioma, lymphoma, leukemia ¾ Pleurodesis
¾ Trauma – Vascular injury, contusion / laceration, esophageal ~ Pleural mass
rupture ¾ Pleural plaques
~ Bilateral effusions ¾ Loculated effusion
¾ See above ¾ Round atelectasis
¾ CHF ¾ Pleural thickening
¾ Pleural mets ¾ Empyema
¾ CVD ¾ Neoplasm – extension of rib tumor, peripheral lung ca, mets,
¾ Meigs’ syndrome (benign effusion with ovarian neoplasm) extrapleural tumor, mesothelioma, fibrous tumor
~ Effusion with CM
¾ CHF
¾ Pericarditis
¾ PE
Chest Differentials Page 5

DIAPHRAGM AND CHEST WALL

~ Extrapleural lesion ~ Inferior rib notching
¾ Lipoma ¾ Arterial collaterals
¾ Hematoma ¾ Neurofibromatosis
¾ Rib mets or multiple myeloma ¾ Nerve sheath tumor
¾ Chest wall infection ¾ Venous collaterals
~ Soft tissue calcifications ~ Superior rib notching
¾ Hemangioma ¾ Neurofibromatosis
¾ Scleroderma ¾ CTD
¾ Dermatomyositis ¾ Hyperparathyroidism
¾ Myositis ossificans ~ Distal clavicular resorption
~ Peripheral pulmonary disease and chest wall mass ¾ Post traumatic
¾ Tumor ¾ Infection
ƒ Bronchogenic carcinoma, invasive breast, lymphoma ¾ RA
¾ Infection ¾ Hyperparathyroidism
ƒ Actinomycosis
ƒ Mucormycosis

MEDIASTINUM AND HILA

~ Unilateral hilar enlargement ~ Enlarged / widened mediastinum
¾ 1° lung neoplasm ¾ Lipomatosis
¾ Mediastinal tumor ¾ Vascular
¾ Bronchogenic cyst ¾ Adenopathy
¾ Mets ¾ Tumor
¾ Granulomatous ¾ GI source
~ Bilateral hilar enlargement ¾ Blood / fluid
¾ PAH ¾ Duplication cyst
¾ Sarcoid / silicosis ¾ Pericardial cyst
¾ Granulomatous ~ Thoracic inlet mass
¾ Mets ¾ Thyroid origin
¾ Lymphoma / leukemia ¾ Lymphoma
¾ Castleman’s disease ¾ Thymic mass
~ Calcified lymph nodes ~ Anterior mediastinum (4 T’s)
¾ Granulomatous ¾ Thymic tumors (thymic cyst, thymolipoma, thymoma, thymic
¾ Disseminated PCP carcinoma, thymic carcinoid, thymic lymphoma)
¾ Mets (osteosarcoma, mucinous) ¾ Thyroid lesions
¾ Eggshell – silicosis, sarcoid, treated lymphoma ¾ T cell lymphoma (hodgkin’s most common)
~ Low attenuation lymph nodes ¾ Teratoma (and other germ cell tumors – seminoma, embryonal
¾ TB cell carcinoma, choriocarcinoma)
¾ Mets (bronchogenic, testicular, ovarian) ~ Middle mediastinum
¾ Infectious ¾ Adenopathy
~ Enhancing lymph nodes ¾ Benign – sarcoid, TB, fungal, infection
¾ Castleman’s disease ¾ Malignant – lymphoma, mets, leukemia
¾ Vascular mets ¾ Bronchopulmonary foregut malformation – bronchogenic cyst,
¾ HIV adenopathy enteric cyst
¾ Paraganglioma ¾ Pericardial cyst
~ Pneumomediastinum ¾ Aneurysm (aortic, pulmonary)
¾ Iatrogenic / Trauma ~ Posterior mediastinum
¾ Extension from neck or abdomen ¾ Schwannoma, neurofibroma
¾ Pneumothorax ¾ Ganglioneuroma, ganglioneuroblastoma, neuroblastoma
~ Ipsilateral mediastinal shift ¾ Pheochromocytoma, paraganglioma
¾ Atelectasis / collapse ¾ Lateral meningomyelocele
¾ Lobectomy ¾ Extramedullary hematopoiesis
¾ Unilateral fibrosis ~ Cardiophrenic angle masses
¾ Scimitar syndrome ¾ Fat pad
~ Contralateral mediastinal shift ¾ Diaphragmatic hernia
¾ Large effusion ƒ Morgagni – anterior, right
¾ Tension pneumothorax ƒ Bochdalek – posterior, left (not true CP mass)
¾ Asymmetric emphysema ¾ Pericardial cyst
¾ CP nodes – lymphoma, usually recurrent s/p XRT
¾ Aneurysm, dilated right atrium
¾ Anterior mediastinal mass
¾ Primary lung or pleural mass
Chest Differentials Page 6

CARDIAC ABNORMALITIES
~ Enlarged cardiac silhouette ~ Aortic insufficiency
¾ CHF ¾ Bicuspid aortic valve
¾ Pericardial effusion ¾ Rheumatic heart disease
¾ Cardiomyopathy ¾ Bacterial endocarditis
¾ Valvular disease ¾ Cystic medial necrosis (Marfan’s)
¾ Congenital heart ¾ Trauma / dissection
~ Cardiac mass ~ Mitral insufficiency
¾ Bland thrombus ¾ Rheumatic heart disease
¾ Tumor – myxoma (LA most common), atrial septal lipoma, ¾ Mitral annulus dilatation (LV dilatation, cardiomyopathy)
rhabdomyoma ¾ Papillary muscle dysfunction
¾ Tumor emboli ¾ Other – endocarditis, rupture of chordae tendineae, mitral valve
¾ Valve vegetation prolapse, ECD, atrial myxoma
~ Pericardial effusion ~ Tricuspid insufficiency
¾ Idiopathic (1/3 of all cases) ¾ Endocarditis (IVDA)
¾ Infectious ¾ Rheumatic heart
¾ Dressler’s syndrome ¾ RV dilation
¾ Uremia ¾ PHTN
~ High-output CHF ~ Congenital heart disease – Left to right shunt
¾ Anemia (SCD) ¾ ASD
¾ Fluid overload ¾ VSD
¾ AVM ¾ PDA
¾ Polycythemia vera ¾ ECD
¾ Pregnancy ¾ APVR
~ Right atrial enlargement ~ Congenital heart disease – Right to left shunt
¾ ASD ¾ TOF
¾ Right ventricular failure ¾ Pulmonary atresia with intact ventricular septum (R p L
¾ ECD usually through ASD)
¾ APVR ¾ Tricuspid atresia
¾ Valvular – TS, TI, Ebstein’s ¾ TAPVR
~ Right ventricular enlargement ~ Congenital heart disease – Normal or decreased pulmonary
¾ ASD vascularity with cyanosis
¾ Cor pulmonale ¾ Ebstein’s
¾ Valvular – Pulmonary or tricuspid insufficiency ¾ Pulmonary atresia with intact ventricular septum
~ Left atrial enlargement ¾ Tricuspid atresia
¾ Mitral stenosis ¾ TOF
¾ Mitral insufficiency ~ Congenital heart disease – Increased pulmonary vascularity
¾ L p R shunts ¾ Cyanosis (Blue)
¾ Left atrial myxoma ƒ TGA
~ Left ventricular enlargement ƒ Truncus arteriosus
¾ CHF ƒ TAPVR
¾ Ischemia ƒ Tricuspid atresia
¾ High-output CHF ƒ Single ventricle
¾ Valvular – AI, AS, MI ¾ Without cyanosis (Pink)
¾ AMI ƒ ASD – normal LA
¾ HTN ƒ VSD – large LA
ƒ PDA – large LA
ƒ ECD

VASCULAR ABNORMALITIES
~ Enlarged ascending aorta ~ Enlarged pulmonary arteries
¾ HTN ¾ PAH
¾ Aneurysm ¾ LpR shunt
¾ Aortic stenosis ¾ PVH
¾ Aortic insufficiency ~ Enlarged SVC
¾ Syphilitic aortitis ¾ CHF
¾ Coarctation ¾ APVR
~ Coronary artery aneurysms ¾ Idiopathic
¾ Atherosclerosis ¾ Azygous continuation of IVC
¾ Congenital ¾ Tamponade
¾ Kawasaki ~ Enlarged azygous vein
~ Pulmonary venous hypertension ¾ Elevated CVP – CHF, fluid overload, renal failure, pregnancy
¾ CHF ¾ SVC obstruction
¾ Fluid overload ¾ Portal hypertension
¾ Renal failure ¾ Azygous continuation of IVC
¾ Left atrial obstruction – myxoma, mediastinal fibrosis, mitral ¾ Pregnancy
stenosis
¾ Constrictive pericarditis
¾ APVR
¾ Cor triatriatum