New diagnosis of SCC nasopharyngeal cancer. PMH - history of critical aortic stenosis, breast cancer (bilateral mastectomy), thyroid cancer, BCC, CAD and sternal osteonecrosis. She was in pain and hypotensive on presentation to the RAD ONC clinic for her daily radiation therapy. She has had difficulty swallowing/odynophagia secondary to mucositis from her radiation Tx. Three days ago, she developed a non-productive cough with episodes of chills, sweats, and nausea.
- Mild blunting of right costophrenic angle.
- Stranding opacity at the left apex consistent with radiation change.
- Left upper lobe collapse possibly due to mucus plug.
- Marked calcified aorta.
- Opacity in the right middle lung field, consistent with atelectasis or consolidation.
- The cardiac silhouette is enlarged, consistent with cardiomegaly or pericardial effusion.
- Linear opacity, Kerley-B lines of the right costophrenic angle are more prominent.
- Multiple surgical clips in anterior mediastinum and anterior chest wall.
- Radical mastectomy on the left and modified radical mastectomy on the right.
Aspiration of a sufficient amount of gastric acid produces a chemical pneumonitis characterized by acute dyspnea and wheezing with hypoxemia and infiltrates on chest x-ray in one or both lower lobes. Clinical findings depend on the extent of endobronchial obstruction and ranges from acute apnea to persistent cough. Although the aspiration of oral anaerobes can initially lead to infiltrates, it ultimately results in putrid sputum, tissue necrosis and pulmonary cavities. In 75% of cases, the clinical course of an anaerobic abscess is indolent and mimics pulmonary tuberculosis, with cough, shortness of breath, chills, fevers, night sweats, weight loss, pleuritic chest pain and blood-streaked sputum for several weeks. Patients with anaerobic abscesses are usually prone to aspiration of oropharyngeal contents and have peridontal disease.
Chest x-ray is more sensitive than physical exam for detection of pulmonary infiltrates. Chest x-ray can confirm the presence and location of the pulmonary infiltrate, assess the extent of the pulmonary infection, detect pleural involvement, pulmonary cavitation, hilar lymphadenopathy and gauge the response of antibiotic therapy. However, chest x-ray may be normal when the patient is unable to mount an inflammatory response or is in the early stage of an infiltrative process. High-resolution CT can improve the accuracy of the diagnosis of pneumonia, especially when the process involves lung obscured by the diaphragm, liver, ribs, clavicles or heart.
The anatomic localization of the inflammatory process can have diagnostic implications. Most pulmonary pathogens produce focal lesions. A multicentric distribution suggests hematogenous infection. Heamtogenous pneumonia appears as multiple areas of pulmonary infiltration that subsequently may cavitate. A diffuse distribution suggests P. carini, CMV, hantavirus, measles virus or herpes zoster virus. Pluerisy and hilar nodal enlargement are unusual with PCP and CMV pneumonia. Oral anaerobes, S. aureus, S. pneumoniae serotype III, aerobic gram-negative bacilli, M. tuberculosis, and fungi can produce tissue necrosis and pulmonary cavities. In contrast, H. influenza, M pneumoniae, viruses and most other serotypes of S pneumoniae almost never cause cavities. Apical disease, with or without cavities, suggests reactivation tuberculosis. Anaerobic abscesses are located in dependent, poorly ventilated, and poorly draining bronchopulmonary segments and characteristically have air-fluid levels, unlike the well-ventilated, well drained upperlobe cavities caused by M. tuberculosis, an obligate aerobe. Mucor and Aspergillus invade blood vessels and cause pleural-based, wedge-shaped area of pulmonary infarction which may subsequently cavitate.
In the patient with an uncomplicated course, chest x-ray need not be repeated before discharge, since the resolution of infiltrates may take up to 6 weeks after initial presentation. At times, CT may be especially helpful in distinguishing different processes: pleural effusion versus underlying pulmonary consolidation; hilar adenopathy versus pulmonary mass; and pulmonary abscess versus empyema with an air-fluid level.
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