MyPACS.net: Radiology Teaching Files > Case 6183471

previously visited CAVITARY PARENCHYMAL LUNG MASS
Contributed by: Radiology Residency Program Faculty & Staff, Northeastern Ohio Universities College of Medicine-Canton Affiliated Hospitals, Ohio, USA.
Patient: 54 year old male
History: Chest pain.
History of alcohol abuse.
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Findings: A well-circumscribed cystic mass density is seen in the right midlung on plain film.
Also noted are posterior rib fractures on the right.

On CT cavitary lesions are identified within the right lung corresponding with the abnormality on chest xray.  The wall of the lesion is mostly smooth with some nodularity superiorly.  A soft tissue density is seen within the dependent portion of the lesion.  A smaller similar lesion is seen posterior and likely connecting to the larger one.
Diagnosis: Right lung cavitary lesion
Discussion:

Differential Diagnosis for Cavitary lesions in the lung

C cancer (squamous cell carcinoma)
A autoimmune (RA, Wegener's)
V vascular (bland or septic emboli)
I  infection (staph aureus, aspergillous, TB, strep)
T trauma (pneumatocele)
Y young (C-CAM)

Squamous cell carcinoma of the lung is most directly linked with smoking.  1/3 of these masses will cavitate.

Aspergillosis can cause four types of disease dependent of the immune status of the host.

   1.Allergic bronchopulmonary aspergillosis (ABPA); patients predominately have asthma or cystic fibrosis, type I hypersensitivity reaction.  Hallmark: central, upper lobe, saccular bronchiectasis.

   2.Aspergilloma (fungus ball); lung must have preexisting disease, but normal immune status (COPD, sarcoid or cavitary lesions otherwise), intracavitary mass usually in upper lobes, Monod sign-air surround the aspergilloma

   3.Semi-invasive aspergillosis; mild immunosuppression, appears similar to invasive, but slower to progress.  Risk factors include alcoholism, COPD, diabetes

   4.Invasive aspergillosis; immunocompromised, multiple pulmonary nodules with a characteristic halo of ground glass surrounding them (actually pulmonary hemorrhage), following this the nodules undergo cavitation -Air crescent sign-recovery

Wegener’s granulomatosis is systemic granulomatous process.  It involves lung, upper respiratory tract and kidney.  It can produce multiple nodules with cavitation.

Staph typically a bronchopneumonia pattern, but ¼ to ¾ form abscess cavities.

Tuberculosis in the secondary form is the one that can cavitate.  This is reactivation from a primary infection.  It predominates in the apices.

Scratch the “young” category here, since the patient is known to be 54 years old.

References:

Weissleder R, Wittenberg J, Harisinghani MG.  Primer of Diagnostic Imaging. Philadelphia: Mosby, 2003

Brant, W., Helms, C., Fundamentals of Diagnostic Radiology 3rd Edition, Lippincott, 2007.

Submitted by Emily Janitz, D.O. and Joseph Mendiola, M.D., attending radiologist Mercy Hospital.

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Additional Details:

Case Number: 6183471Last Updated: 11-18-2007
Anatomy: Chest   Pathology: Infection
Modality: CT, Conventional RadiographAccess Level: Readable by all users

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