Case of Case of CavitaryCavitary Lung Lesions Lung Lesions Following Following PharyngitisPharyngitis

Courtney L. Lockhart, HMS III Courtney L. Lockhart, HMS III

Harvard Medical School Harvard Medical School

Gillian Lieberman, MDGillian Lieberman, MD

Our Patient: Initial PresentationOur Patient: Initial Presentation

17 17 yoyo M presents with oneM presents with one--week week

history of history of pleuriticpleuritic chest pain, chest pain,

worse with inspirationworse with inspiration

Our Patient: Cavitations on CXR Our Patient: Cavitations on CXR

Two lung lesions in the anterior lung fields suggestive of cavitations (yellow). Mild blunting of the costophrenic angles (blue) consistent with atelectasis or acute pleural effusion.

•PACS Children’s Hospital Boston

CavitaryCavitary Lung LesionLung Lesion

Pulmonary Pulmonary cavitarycavitary lesionlesion–– AirAir--containing area surrounded by definitive wall containing area surrounded by definitive wall

–– Wall thickness of at least 4mm Wall thickness of at least 4mm

–– Sometimes mistaken for cysts which are thinSometimes mistaken for cysts which are thin-- walled airwalled air--containing lesionscontaining lesions

–– Cavity may also contain blood, pus, fluid, or Cavity may also contain blood, pus, fluid, or debris debris

CavitaryCavitary Lung Lesions on CXR and CTLung Lesions on CXR and CT

ImagingImaging–– CXRCXR

Initial test of choice for all cardiopulmonary Initial test of choice for all cardiopulmonary complaintscomplaints

Defined area of increased Defined area of increased lucencylucency surrounded by surrounded by rim of densityrim of density

Limitations: small lesions may be missed, limited Limitations: small lesions may be missed, limited characterizationcharacterization

–– Chest CTChest CT

1010--20 times more sensitive for evaluation of lung 20 times more sensitive for evaluation of lung nodules of all typesnodules of all types

Provides more detail of lung parenchyma Provides more detail of lung parenchyma

Provides better characterization and localization of Provides better characterization and localization of lesionslesions

Our Patient: Nodular Lesions on Our Patient: Nodular Lesions on Axial Chest CTAxial Chest CT

Axial Chest Axial Chest CT CT –– NonNon--

cavitarycavitary peripheral peripheral lung nodule lung nodule in right in right upper lobeupper lobe

–– Evolving Evolving cavitationcavitation within within nodule nodule along left along left major major fissure fissure

•PACS Children’s Hospital Boston

Axial Chest Axial Chest CTCT–– Peripheral Peripheral

cavitarycavitary lung lung lesion in lesion in the left the left lobelobe

Our Patient: Our Patient: CavitaryCavitary Lesions on Lesions on Axial Chest CTAxial Chest CT

•PACS Children’s Hospital Boston

Our Patient: Our Patient: CavitaryCavitary Lesion on Lesion on Coronal Chest CTCoronal Chest CT

Coronal CT Coronal CT –– Peripheral Peripheral

cavitarycavitary lung lesion lung lesion in the left in the left upper lobeupper lobe

•PACS Children’s Hospital Boston

Differential DiagnosisDifferential Diagnosis

Differential Differential DxDx for for cavitarycavitary nodulesnodules–– C C –– Carcinoma Carcinoma –– typically typically squamoussquamous, , metsmets, ,

lymphomaslymphomas

–– A A –– Autoimmune Autoimmune –– WegenerWegener’’s s granulomatosisgranulomatosis, , rheumatoid nodulesrheumatoid nodules

–– V V –– Vascular Vascular –– emboli (septic or bland)emboli (septic or bland)

–– I I –– Infection Infection –– lung abscess, bacterial pneumonia, lung abscess, bacterial pneumonia, fungal pneumonia, TB, fungal pneumonia, TB, hydatidhydatid cysts (parasitic cysts (parasitic infections)infections)

–– T T –– Trauma Trauma –– lung lacerationlung laceration

–– Y Y –– Young (congenital) Young (congenital) –– cystic cystic adenomatoidadenomatoid malformation, sequestration, malformation, sequestration, bronchogenicbronchogenic cystcyst

MedPix Medical Image Database

Narrowing the Differential of Narrowing the Differential of CavitaryCavitary Lung LesionsLung Lesions

Characterization of Characterization of cavitarycavitary lung lesionslung lesions–– Focal or multifocal v. diffuseFocal or multifocal v. diffuse

–– Wall thicknessWall thickness

–– Contour of inner lining (irregular or smooth)Contour of inner lining (irregular or smooth)

–– Nature of contentsNature of contents

–– Location Location

Clinical parametersClinical parameters–– Rapidity of disease processRapidity of disease process

–– Clinical context Clinical context ••RyuRyu, Jay, et al. Mayo , Jay, et al. Mayo ClinClin Proc. 2003; 78:744Proc. 2003; 78:744--752752

Our Patient: History and Physical Exam Our Patient: History and Physical Exam

HPI ContinuedHPI Continued–– 1 week of sore throat, fever, pain, rigors1 week of sore throat, fever, pain, rigors

–– Throbbing HA, Throbbing HA, hematuriahematuria, , n/v/dn/v/d

–– Right flank painRight flank pain

–– Bilateral knee painBilateral knee pain

Physical ExamPhysical Exam–– VS: T 37.1 BP 124/68 P 80 RR 20 O2Sat 95%RAVS: T 37.1 BP 124/68 P 80 RR 20 O2Sat 95%RA

–– ErythematousErythematous, , exudativeexudative oropharynxoropharynx, , shottyshotty LADLAD

–– Diminished breath sounds over right lung baseDiminished breath sounds over right lung base

–– CVA tenderness bilaterallyCVA tenderness bilaterally

Our Patient: Our Patient: LymphadenopathyLymphadenopathy on on Coronal Chest CT Coronal Chest CT

Coronal Chest Coronal Chest CT CT –– PeribronchialPeribronchial

lymph node in lymph node in the the mediastinummediastinum

•PACS Children’s Hospital Boston

Our Patient: Our Patient: CavitaryCavitary Lung Lesion Lung Lesion on Axial Chest CTon Axial Chest CT

Axial Chest Axial Chest CT CT –– Medial Medial

cavitarycavitary lung lung lesion in lesion in right lobe right lobe anterior to anterior to pericardium pericardium

•PACS Children’s Hospital Boston

Our Patient: Our Patient: CavitaryCavitary Lung Lesion Lung Lesion on Axial Chest CT Lung Windowon Axial Chest CT Lung Window

Axial Chest Axial Chest CTCT–– Medial Medial

cavitarycavitary lung lung lesion lesion anterior to anterior to pericardium pericardium at the end of at the end of pulmonary pulmonary vessel vessel

•PACS Children’s Hospital Boston

Our Patient: Our Patient: CavitaryCavitary Lung Lesion Lung Lesion on Axial and on Axial and SagittalSagittal Chest CTChest CT

Chest CT Chest CT –– Same medial lung Same medial lung cavitationcavitation

anterior to the pericardiumanterior to the pericardium–– Inferior section showing intact Inferior section showing intact

pericardiumpericardium

•PACS Children’s Hospital Boston

•PACS Children’s Hospital Boston

Our Patient: Lab Results Our Patient: Lab Results

CBCCBC–– WBC 9.14, RBC 4.28 (WBC 9.14, RBC 4.28 (HctHct 36.7%), 36.7%), PltPlt 452 452

UrineUrine–– Turbid, pH 7.0, 2+ blood, 10Turbid, pH 7.0, 2+ blood, 10--20 RBC/20 RBC/hpfhpf

Blood culture Blood culture –– Positive for gram negative rodsPositive for gram negative rods

Diagnosis????Diagnosis????

LemierreLemierre’’ss DiseaseDisease

Also known as postAlso known as post--anginalanginal sepsis sepsis characterized internal jugular vein septic characterized internal jugular vein septic thrombophlebitisthrombophlebitis

Characteristically seen in adolescents or Characteristically seen in adolescents or young adults young adults

Sepsis following a Sepsis following a tonsillartonsillar or or peritonsillarperitonsillar infectioninfection

May also be preceded by May also be preceded by mastoiditismastoiditis, , cellulitiscellulitis or or odontogenicodontogenic infection infection

Spread via lymphatic and venous systems Spread via lymphatic and venous systems into the lateral pharyngeal spaceinto the lateral pharyngeal space

LemierreLemierre’’ss Disease Continued Disease Continued

Classically caused by Classically caused by FusobacteriumFusobacterium necroporumnecroporum

Staph, Strep, Staph, Strep, EikinellaEikinella, , BacteroidesBacteroides are other are other causative organismscausative organisms

Sore throat, fever, rigors, productive cough w/ Sore throat, fever, rigors, productive cough w/ bloodblood--tinged sputum, neck swelling along the tinged sputum, neck swelling along the sternocleidmastoidsternocleidmastoid m. m.

Reports of carotid rupture, Reports of carotid rupture, dysphagiadysphagia, Horner, Horner’’s s syndrome, and syndrome, and trapeziustrapezius paralysis during initial paralysis during initial spread to the internal jugular veinspread to the internal jugular vein

Metastatic abscesses to the lungs, pleura, joints, and Metastatic abscesses to the lungs, pleura, joints, and soft tissues soft tissues

PleuriticPleuritic chest pain, chest pain, dyspneadyspnea, , hepatomegalyhepatomegaly, , jaundice, joint pain, encephalopathy, jaundice, joint pain, encephalopathy, hematuriahematuria

Head and Neck AnatomyHead and Neck Anatomy

PeritonsillarPeritonsillar Abscess on Head CTAbscess on Head CT

Head and Neck CT with Head and Neck CT with contrastcontrast–– LowLow--attenuation mass attenuation mass

with a minimally with a minimally enhancing wall in the enhancing wall in the right right peritonsillarperitonsillar regionregion

–– Associated edema, mild Associated edema, mild compression of the compression of the internal carotid and internal carotid and internal jugular vein, and internal jugular vein, and deviation of the airway deviation of the airway are present.are present.

*

•Emerg Med 37(5):18-47, 2005

Examination of Internal Jugular Vein Examination of Internal Jugular Vein

UltrasoundUltrasound–– Test of choice: Cost effective, easily accessible, Test of choice: Cost effective, easily accessible,

realreal--time evaluation, no radiationtime evaluation, no radiation–– LumenalLumenal for dilatation, filling defect and flowfor dilatation, filling defect and flow–– ThrombophlebitisThrombophlebitis: : EchogenicityEchogenicity within a within a

dilated lumen; decreased dilated lumen; decreased compressibiltycompressibilty

CT CT –– Rapid test, more sensitive in the evaluation of Rapid test, more sensitive in the evaluation of

fresh thrombus and additional pathologyfresh thrombus and additional pathology–– Better visualization of anatomy Better visualization of anatomy –– ThrombophlebitisThrombophlebitis: Low : Low attentuationattentuation of filling of filling

defect with soft tissue swelling defect with soft tissue swelling

Our Patient: Internal Jugular Vein Our Patient: Internal Jugular Vein UltrasoundUltrasound

IJV Ultrasound

- IJV lumen with and without compression

- Normal lumenal diameter

- Full compression with probe

- IJV flow for stasis or filling defect

- Normal flow with no filling defects

•PACS Children’s Hospital Boston

•PACS Children’s Hospital Boston

Companion Patient: Companion Patient: ThrombosedThrombosed Internal Jugular Vein UltrasoundInternal Jugular Vein Ultrasound

IJV Ultrasound– IJV examination for

stasis or filling defect

Filling defect with disruption of flow

IJV Ultrasound– IJV lumen

Increased lumenal diameter

Echogenic foci within the lumen

•Courtesy of Dr. D. Ferris, PACS Children’s Hospital Boston

•Courtesy of Dr. D. Ferris, PACS Children’s Hospital Boston

Our Patient: Treatment and Outcome Our Patient: Treatment and Outcome

Patient treated with long course of Patient treated with long course of high dose antibiotichigh dose antibiotic

FollowFollow--up CXR was normalup CXR was normal

Take Home Points Take Home Points

LemierreLemierre’’ss disease is an easily forgotten disease is an easily forgotten DDxDDx even when characteristic signs and even when characteristic signs and symptoms are presentsymptoms are present

Blood cultures and radiological Blood cultures and radiological examination of IJV and effected organs are examination of IJV and effected organs are essential to confirm diagnosis and assess essential to confirm diagnosis and assess the extent of disease the extent of disease

Our patient had a good outcome but most Our patient had a good outcome but most are fatal, though mortality has decreased are fatal, though mortality has decreased in the era of antibiotic usein the era of antibiotic use

Take Home Points ContinuedTake Home Points Continued

CT is the best imaging modality for CT is the best imaging modality for characterizing cystic or characterizing cystic or cavitarycavitary lung lung lesionslesions

US is the most convenient, cost effective, US is the most convenient, cost effective, and rapid imaging modality for evaluation and rapid imaging modality for evaluation of thrombus in vessels of the neck, of thrombus in vessels of the neck, especially in the pediatric populationespecially in the pediatric population

Neck CT is the test of choice when neck Neck CT is the test of choice when neck pathology such as abscess or tumor is pathology such as abscess or tumor is suspected suspected

AcknowledgmentsAcknowledgments

Dr. Diane Ferris, BIDMC Radiology Dr. Diane Ferris, BIDMC Radiology ResidentResident

Dr. Katie Taylor, CHB PGYIDr. Katie Taylor, CHB PGYI

Dr. Amanda Dr. Amanda GrowdonGrowdon, CHB Attending, CHB Attending

Dr. Lieberman, Radiology Clerkship Dr. Lieberman, Radiology Clerkship DirectorDirector

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