The CXR shows a mass in the right lower zone. The mass has a sharp margin and two vessels (supplying artery and draining vein) leading to the mass (Fig. 18.2). The CT (Fig. 18.3) shows marked enhancement of the "mass" with contrast confirming the presence of pulmonary arteriovenous malformation (pAVM). Of patients with pAVM, 60% have Osler's disease, and 10% of patients with Osler's disease have pAVM. This condition is autosomal dominant. Other sites of involvement include skin, nose (epistaxis), gastrointestinal (GI) system (bleeding GI and anemia). Paradoxical embolism can occur resulting in cerebral vascular accidents or brain abscess. Pulmonary angiogram and embolotherapy are recommended if the pAVM is more than 2 mm.
Case 19. An 80-year-old female, 100-pack-a-year smoker with 5-year history of dyspnea on exertion. Describe her CXR (Fig. 19.1). What is the diagnosis?
CASE 19 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
The CXR of COPD typically demonstrates evidence of air trapping. The signs are horizontality of the ribs, hyperinflated lungs (normally the right sixth rib bisects the right hemidiaphragm), hyperlucent lung fields, bilateral symmetrical attenuated pulmonary vasculature, long tubular heart, scalloping and flattening of the diaphragm. The commonest cause of COPD worldwide is tobacco smoking. However, it is recognized that alpha-1-antitrypsin deficiency can also cause emphysema. One should look out for alpha-1-antitrypsin deficiency, especially if the COPD patient is young (<45 years old) or demonstrates basal predominance on CXR.
Case 20. This 55-year-old male was admitted in shock. He was recently diagnosed with inoperable lung cancer. Clinical exam also showed distended neck veins and muffled heart sounds. This was his CXR (Fig. 20.1). What is the diagnosis?
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