0:01

All right, it's Mark again, and we're

0:03

going to move on from acute consolidation

0:06

to the chronic consolidated processes.

0:09

Again, consolidation representing

0:11

some clouds in the lung.

0:14

We'll talk about some of the common

0:15

pathologies and etiologies for chronic

0:17

consolidated processes, but overall,

0:20

these are a little less common.

0:22

All right, we're going to understand

0:24

a little bit about the importance of

0:26

when you see traction bronchiectasis

0:28

and irregular visceral pleura

0:30

in a chronic consolidation.

0:32

That's a sign of chronicity.

0:34

And I'm going to give a little bit of a shorter

0:36

differential when you see enlarged lymph nodes.

0:39

So the pertinent findings you want to be

0:42

looking for are traction bronchiectasis, irregular

0:44

visceral pleura, signs of architectural

0:46

distortion, and enlarged lymph nodes.

0:50

So from the concept map in the card,

0:52

we're going to be focusing on this

0:53

area here, chronic consolidation.

0:56

These are going to be your players and start

0:59

you off, and then we'll come back to it later.

1:01

35 years old, chronic cough, no fever.

1:04

These are consolidations, right?

1:06

They're ill-defined.

1:07

There are some air bronchograms.

1:09

They're peripheral, but also notice

1:11

that the mediastinum is convex.

1:13

It's too dense, much more

1:14

dense than the aortic arch.

1:15

The aortic pulmonary recess and

1:17

both hilum are enlarged and dense,

1:19

consistent with enlarged lymph nodes.

1:21

Okay.

1:21

What do you think this is?

1:25

This is going to be one of these.

1:27

These are the more common diseases, and none of

1:30

them are really common, but more common diseases

1:32

that manifest as chronic consolidation.

1:35

Again, you don't have to say airspace or

1:36

interstitial, just, it's consolidated.

1:39

Chronic usually refers to

1:41

greater than maybe two weeks.

1:43

Um, that one to two week period being

1:45

the subacute period where you kind of

1:48

have to think about both acute

1:50

and chronic consolidated opacities.

1:52

Thanks.

1:53

These are your players: the neoplastic

1:55

ones, the granulomatous ones,

1:57

TB, fungal, and alveolar sarcoid.

1:58

Whenever you say TB, you always say fungal

2:01

because they are both granulomatous infections

2:04

and they have a great deal of similarity.

2:07

Imaging-wise.

2:08

Inflammatory causes: COP

2:10

versus eosinophilic pneumonia.

2:11

COP is much more common than

2:13

eosinophilic pneumonia, by the way.

2:14

And, uh, older, I just put older, uh,

2:17

chronic aspiration lipoid pneumonia.

2:19

This will be dependent.

2:21

The big hint: if you have enlarged

2:22

lymph nodes, you think lymphoma

2:24

and the granulomatous diseases.

2:26

So, these patients all have something

2:29

different, uh, oh sorry, all have

2:31

similar consolidation, but they're from

2:34

different causes, different etiologies.

2:36

This patient has consolidation and

2:38

there's traction bronchiectasis.

2:40

And there's a little bit of

2:41

irregularity to the visceral pleura

2:43

and some architectural distortion.

2:45

The same here: a little bit of pulling apart

2:48

of the airways, a little irregular visceral

2:50

pleura here, and some architectural distortion.

2:53

These two are chronic consolidation.

2:56

When you see traction bronchiectasis and scarring,

2:59

that tells us that this most likely is

3:01

something that's more longstanding or chronic.

3:04

And so that's when you would

3:05

start shifting your differential.

3:08

This patient does not have traction

3:10

bronchiectasis, just a lot of consolidation.

3:13

So we would favor, hmm, that might be acute.

3:16

And in fact, that was acute.

3:17

This was a corona, this was COP, and

3:20

this was graft-versus-host disease

3:22

inducing organizing pneumonia.

3:25

So the presence and absence of traction

3:28

bronchiectasis, architectural distortion, irregular

3:30

visceral pleura do support a chronic process.

3:33

Now what is cryptogenic organizing pneumonia?

3:35

That's probably one of the more common

3:36

causes of chronic consolidation.

3:38

It's a little confusing.

3:40

The body is reacting as if a pulmonary infection

3:42

is present, although there are different

3:44

etiologies, and you never know, there might

3:47

be an infection there, we just didn't find it.

3:51

It's reacting, and it's usually going to be

3:55

subacute to chronic, and there'll be some

3:57

evidence of traction bronchiectasis or scarring.

4:01

Now this, uh, organized pneumonia response,

4:05

even when the etiology is removed, is still

4:07

occurring, so it's kind of like a computer

4:11

that's just kind of flipping through

4:13

and not stopping, and now this is coming.

4:15

How do we stop this?

4:17

I don't know.

4:17

Let's reboot the dang thing, right?

4:19

And so that's kind of what corticosteroids

4:21

are doing: it's kind of shutting down

4:24

that immune reaction, and then it resets.

4:28

Now, if it comes back, you know, the so-called

4:31

resistant cryptogenic organizing pneumonia,

4:33

that probably tells us that whatever the

4:35

etiology is that's causing it is still present.

4:40

So, BMT patient, there are some areas of

4:42

consolidation, maybe a little traction

4:45

bronchiectasis, but there's definitely some

4:47

irregularity here and architectural distortion.

4:50

So this is a patient who's got

4:52

some chronic consolidation.

4:54

Uh, I would say, yeah, this is

4:56

an organizing pneumonia reaction.

4:58

Maybe there's an infection there,

5:00

but you'd start thinking graft

5:01

versus host or some other etiology.

5:05

This is a patient with alveolar proteinosis.

5:07

Now, this is different.

5:09

Alveolar proteinosis gives a

5:11

consolidation and ground-glass

5:13

process, the so-called crazy paving.

5:16

Crazy paving just means that there

5:17

are lines here and surrounding

5:20

ground-glass and consolidation.

5:22

Okay.

5:23

Now this usually, or we feel, is related

5:27

to poor alveolar macrophage clearing

5:29

(macrophages), pulmonary macrophages

5:31

clear the surfactant and debris.

5:33

And in these patients, the pulmonary alveolar

5:36

macrophages are, uh, they're on strike, right?

5:38

So this stuff kind of

5:40

slowly accumulates in the lung.

5:42

One of the hallmarks

5:43

though, is that this has no

5:46

imaging evidence for scarring,

5:48

no traction bronchiectasis.

5:51

The others that do this would be things like

5:53

lipoid pneumonia or mucinous adenocarcinoma.

5:56

These are forms of chronic

5:57

consolidation that do not give fibrosis.

6:01

16-year-old with Rett syndrome

6:04

aspirates, has a consolidation in the

6:08

right middle lobe and left lower lobe.

6:11

And it's unchanged from two years ago.

6:14

And when you look at the CT, you'll

6:16

see, yeah, that's consolidated,

6:18

but it's really low density.

6:19

It's actually close to the subcutaneous fat.

6:22

This is lipoid pneumonia.

6:24

The patient was given mineral oil and she

6:27

aspirated it two years ago, and it's just kind

6:29

of hanging in there, not a lot of fibrosis here.

6:34

Another patient, more of a ground

6:35

glass to consolidative appearance.

6:38

There is no real evidence, maybe a

6:40

little bit there, but no evidence

6:41

for real traction bronchiectasis.

6:44

Um, you know, what do you think?

6:45

Well, when you see such widespread

6:48

disease like this, it's usually best to

6:51

look in the areas of less involvement.

6:54

And you'll see that the underlying process

6:56

here is one of ground-glass nodules that are

7:00

sharply defined that then probably coalesced.

7:05

In this patient, no fibrosis.

7:09

Panic progressive kind of consolidation,

7:11

some ground-glass, um, ground-glass

7:14

nodules that are well defined.

7:16

Well, yeah, this turned out to be mucinous

7:19

secreting adenocarcinoma, and the adenocarcinoma

7:22

is growing, secretes the mucus, which then

7:24

accumulates in the, uh, lung parenchyma, giving

7:27

you that kind of ground-glass consolidated

7:29

process without imaging evidence of fibrosis.

7:33

Well, let's compare it to this person.

7:36

She has chronic productive cough.

7:38

She has consolidation and clearly

7:40

has some traction bronchiectasis.

7:43

And you'll notice the

7:44

distribution is bronchovascular.

7:47

Well, geez, to me, this is, uh,

7:49

organized pneumonia, COP, organized

7:51

pneumonia, COP, organized pneumonia, COP.

7:53

I mean, that's what it is.

7:56

It progressed.

7:57

It's progressed quite a bit, in fact.

7:59

And in bronchoscopy, they

8:01

got a lot of lymphocytes.

8:03

So, it turns out that this is actually

8:05

a form of primary pulmonary lymphoma.

8:08

This is very uncommon.

8:11

You might see it sometime in your career.

8:14

The clues here were that it's bronchovascular,

8:16

it's consolidated, and it turns out lymphoma is

8:21

a, gives a form of sort of scarring as opposed

8:25

to the mucinous secreting adenocarcinoma.

8:28

So, unlike the other tumors.

8:30

This one does induce evidence of scarring.

8:33

The other thing that's notable about

8:35

primary pulmonary lymphoma is only about

8:36

half of them have enlarged lymph nodes.

8:41

So, let's go back to this person.

8:43

Consolidation enlarged lymph nodes,

8:46

chronic, no fever, this, and you

8:50

can see the air bronchograms.

8:51

This is an example of, um, alveolar sarcoid.

8:56

Do you want to call this airspace?

8:57

No.

8:58

Do you want to call it interstitial?

8:59

No, don't bother.

9:00

It's, it's chronic consolidation in

9:02

the setting of enlarged lymph nodes.

9:04

I would think about histoplasmosis

9:07

or some fungal infections.

9:09

I would consider things like,

9:10

um, non-Hodgkin's lymphoma.

9:12

Not the primary pulmonary,

9:13

but more of the systemic.

9:15

But in this case, this was, this is pretty

9:18

characteristic for alveolar sarcoid,

9:20

especially in the setting of no fevers.

9:24

This patient has enlarged lymph

9:26

nodes and a chronic consolidation.

9:29

They're from Vietnam.

9:30

And this turned out to be primary tuberculosis.

9:35

Primary tuberculosis gives you

9:36

that chronic consolidation with

9:38

associated enlarged lymph nodes on CT.

9:41

The clue about this, that it's not sarcoid, is

9:44

that those lymph nodes will be necrotic, right?

9:49

Sarcoid lymph nodes are not necrotic.

9:53

And then we'll finish with this

9:55

one, uh, multifocal areas of

9:57

consolidation, kind of unusual.

9:59

This is sort of the reverse

10:00

halo sign or the atoll sign.

10:03

Um, I don't use signs like that very much.

10:05

I just say, hey, that's consolidated.

10:07

I know that they have two months of dyspnea.

10:09

This is a chronic process.

10:11

There were no enlarged lymph nodes.

10:13

I really don't see too much

10:14

here to suggest scarring.

10:16

Um, you know, an infection-induced

10:19

organizing pneumonia and indolent infection.

10:23

Maybe, uh, you know, in the end,

10:27

um, you know, drug toxicity?

10:29

No, not really.

10:30

In the end, what do you do?

10:31

Well, you go to biopsy, and when they

10:34

removed it, they found cryptogenic

10:36

organized pneumonia and cellular SIP.

10:38

Um, these are unusual diseases, but they do

10:42

tend to manifest with that consolidated process.

10:45

Um, and that's what it is.

10:46

Sometimes, though, you have to go to biopsy.

10:49

So, chronic consolidations

10:52

are not common, but when they are,

10:54

they have a few common pathologies.

10:57

Cryptogenic organized pneumonia,

10:58

perhaps being the most common.

11:00

Look for evidence of tracheobronchial

11:02

cysts or scarring, uh, that is associated

11:05

with chronic inflammation, the presence

11:07

of pathologically enlarged lymph nodes,

11:09

a very useful clue for lymphoma, not the

11:12

primary, but the lymphoma and granulomatous.

11:16

And with that, I thank you very much.