0:00

So we do have another case with a similar presentation, and that's this patient here

0:06

who is 69 years old, complaining of shortness of breath.

0:10

And again, if we go through in a very

0:13

organized fashion on the AP view, the portable AP view, again,

0:17

we see the same or very similar degree of haziness throughout the lungs.

0:21

There seems to be a little bit of Perihilar opacifications bilaterally.

0:26

We don't see large pleural effusions.

0:28

We don't see focal consolidations.

0:30

There's no pneumothorax at all.

0:32

We do see overlying monitoring wires.

0:35

There is a spinal stimulator here. On the bone-enhanced windows,

0:39

you know, it's really more of the same,

0:41

but you get a sense of how busy the interstitial might be.

0:44

And it really does seem to be a much more

0:46

centralized appearance, which can be seen in pulmonary edema.

0:50

And so, you know, I think we were prepared to call this pulmonary edema,

0:54

but also just kind of saying with the caveat,

0:56

you know, if there are signs and symptoms that suggest infection,

0:59

then, you know, please consider that because, again, the overlap can be very real.

1:04

And so this patient did have a CT, and I'll share that with you now.

1:08

And just on the scout view here,

1:10

a very similar appearance of the prominent interstitium, the involvement of the hilar

1:17

region, the spinal stimuli that we saw before in the overlying monitoring wires.

1:21

We'll take a look through.

1:22

Again, we did give contrast here. From the top,

1:25

flying down, just taking a look at the vessels.

1:28

Major vessels are looking good so far.

1:30

The carotid's thyroid gland is normal.

1:35

Three vessel arch.

1:37

Just taking a look at the aorta down

1:39

into the left ventricle, and then back out. Again, looking at the entirety

1:46

of the aorta, there's no dilatation. There is no evidence of dissection.

1:53

And we can see that the celiac and the SMA are patents in their branches and their takeoffs.

2:00

Underneath the diaphragm looks fine.

2:02

As we come back up through the diaphragm,

2:05

I do notice that the esophagus is pretty thickened.

2:09

This is the esophagus here, almost as large as the aorta itself.

2:15

As we move through, and again, we get a peak in the lumen.

2:19

But the esophagus is thickened, almost in its entirety so far.

2:26

And again right here, still pretty thickened. Still pretty thickened.

2:33

So it's diffuse circumferential thickening of the esophagus.

2:37

So an esophagitis certainly could look like this.

2:40

It's not focal. It doesn't look like an apple core lesions.

2:43

So something very focal, like a cancer,

2:47

probably not as much, but something more diffuse-like.

2:50

Inflammation or an infection can certainly look like this.

2:53

Patients with long-standing, really horrible GERD and reflux, could

2:57

certainly have an esophagus that looks like this.

3:00

Take a look at the mediastinum to see if there's any sort of adenopathy.

3:04

And we don't. One thing about the esophagus,

3:07

just to go back, there's this nonspecific calcification that is right here.

3:13

And it's not really clear if we're looking at calcification or we've given contrast.

3:18

It's the same attenuation, it's just a small little bleed. On this one phase,

3:23

it's hard to know.

3:24

We didn't give a non-contrast run, so we're going to differentiate that out.

3:28

So this is something to kind of, you know, check with.

3:31

If this patient is anemic, if this patient has got guaiac positive

3:35

blood or coughing up blood, I would put this in a different category,

3:40

versus this is something that's just calcified.

3:42

Looking at the pulmonary vessels,

3:44

don't see any large evidence of pulmonary embolism.

3:50

The branching vessels, the subsegmental, segmental,

3:53

lobar vessels on the right and the left look normal.

4:01

We see some lymph nodes.

4:02

They don't necessarily look too large in the pretracheal region.

4:06

We got some prominent ones here in the right hilar region. Right along here.

4:14

Let's take a look at the lung windows

4:16

and understand what's happening here, and see if we can put some synthesis

4:20

around this patient's presenting symptoms and what's going on with them.

4:26

So, again, a lot of ground glass opacity is seen bilaterally.

4:30

This is in the more dependent area.

4:32

So sometimes at atelectasis. You might say, 'Yeah, this is atelectasis.'

4:35

But if we move beyond some of those

4:37

dependent areas, we're seeing very similar findings.

4:42

We're going to see it here in, again,

4:44

some of the dependent areas, but also in some of the non-dependent areas.

4:48

So I would not attribute all of this

4:51

stuff, this ground glass opacity, to just atelectasis, all these ground glass.

4:57

So this is like a multifocal ground glass opacity.

5:01

A lot of the ground glass opacities...

5:03

Some of them are beginning to consolidate

5:05

into more noduler forms, and are a little bit more dense than just the ground glass.

5:11

Again, we don't see large effusion.

5:13

We don't see pneumothorax.

5:15

I don't see a dominant mass or even a nodule.

5:20

In a patient with esophagitis, you know, could some of this have been aspiration?

5:24

The distribution is not great.

5:26

It's not just in the dependent areas.

5:28

I don't see anything in the airways,

5:29

but certainly, some sort of inflammatory or infectious process I would consider.

5:34

So when we go back to where we started

5:36

on the x-ray, this is a situation where you have an x-ray that, you know, certainly could have

5:41

fit really nicely into the pulmonary edema pattern.

5:45

But remember that some of that overlap

5:47

between pulmonary edema, and then some of that atypical infection and/or

5:52

inflammation, can be determined or differentiated on CT.

5:57

So give your clinicians a call and try to figure out what's going on.

6:01

If there are signs and symptoms

6:02

that suggest infection or inflammation, the CT may be helpful.

6:05

If it's a straightforward,

6:07

you know, this is a patient who's got a history of edema, or we think this is just

6:10

pulmonary edema, the findings may be adequate on x-ray.

6:14

A lot of the information here is around what's going on with the patient, and then

6:18

being able to actively decide what's the appropriate next clinical imaging step.