Case 1
A 35 year old female presents with haemoptysis, epistaxis and acute renal impairment. A chest radiograph is taken and a second radiograph is taken a week later.
1. Which of the following is the least likely diagnosis for these radiographic appearances?
a) Pulmonary infarcts
b) Systemic sclerosis
c) Sarcoidosis
d) Vasculitis
e) Septic emboli
2. What is the most likely unifying diagnosis given the clinical history?
a) Osteosarcoma metastases
b) Systemic lupus erythmatosis
c) Rheumatoid arthritis
d) Granulomatosis with polyangiitis
e) Pulmonary infarcts
Case 2
A 33-year-old male non-smoker presents with wheeze and abnormal liver function tests on blood biochemistry.
1. Consult the chest radiograph and determine the most likely underlying diagnosis
a) Asthma
b) α1-Antitrypsin deficiency
c) Chronic obstructive pulmonary disease
d) Obstructive sleep apnoea
e) Pulmonary fibrosis
Answers
Case 1
1. b) Systemic sclerosis. Systemic sclerosis does not typically result in multiple cavitating lesions. On the initial radiograph there are multiple discrete nodules within both upper zones and within the left midzone. Cavitation of these nodules is apparent on the subsequent radiograph and which appear thick-walled.
The differential diagnosis for the development of multiple thick walled cavities includes:
Infective | Staphylococcus aureus Klebsiella pneumoniae Tuberculosis |
Vascular | Multiple pulmonary emboli |
Neoplastic | Metastases (common primaries include squamous cell, sarcoma, colon cancer) |
Granulomas | Granulomatosis with polyangiitis Rheumatoid nodules Sarcoidosis |
2. d) Granulomatosis with polyangiitis. In this case, the patient was diagnosed with Granulomatosis with polyangiitis previously known as Wegener’s granulomatosis. This is characterised by a necrotising granulomatous inflammation of the upper and lower respiratory tracts. Small vessel necrotising vasculitis affecting the arteries and veins as well as a focal, necrotising glomerulonephritis. The acute renal impairment …