Today’s case is a 4 year old male neutered Brittany Spaniel with lethargy, coughing, and difficulty breathing.
4 year old Brittany Spaniel
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{ 12 comments… read them below or add one }
There is increased caudally diffused broncho alveolar pattern with a local alveolar pattern in the right caudal lung lobe close to the heart base. Cardiac silhouette is obscure but size appears to be within normal limits. Cranial pulmonary vessels are symmetric and normal in size. Small amount of fluid accumulation on the left cranial pleural space. Lymph nodes are not noticeable.
RDx
Pleural effusion
Suspected Pneumonia VS CHF further history ( heart murmur, temperature on presentation, nasal discharge, travelling history) will help me in my interpretation.
There is an mixed patterns (bronchial,alveolar and interstizial) localized predominantly in the right caudal lung lobe; in vd there are air bronchograms. In the right lateral projection pleural effusion is present. Heart silhouette can’t be studied because of increased opacity. Vascolar structures are normal. No lymphhadenopathy.
DDX: Bronchopneumonia (mycotic, bacterial) with pleural effusion; an eosinophilic pneumonia can’t rouled out.
Both of you have noted the unusual alveolar pattern without obvious cardiac disease, plus pleural effusion. So let’s step back and look at this case again. What do you think about the mediastinum? What are broad categories for fluid in the lungs or pleural space? Is this a typical distribution for pneumonia?
I am not seen abnormalities in the caudal mediastinum. In the cranial mediastinum there is increase radiopacity on the lateral view but no deviation of the trachea in the VD. There is slight enlargement on the right side of the cranial mediastinum.
I though that some of these changes were due to pleural effusion.
In terms of broad categories
1) Decreased oncotic pressure
2) Vascular overload
3) Increased vascular permeability
4) other ( Upper respiraotry obstructions, seizures, head trauma, drowning)
I guess other clasiffication would be
cardiogenic, non-cardiogenic and neurogenic edema.
I usually see peumonia in the right middle lung lobe and tens to affect the pending size of the lung so the appex.
Am I in the right track here
The trachea is a little bit lifted. The cardiac silhouette can’t be studied because of the presence of increased radiopacity. Interlobar fissures are visible in right lateral projection; all this signs are reported to pleural effusion. There is a mixed pattern in the caudal lobes. In VD the increase of radiopacity is localized in part of the middle right lobe, and predominantly in the right caudal lobe. I think there is also poor visualization of pulmonary vessels. I agree with vet 76 that little mediastinum changes could be a side effect of the pleural effusion. Here are some categories of pleural effusion: cronic heart failure, trauma, hypopreteinemia, mediastinitis, pyothorax, neoplastoc processes. Thinking about fluid in the lungs, other categories are:cardiogenic or non cardiogenic edema, bronchopneumonia (frequently in middle and caudal lobes), lobar torsion (accompanied with free fluid in pleural space), lobar atelectasia (obstruction, foreign body), neoplastic processes.
Those are good lists of differentials. To think of differentials in broad categories of fluid, I always start with blood, pus and water. From there you can branch off to more specific disease process as listed above. Did you notice one was missing from your differentials?
If you look at the cranial mediastinum on the d/v projection, it’s wider than you would expect with the small amount of pleural effusion present. I agree that there is no mass visible on the lateral projection. In addition, look closely at the trachea on the lateral projections…
In the right lateral projection, looking closely at the trachea, I think that one of the bronchial branches appears deviate from his original position.
It could derive from the presence of something taking up space, like a tracheobronchial limph node?
Consequently, the mixed pattern before highlighted could be defined an unstructured interstitial pattern, caused by an inflammatory or neoplastic cellular infiltrate?
Thank you for the clarification about the mediastinum.
Now, the intrathoracic tracheal lumen in the right lateral view appear reduce with a thicker dorsal wall, Not noted on the left lateral so a membrane remanance can be the reason. Also the external tracheal wall is visible.
Yes, the dorsal tracheal wall is thickened. Can anyone put the signs together for a diagnosis? This is a tough one!
The thickening of the dorsal tracheal wall can be a sign of anticoagulant poisoning, these explains also the diffuse bronco-interstitial pattern and the mild pleural effusion.
Exactly. The widened cranial mediastinum is also due to hemorrhage.
Thank you very much, it was a tough case for me however I got new concepts that I will apply in my future readings.
Keep them comming Dr Zwingenberger.
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