The MIRC site is working again thanks to a home on a new server. This week’s case is a 3 year old female neutered Yorkshire Terrier with 1 week history of lethargy, dyspnea, and decreased appetite. Go straight to the case or browse to it through the MIRC site. Since everyone did so well in describing the last case before seeing the answer, I’m going to keep the interpretation and diagnosis hidden for a few days. The second set of radiographs was taken two weeks post-treatment. Post your interpretations and differentials in the comments section!
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November 15th, 2007 at 10:13 pm
There was no cough? then this one may be tricky.
A. Pre-Tx
Radiographic findings
- Multifocal, patch-like peripheral alveolar patterns (air-bronchogram, air-alveologram) are identified in the lung fields, especially in the right middle lung lobe, the caudal part of the left cranial lobe, and the caudal lung lobes.
- Hazy interstitial patterns and mild to moderate bronchial patterns are noticed.
- The cardiac silhouette is obscured by pulmonary infiltrations on the VD radiograph.
Radiographic Dx
: A Lung infiltration with mixed patterns (alveolar, interstitial, bronchial)
DDx
1. Bronchopneumonia (even though there was no cough, we can not ignore this one)
2. Pulmonary hemorrhage (probably from intoxication. Not from trauma)
3. Dirofilariasis
-although there are no classic signs of HW diz (MPA bulging, Pulmonary artery enlargement and tortous shape of it…), and usually the lung infiltration is getting worse after treatment.
4. Allergy or Smoke inhalation (if there was a history)
5. Metabolic pneumonitis ???
Need cytologic exam (TTW or BAL)
B. Post-Tx
Radiographic findings
1. Most pulmonary infiltration had been resolved
2. On the VD radiograph, the heart looks bigger than normal but the cardiac size is within normal limit on lateral radiographs
3. 2 radiopaque, ring-shape gastric foreign bodies
Radiographic Dx
- Gastric foreign body
November 16th, 2007 at 9:27 am
I agree that it’s a mixed pattern, but primarily alveolar with some interstitial disease. I don’t see any doughnuts or tram-tracks to indicate a bronchial component. The patchy alveolar densities are poorly defined and distributed throughout the lung.
Let’s back up from specific diagnoses for a minute and think about broad categories. Working from the DAMNIT scheme, our findings point to things like inflammatory, infectious, idiopathic disease, and rule out trauma and neoplasia. Your top differentials are all in these categories.
Whenever I see these ill-defined alveolar patches, I think infectious/inflammatory disease. Neoplastic nodules are always much more well-defined.
November 16th, 2007 at 5:09 pm
Thanks Dr.Z
That’s a good advice. I always got confused with bronchial patterns, and concerned about over-diagnosis with bronchial patterns. How I can tell the normal bronchial changes (senile changes, large-breed dog’s prominent bronchi…) from the pathologic changes without histories? I know it’s hard to tell, but is there any tip?
It’s been so long to hear “DAMNIT” (:
November 17th, 2007 at 3:38 pm
Good question. As it happens, the case for next week is right along those lines! I’ll also post a short topic on bronchial patterns with some tips to help you interpret them. Thanks for the questions!
November 17th, 2007 at 10:39 pm
OK, the answers are visible now if you view the case in MIRC.