Pulmonary Alveolar Microlithiasis - Chest X Ray

A 39 years old female came to radiology department for X-ray chest with history of dyspnea on exertion. The X ray is shown as below:

Radiological Findings on the X ray Chest: X-ray chest (in the picture above) shows that the lung fields are diffusely occupied by discrete high density opacities resembling grains of sands. In spite of
superimposition or summations of shadows the individual deposits are identifiable and measure about a 1 mm in diameter thick and streaky. The opacity appears confluent showing the lungs as almost white with obliteration of the mediastinal and diaphragmatic contours and pulmonary vascular marking are indistinct. The density is greater over the lower than the upper zone.

Comments and Explanation: The characteristic finding on the chest radiograph is that of a fine, dense stippling. This is a well-defined, nodular infiltrate which involves both lungs, and may be so extensive as to cause opaque lungs with relative lucency of the mediastinal structures, diaphragm and pleura. There is widespread parenchymal calcification.
In addition to the finding seen, other findings that may be seen include bullae in the lung apices, a zone of increased lucency between lung parenchyma and the ribs (a black pleural line) and pleural calcification.
In some patients concentration of the nodules in subpleural, para septal and peribronchiolar alveoli can produce linear strands of calcification parallel to or perpendicular to the pleural surface.

Bullous Myringitis - Clinical presentation & Management

Bullous myringitis is a direct inflammation and infection of the tympanic membrane secondary to a viral or bacterial agent. Vesicles or bullae filled with blood or serosanguinous fluid on an erythematous tympanic membrane are the hallmarks. Frequently, a concomitant otitis media with effusion is noted.
Typical pathogens are the same as seen in Acute otitis media.

Clinical Presentation: The onset of bullous myringitis is preceded by an upper respiratory tract infection and is heralded by sudden onset of severe ear pain, scant serosanguinous drainage from the ear canal, and frequently some degree of hearing loss.
Otoscopy reveals bullae on either the inner or outer surface of the tympanic membrane.

Bullous Myringitis. A large fluid-filled bulla is seen distorting the surface of the tympanic membrane.

Patients presenting with fever, hearing loss, and purulent drainage are more likely to have concomitant infections, such as Otitis media and otitis externa .

Management: Differentiation between viral and bacterial etiologies for tympanic membrane bullae is not necessary. Although most episodes resolve spontaneously, many physicians prescribe antibiotics. Warm compresses, topical or strong analgesics, and oral decongestants provide symptomatic relief. Referral is not necessary in most cases unless rupture of the bullae is required for pain relief.

The External Ear - Different Conditions With Pictures

Eczematous Otitis Externa.
Eczema of the meatus and pinna (see picture below) may be associated with eczema elsewhere, particularly in the scalp, or it may be an isolated condition affecting only one ear.
Itching is the main symptom, with scanty discharge.

The eczematous type of otitis externa usually settles with the use of a topical corticosteroid and antibiotic drop. Cleaning of the meatus may also be necessary, either with cotton wool on a probe, or
suction and the Zeiss microscope. Otitis externa tends to recur.

A Furuncle In the Meatus
A furuncle in the meatus is the other common type of otitis externa. It is characterized by pain; pain on movement of the pinna or on inserting the auriscope is diagnostic of a furuncle.

Diabetes mellitus must be excluded with recurrent furuncles.

Coronary Angiography - Flash Cards

Foreign Body Seen on X ray

A 65-year-old male presented with cardiogenic shock. He had an emergency CABG (Coronary artery bypass grafting) which was associated with a very stormy peri-operative period.  His CXR (shown in picture below) was taken upon arrival at the Intensive Care Unit (ICU).

What is the most significant abnormality?

Case Discussion:

The CXR shows an opaque density in the region of the right lower zone.
Each lung field on an erect CXR is divided into three zones.

1. The upper zone is an area which lies above a horizontal line drawn from the medial end of the second rib anteriorly. 
2. The middle zone lies below this and is bordered inferiorly by a line drawn similarly from the fourth rib. 
3. The lower zone lies below this. 

This opaque density is similar in configuration to a tooth which was dislodged during emergency
intubation of this patient.

See the X ray again with the arrow pointing to the opacity

ECG and Brief Discussion - Right Atrial Hypertrophy

ECG Criteria
• P - Tall, > 2.5 mm (> 2.5 small squares), better seen in LII, LIII, aVF and sometimes in V1 .
(Tall P is called P pulmonale).
• P in V1 - Biphasic, tall initial positive deflection (> 1.5 mm) with a small negative deflection (only positive deflection may be present).

Q. What does P pulmonale indicate?
Ans. It indicates right atrial hypertrophy or enlargement.
(It is called P pulmonale, because it is commonly seen in severe pulmonary disease).

Q. What are the causes of P pulmonale?
Ans. As follows: