Biomedical subjects
J P Balikian
Publications and source records attributed to J P Balikian.
Parietal pleural changes in empyema: appearances at CT.
The parietal pleura bordering pleural space collections was analyzed with computed tomography (CT) in 35 patients with thoracic empyema, 30 patients with malignant effusion, and 20 patients with transudatory effusion. Enhancement of the parietal pleura was present in 96% of the 25 patients with empyema who underwent contrast material-enhanced examinations. Of the 35 patients with empyema, 86% showed thickening of the parietal pleura, 60% showed thickening of the extrapleural subcostal tissues, and 35% showed increased attenuation of the extrapleural fat. None of the 20 patients with transudatory effusion showed these findings. Of the 30 patients with malignant effusion, eight patients (27%) showed chest wall changes similar to those of the patients with empyema. However, two-thirds of these patients had a recognized superimposed complication (ie, sclerotherapy). Contrast-enhanced CT appears to be sensitive to chest wall changes in patients with empyema. CT study of the parietal pleura may help suggest occult pleural space infections and may influence therapeutic decisions that vary with the stage of empyema.
Idiopathic bronchiolitis obliterans organizing pneumonia with peripheral infiltrates on chest roentgenogram.
We report five patients with chest roentgenograms showing peripheral infiltrates similar to that described for chronic eosinophilic pneumonia (CEP). While lung biopsy specimens (transbronchial and open in two and transbronchial only in three cases) revealed typical changes of bronchiolitis obliterans organizing pneumonia (BOOP) as the predominant finding in all cases, two cases had changes consistent with a resolving CEP. We speculate that (1) it may be common for BOOP to present with peripheral infiltrates, (2) chest roentgenograms showing peripheral infiltrates are not diagnostic of any specific entity, (3) idiopathic BOOP may represent the evolution of untreated CEP, (4) a lung biopsy may be a more appropriate initial approach than the therapeutic trial of corticosteroids when peripheral infiltrates of unknown origin are present, and (5) transbronchial biopsy may be adequate to establish a working clinical diagnosis of BOOP.
Organ envelopment in lymphoma visualised by computed tomography.
In 12 patients computed tomography revealed an unusual pattern of lymphomatous growth resulting in envelopment or engulfment of an organ. The kidneys were involved in eight cases, and the mediastinum and pericardium, oesophagus, stomach and rectosigmoid colon, and psoas muscle in one case each. Ten patients had non-Hodgkin's lymphoma and two had Hodgkin's disease; in every case, lymphomatous masses surrounded but did not destroy the affected tissues. The potential for both Hodgkin's and non-Hodgkin's lymphomas to enwrap both renal and non-renal tissues has not previously been emphasised.
The efficacy of routine whole lung tomography in germ cell tumors.
A prospective analysis was undertaken to evaluate the efficacy of performing routine whole lung tomography in addition to conventional chest radiography in the initial staging and subsequent management of 120 patients with seminomatous and nonseminomatous germ cell tumors. Two hundred fifty whole lung tomographs were performed on these patients. At presentation, only one patient (0.8%) had positive tomography with simultaneously normal posteroanterior and lateral chest films. On follow-up tomographic examinations, three patients had metastases when chest roentgenographs were normal. In only one patient was therapy altered by tomographic findings. The results indicate that routine whole lung tomography is not useful or cost-effective in the initial staging and subsequent management of patients with germ cell tumors.
Pulmonary complications associated with combination chemotherapy programs containing bleomycin.
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Peri- and paracardial involvement in lymphoma: a radiographic study of 11 cases.
Eleven patients with pericardiac and paracardiac lymphomatous involvement were studied. Computed tomography (CT) of the chest was compared to plain chest films for its ability to define the sites and extent of involvement in the paracardiac area. Nine of the 11 patients had abnormalities on chest radiography, which included abnormal contours in the fat pad areas and along the heart border, or an enlarged cardiac silhouette. Two patients had normal cardiac silhouettes; however, CT showed definite abnormalities. CT differentiated adenopathy from fat pads in two patients and pericardial effusion from cardiomegaly or paracardiac adenopathy in two patients. The exact location and extent of the paracardiac adenopathy initially seen on chest film was defined by CT. Careful analysis of the peri- and paracardiac areas by plain films and CT is essential to the diagnosis and the proper management of patients with Hodgkin and non-Hodgkin lymphoma.
Pathologic patterns of Serratia marcescens pneumonia.
To characterize the pulmonary lesions caused by Serratia marcescens, the authors reviewed all autopsy-culture-proven cases of S. marcescens pneumonia occurring at their hospital between 1968 and mid-1980. In 16, S. marcescens was the only organism cultured from the lungs during life or at autopsy. This report describes primarily these pure infections. Two histopathologic reactions were seen. Nine non-neutropenic patients had acute, hemorrhagic bronchopneumonia, seven with microabscesses and two with larger cavities. In seven, distinctive vasculitis was apparent in vessels larger than 75 microns in diameter; intramural gram-negative rods were identified in two. Seven immunosuppressed patients had diffuse neutropenic pneumonitis resembling diffuse alveolar damage, with extensive intra-alveolar fibrinous exudates and pulmonary hemorrhage. In two patients, bacteria without cellular reaction were present. In patients with prolonged infections, focal areas of intra-alveolar organization and bronchiolitis obliterans accompanied both patterns. Since the incidence of nosocomial S. marcescens infection is increasing and since pneumonia caused by this organism is recognizable histologically, autopsy cultures positive for S. marcescens should not be disregarded.
350 kV chest radiography has no diagnostic advantage: a comparison with 140 kV technique.
It has been suggested that a 350 kV technique will produce better chest radiographs than lower kilovoltage techniques. This is because the 350 kV x-ray spectrum provides better penetration of the overlying bony structures and results in a clearer delineation of the mediastinum. Fifty cases, containing 92 definite and significant abnormalities, were selected from a pool of 500 patients who had both 350 and 140 kV chest radiographs on the same day. The 50 paired films were studied at separate times by five experienced radiologists. The interpretations were analyzed for accuracy, significance, and confidence level; interpretation times and the utility of the lateral radiograph were also noted. When all the definitely and potentially significant abnormal findings were considered, the 350 kV films produced fewer true-positive reports and more false-positive reports than the 140 kV films. The receiver operating characteristic (ROC) curves, constructed from the observers' confidence ratings, were shifted toward less satisfactory performance for the 350 kV readings. When only statements about nodules and masses were considered, identical ROC curves were produced by the two techniques. Despite their potential advantages, the 350 kV films showed no diagnostic superiority over the 140 kV films.
Pulmonary complications of chemotherapy regimens containing bleomycin.
Twenty patients with pulmonary complications associated with combination chemotherapy regimens containing bleomycin were studied to determine common patterns of pulmonary radiographic abnormalities. All patients were receiving bleomycin on one of two different regimens of combination chemotherapy. Ten patients with non-Hodgkin lymphoma received a relatively low dose (22-64 mg total) and 10 patients with testicular cancer received a higher dose (360 mg total). The high-dose group showed subclinical radiographic lung toxicity changes in eight (80%) patients during and after therapy. Chronic pulmonary abnormalities were seen in nine (90%) patients in the high-dose group but in only three (30%) patients in the low-dose group. These was no significant difference in the pattern and distribution of lung infiltrates in these two groups. Infiltrates involving mainly the costophrenic triangle were seen in 18 (90%) patients; in six (33%) of these the changes were confined to the costophrenic triangles bilaterally and nearly symmetrically. Five (25%) patients had infiltrates at the periphery of the lungs. Elevation of the diaphragm was seen in 16 (80%) patients. A pleural reaction without gross effusion was seen in nine (45%) patients, of whom five (55%) demonstrated thickening of the interlobar fissures. Chronic lung changes were mostly confined to the bases in the form of failure of reexpansion of the costophrenic triangle (55%), persistent elevation of the diaphragm (35%), and a reticular meshwork of fibrosis at the costophrenic triangles (25%). Minimal lung disease was manifest as ground glass appearance at the lung bases and as fine, linear or reticulonodular densities that involved the costophrenic triangles.
Exogenous lipoid pneumonia.
Eleven patients with exogenous lipoid pneumonia are reported. A history of usage of oil was obtained in all, but in five only retrospectively after thoracotomy. The clinical presentations ranged from occasional cough to severe respiratory difficulties. The radiologic manifestations varied from a solitary lipoid granuloma and larger consolidations simulating carcinoma to extensive subacute bronchopneumonia. The definitive diagnosis was made by history and radiographic findings in three, by history and analysis of sputum or bronchial washings in two, and after thoracotomy in six.
Serratia pneumonia.
The clinical and radiological manifestations were correlated with the necropsy findings in the lungs of 18 patients who died of Serratia marcescens infection. Ten died during a hospital epidemic affecting 74 patients. In 14, only Serratia was identified at autopsy; in 4, other organisms were also cultured. Ten patients had septicemia. The predominant radiological findings were focal bronchopneumonia in 13, lobar consolidation in 2, and diffuse nonhomogeneous infiltrates in 10. Small radiolucent areas within the infiltrates were seen in 5, a large pulmonary abscess in 1, and pleural effusion in 7. The predominant pathological findings were focal necrotizing bronchopneumonia (sometimes with microscopic abscesses) in 14 and diffuse hemorrhage in 3. Three patients had endocarditis and 3 others showed dissemination to the brain or kidneys.
Non-Hodgkin lymphoma of the lungs.
Twenty-seven consecutive cases of pulmonary involvement by non-Hodgkin in lymphoma, including 2 cases of primary pulmonary disease, were anlyzed. The radiological manifestations of illness were divided into (a) nodular (subpleural, deep parenchymal, or perihilar), (b) pneumonic-alveolar (segmental or lobar), (c) bronchovascular-lymphangitic (central bronchovascular or diffuse lymphangitic), and (d) miliary-hematogenous. Histiocytic lymphoma was associated with infiltration of rapid onset in 6, cavitating nodules in 2, and diffuse lymphangitic dissemination in 9. Of 16 patients with lymphocytic lymphoma, 7 had lobar or segmental alveolar involvement.
Pulmonary nocardiosis.
Six cases of pulmonary nocardiosis are reported. All patients were compromised hosts treated with corticosteroids and/or immunosuppressive agents. The clinical presentations ranged from malaise to respiratory failure. The radiological manifestations varied from a solitary nodule to extensive cavitary bronchopneumonia with distant dissemination. The diagnosis was made by sputum culture in one, open lung biopsy in 3, and at autopsy in 2 others. In 3 patients, in whom early diagnosis was made, the infection was controlled by sulfonamide therapy.
Giant hyperplastic parathyroid gland in the mediastinum--partially cystic and calcified.
A large, calcified paratracheal mass was identified in a patient with secondary hyperparathyroidism. The mass proved to be a giant, calcified, cystic, hyperplastic parathyroid gland. Radiographic and ultrasonic imaging techniques were quite useful in diagnostic evaluation. Whenever a calcified mediastinal or neck mass is discovered, especially in a patient with hyperparathyroidism, parathyroid enlargement should be a diagnostic consideration.
Pulmonary actinomycosis. A report of three cases.
The diagnosis of thoracic actinomycosis is readily made when the patient presents with the constellation of poor oral hygiene, pulmonary infiltrates, empyema, sinus tracts, and osteomyelitis of the ribs. However, in the absence of rib and chest wall involvement, the disease may be overlooked. Three cases of primary pulmonary actinomycosis are presented showing three different pulmonary forms of the disease and comprising (a) subacute patchy pulmonary infiltrates, (b) a cavitary lesion simulating tuberculosis, and (c) a central mass lesion simulating bronchogenic carcinoma.
The pulmonary-renal syndrome.
The pulmonary-renal syndrome is characterized by the coexistence of life-threatening pulmonary hemorrhage and renal disease in individuals without any concomitant destructive pulmonary disease or coagulopathy. Six patients fulfilled the above criteria despite diverse etiologies and pathomechanisms of disease. Two patients showed evidence of anti-glomerular basement membrane antibodies, while three others showed immune complexes in their kidneys. Therefore, it is likely that immunologic events play an important pathogenic role in this syndrome, explaining the effectiveness of nephrectomy as demonstrated in these patients. The chest radiograph was a reliable indicator of the extent of the pulmonary hemorrhage and was representative of the clinical presentation and blood gas levels. During the recovery phase the radiographic findings lagged somewhat behind the clinical improvement in the gas exchange.
Fulminant necrotizing amebic colitis in children.
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