If pushed, this film is another situation where a surgical sieve will help to recall causes of multiple pulmonary nodules/masses (Table 1.11).
Table 1.11 Causes of multiple pulmonary nodules/masses
Metastasis Breast, renal, thyroid, squamous carcinoma (head and neck), gastrointestinal tumours, osteosarcoma
Bacterial Abscesses, Staph. aureus, Pseudomonas, TB
Multiple pulmonary infarct
Vascular Pulmonary avm
Granuloma Wegeners Rheumatoid nodule
Occupation Caplans, PMF
Papillomatosis of the lung
Answer Miliary nodules
There are multiple miliary nodules in both lungs (see CT Fig. 1.69). The patient is from Africa and is unwell making miliary TB the most likely diagnosis. Barrier nursing in isolation should be undertaken.
TB is spread by the respiratory route, so precautions must be taken to sterilise ventilation equipment following use. Disposable equipment should be used where possible and bacterial filters should be used to protect the ITU ventilator. Medical and nursing staff are at risk of infection, full face masks and eye protection should be worn during procedures involving the airway. If he was well, consider sarcoid or pneumoconiosis (old films would help in this latter differential). Any history of primary malignancy is important, thyroid malignancy, bone sarcoma and trophoblastic disease can give rise to miliary metastases. Further less common possibilities include acute extrinsic allergic alveolitis, nodular pulmonary fibrosis and histiocytosis X.
Haematogenous metastases tend to go to the bases and inhaled dusts to the apices. Densely calcified tiny nodules have a different differential diagnosis (Table 1.12).
Table 1.12 Miliary nodules
• Dust inhalation/pneumoconiosis
• Extrinsic allergic alveolitis
• Miliary metastases: thyroid, melanoma
■ Dense miliary nodules
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