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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

Tumour

Metastasis Breast, renal, thyroid, squamous carcinoma (head and neck), gastrointestinal tumours, osteosarcoma

Lymphoma Infection

Bacterial Abscesses, Staph. aureus, Pseudomonas, TB

Parasitic Hydatid

Infarction

Multiple pulmonary infarct

Vascular Pulmonary avm

Granuloma Wegeners Rheumatoid nodule

AIDS

Kaposi sarcoma

Occupation Caplans, PMF

Others Amyloid

Papillomatosis of the lung

Question 23

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).

Fig. 1.69 CT miliary nodules -miliary TB. There are innumerable tiny nodules distributed throughout both lungs. The clinical setting is important in making the diagnosis as dust inhalation, granulomatous diseases, infection and metastases can give a similar appearance.

Table 1.12 Miliary nodules

• Dust inhalation/pneumoconiosis

• Extrinsic allergic alveolitis

• Miliary metastases: thyroid, melanoma

■ Dense miliary nodules

• Haemosiderosis

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