Thread by @PulmPEEPs

Nothing like #RadiologyRounds to kick off a work week after a long weekend!

A middle aged man with metastatic esophageal cancer presents with 2 weeks of low grade fevers and more recently progressive dyspnea . Exam notable for late inspiratory crackles throughout the right lung

A CT scan was obtained and here are the images:

How would you describe these findings??

What is your lead differential when you see predominantly unilateral GGOs and consolidations?

The patient had predominant GGOs that progressed to more consolidation opacities in a craniocaudal gradient. They were predominantly right sided and both peripheral and central, with superimposed septal thickening

A bronchoscopy was performed and an expanded infectious panel was sent and all negative, as were serum infectious studies (e.g. histoplasmosis ag, urine legionella etc).

A tbbx biopsy showed plugs of granulation tissue filling the alveolar spaces

The patient was on 4 L of oxygen but otherwise stable thus far. Based on this what is your next treatment?

The patient was diagnosed with immune check point inhibitor pneumonitis. The pathology was most consistent with Organizing Pneumonia, and that with her exposure history and the time course of illness made the diagnosis. Pathology and CT findings in ICI pneumonitis can vary widely

She was treated with steroids but her hypoxemia progressed and she was ultimately intubated. What is your treatment of choice for refractory ICI pneumonitis?

Severe ICI is rare and the treatment for steroid refractory disease is still based on small series and case reports

This patient was treated with high dose steroids (2mg/kg), IVIG, MMF, and tocilizumab. With that she improved after 10 days intubated and was weaned to RA

Thanks for following along!! Listen in next week for a partnered episode with @CardioNerds on the management of acute RV failure!