Pulmonary Cutaneous Syndromes
Eric J. Stern, MD
DIFFERENTIAL DIAGNOSIS
Common
Infections
Tuberculosis, Coccidioidomycosis, Histoplasmosis, Aspergillosis, Zygomycoses, Herpes Zoster
Superior Vena Cava Syndrome
Less Common
Wegener Granulomatosis
Hypertrophic Osteoarthropathy
Fat Embolism Syndrome
Hereditary Hemorrhagic Telangiectasia
Rare but Important
Neurofibromatosis Type 1
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Imaging depends upon associated condition
With pulmonary cutaneous infections, usually disseminated disease
Helpful Clues for Common Diagnoses
Infections
Patients typically immunocompromised
Tuberculosis: Primary cutaneous tuberculosis, lupus vulgaris, scrofuloderma
Primary tuberculosis may show unilateral hilar lymphadenopathy, unilateral pulmonary consolidation, pleural effusion
Reactivation tuberculosis shows fibrocavitary disease in upper lobes
Miliary disease uncommon but indicates hematogenous dissemination
Coccidioidomycosis: Nonspecific erythema nodosum
Nonspecific patchy segmental consolidation, hilar or paratracheal lymphadenopathy
5% have persistent consolidation or fibrocavitary changes
Remote disease shows single thin-walled cavity or nodule in periphery of upper lobe
Miliary pattern suggests disseminated disease
Histoplasmosis: Cutaneous findings variable and include erythema multiforme and erythema nodosum
Imaging findings of acute histoplasma pneumonia nonspecific; solitary or multifocal airspace opacity, ipsilateral hilar and mediastinal lymphadenopathy
Subcentimeter calcified or noncalcified pulmonary granulomas often persist after resolution of pneumonia
Chronic cavitary disease indistinguishable from reactivation tuberculosis
Aspergillosis: Only angioinvasive disease can manifest cutaneously
Classic presentation as nodule surrounded by “ground-glass” opacity; halo sign
Consolidation and cavitation often progressive with prolonged infection
Zygomycoses: Particularly Mucor species
Commonly involves paranasal sinuses and orbit but can include any tissue
Can spread hematogenously or directly from lung or sinus
Most commonly seen in patients with diabetes mellitus
Superior Vena Cava Syndrome
Impaired venous drainage of head, neck, and upper extremities due to obstruction to flow in superior vena cava
Facial plethora, arm swelling, dyspnea, cough, dilated chest veins
External compression more common than in situ thrombosis
Classically small cell lung cancer
2-4% incidence of SVC syndrome with any lung cancer or non-Hodgkin lymphoma, 10% incidence with small cell lung cancer
Chest radiograph shows mediastinal widening
Chest CT confirms obstruction of major veins and associated dilation of collateral vessels
Helpful Clues for Less Common Diagnoses
Wegener Granulomatosis
Small to medium vessel autoimmune vasculitis
Nearly all patients have upper airway or lung involvement
Skin involvement includes palpable purpura, subcutaneous nodules, ulcers, digital infarcts and gangrene, pyoderma, rheumatoid papules, urticaria, gingival hyperplasia
Multiple pulmonary nodules without zonal predominance, 50% with cavitation
Diffuse or focal tracheal thickening or narrowing
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