Lymphadenopathy;

Chest CT scan of my patient with congestive heart failure (CHF) and shortness of breath shows mediastinal adenopathy.  Can mediastinal adenopathy be caused by CHF alone?

FA Manian MD, MPH, , , , , , Leave a comment

Yes! Mediastinal adenopathy (commonly defined as 1 or more lymph nodes with a short axis diameter >1 cm) may be caused by CHF alone (AKA “congestive adenopathy”). 1-4

Although not as common as alveolar/interstitial edema on chest CT scan, hypertrophy of mediastinal lymph nodes may occur in a significant number of patients with CHF.  In a study involving 215 patients with CHF and no confounding etiology of adenopathy, 68% had evidence of adenopathy, particularly involving the right paratracheal and precarinal, subcarinal and other mediastinal lymph nodes; hilar and single station adenopathy were less common. The findings of pulmonary edema on CT and pleural effusion were significantly associated with adenopathy.1

In a study involving 3 patients with mediastinal adenopathy and CHF, lymph node biopsy showed noninflammatory, benign lesions that did not affect the node structure. Follow-up CT scan in 2 patients at 8 and 10 months showed no changes in the morphologic characteristics of mediastinal lymph nodes, while in another patient most of the enlarged lymph nodes disappeared at 5 months post- acute phase of the CHF.2   Interestingly, another study involving 31 cases of “subacute left heart failure” found that average ejection fraction was lower among patients with adenopathy (34% vs 43%).3

One potential mechanism for CHF-related adenopathy is that the excess lung fluid causes increased flow of fluid through the lymphatic channels and into the lymph nodes resulting in their congestion and enlargement.1

 

Bonus Pearl: Did you know that experimental animal studies have shown that acute CHF is associated with significant increases in mediastinal lymphatic flow and lymphatic vessel dilatation? 4-5

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References

  1. Shweihat YR, Perry J, Etman Y, et al. Congestive adenopathy: A mediastinal sequela of volume overload. J Bronchol Intervent Pulmonol 2016; 23:298-302. https://pubmed.ncbi.nlm.nih.gov/27623420/
  2. Ngom A, Dumont P, Diot P, et al. Benign mediastinal lymphadenopathy in congestive heart failure. CHEST 2001;119: 653-656. https://pubmed.ncbi.nlm.nih.gov/11171755/
  3. Chabbert V, Canevet G, Baixas C, et al. Mediastinal lymphadenopathy in congestive heart failure: a sequential CT evaluation with clinical and echocardiographic correlations. Eur Radiol 2004;14:881-889. https://pubmed.ncbi.nlm.nih.gov/14689226/
  4. Drake RE, Dhother S, Teague RA, et al. Lymph flow in sheep with rapid cardiac ventricular pacing. Am J Physiol 1997; 272:1595-1598. https://pubmed.ncbi.nlm.nih.gov/9176352/
  5. Leeds SE, Uhley HN, Telesky LB. Direct cannulation and injection lymphangiography of the canine cardiac and pulmonary efferent mediastinal lymphatics in congestive hart failure. Invest Radiol 1981;16:193-200. https://pubmed.ncbi.nlm.nih.gov/6266975/

Disclosures/Disclaimers: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Chest CT scan of my patient with congestive heart failure (CHF) and shortness of breath shows mediastinal adenopathy.  Can mediastinal adenopathy be caused by CHF alone?

What findings should I look for in the chest imaging of my patients with the novel Coronavirus disease/Covid-19?

FA Manian MD, MPH, , , , , , , , , , , 1 Comment

Chest imaging is often obtained to evaluate for pneumonia and progressive lung injury due to Covid-19. Given the concerns over healthcare worker exposure and environmental contamination, radiographic imaging should be minimized and obtained only when clinically indicated (1).

 
Routine chest radiograph: In a study involving over 1000 hospitalized patients with Covid-19, chest Xray abnormalities on admission were observed in about half of patients with nonsevere disease and three-quarters of those with severe disease (2). Many infiltrates are bilateral, patchy and peripheral in distribution (2,3).

 
Chest CT (without IV contrast):  CT abnormalities on admission have been observed in 84% of patients with nonsevere and 94% of patients with severe disease (2). Ground glass opacities (GGOs) and consolidation have been reported in the majority of patients. Infiltrates are often bilateral, peripheral, and posterior in distribution ( 2-5).

Compared to other causes of pneumonia, the most discriminating features of Covid-19 pneumonia on CT include peripheral distribution of infiltrates (80% vs 57%) and GGOs (91% vs 68%) (5).

CT findings are time dependent. Early during the course of infection, peripheral focal or bilateral multifocal GGOs are frequently observed, later giving rise to “crazy paving” and consolidation with occasional “reverse halo sign” as the disease progresses (see Bonus Pearl below), peaking around 9-13 days (6,7) . Pleural effusion and lymphadenopathy are uncommon (5,7).

 
Point of care ultrasound (POCUS): This relative newcomer offers a potentially useful and rapid means of evaluating for pneumonia or lung injury in Covid-19 and may be more sensitive than chest Xray. Its findings are not specific for Covid-19 lung pathology, however. In a preliminary report involving 12 patients with Covid-19 pneumonia (without ARDS) who underwent POCUS, a diffuse B-line pattern with spared areas was seen in all patients (8,9). Strict adherence to proper isolation precautions and decontamination of the ultrasound probe are essential.

 

Bonus Pearl: “Crazy paving” pattern on CT refers to GGOs with superimposed interlobular septal thickening and intralobular septal thickening, while “reversed halo sign” is a central GGO surrounded by denser consolidation of crescentic shape ring at least 2 mm in thickness (reference 7 has nice photos).

 

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References
1. ACR recommendations for the use of chest radiography and computed tomography (CT) for suspected COVID-19 infection. March 19, 2020. https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection
2. Guan WJ, Zheng-yi N, Hu Y, et al. Clinical characteristics of Coronavirus disease 2019 in China. N Engl J Med 2020; February 28. https://www.nejm.org/doi/full/10.1056/NEJMoa2002032
3. Ai T, Yang Z, Hou H, et al. Correlation of chest CT and RT-PCR testing in Coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology 2020. https://pubs.rsna.org/doi/10.1148/radiol.2020200642
4. Yoon SH, Lee KH, Kim JY, et al. Chest radiographic and CT findings of the 2019 Novel Coronavirus disease (COVID-19): Analysis of nine patients treated in Korea. Korean J Radiol 2020;21 :494-500. https://www.kjronline.org/Synapse/Data/PDFData/0068KJR/kjr-21-494.pdf
5. Bai HX, Hsieh B, Xiong Z, et al. Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT. https://pubs.rsna.org/doi/10.1148/radiol.2020200823
6. Kanne JP, Little BP, Chung JH, et al. Essentials for radiologists on COVID-19: An update—Radiology scientific expert panel. Radiology 2020; February 27. https://pubs.rsna.org/doi/10.1148/radiol.2020200527

7. Bernheim A, Mei X, Huang M, et al. Chest CT findings in Coronavirus Disease-19 (COVID-19):Relations to duration of infection. Radiology 2020 Feb 20:200463.  https://pubs.rsna.org/doi/pdf/10.1148/radiol.2020200463
8. Poggiali E, Dacrema A, Bastoni D, et al. Can lung US help critical care clinicians in the early diagnosis of novel Coronavirus (COVID-19) pneumonia? Radiology 2020; https://www.ncbi.nlm.nih.gov/pubmed/32167853

9. Peng QY, Wang XT, Zhang LN, et al. Findings of lung ultrasonography of novel Coronavirus pneumonia during the 2019-2020 epidemic. Intensive Care Med 2020. https://doi.org/10.1007/s00134-020-05996.

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

What findings should I look for in the chest imaging of my patients with the novel Coronavirus disease/Covid-19?