Subpleural

Fig. 3. Drawing of a rat showing placement of the pressure sensitive subpleural catheter and radiotelemetry transmitter for chronic measurement of pleural pressure in conscious animals. The enlargement is a cross-section through the esophagus showing the position of the catheter between the serosal and muscularis layers.

All animals had stertorous respirations and lung weights were increased. At 175 ppm, 5 of 6 rats died at 20- and 30-min exposure groups. At 400 ppm, all 6 rats died in 10- and 20-min groups. Histology revealed foamy, serosanguinous fluid in trachea, subpleural bleeding, pale discoloration. 

In both cases, pneumothorax occurred with a delay after cocaine inhalation. The authors suggested that it was therefore unlikely that these cases of pneumothorax were due to direct traumatic effects of the drug powder inhaled, to barotrauma due to exaggerated inspiration, or to a Valsalva maneuver. Histological examination in both cases showed small foreign body granulomas with polarized material in the subpleural parenchyma. The authors proposed that the pleural damage could have been directly caused by a filler substance known as mannite (a fine white powder comprised of insoluble cellulose fibers). 

There has been a single report of a lung disorder with cough, which was traced to intravenous injection of a so-called health tonic containing bismuth, which had resulted in bismuth-containing subpleural opacities in the lungs (15). 

A 69-year-old man developed dyspnea, hypoxia, and heart failure 4 days after starting to take tretinoin 70 mg/day. His highest white blood cell count was 72 X 109/1. A plain chest X-ray showed two pulmonary opacities, increased attenuation in the left lower lobe, and bilateral pleural effusions, but a chest CT also showed multiple irregular-shaped opacities localized in the centrilobular and subpleural regions. He improved over 10 days with prednisolone (total dose 5750 mg) and daunorubicin (total dose 360 mg). 

Intramuscular Toxicity. On a molar basis, HCN and NaCN are both equitoxic, and more toxic than KCN. Signs appear within minutes, and include rapid breathing weak and uncoordinated movements, ataxia, tremors, convulsions, and respiratory arrest. Postmortem features are few, and include alveolar and subpleural hemorrhages, and congestion of tracheal mucosa (Ballantyne et ah, 1972). 

Sclerosing hemangioma is one of the most extensively studied rare pulmonary neoplasms, and it usually occurs as a round-oval solitary subpleural mass, " the majority of which occur in relatively young women.Most sclerosing hemangiomas are... 

Moran and associates reported on 8 cases of primary intrapulmonary thymoma in which there was no evidence of mediastinal masses radiographically or at surgery. The masses varied from 0.5 to 10 cm in diameter. Five were located close to the hilum, and 3 were in a subpleural location. The masses were composed of mixtures of lymphocytes and epithelial cells that were separated by fibrous bands. The epithelial cells immu-nostained for keratins and epithelial membrane antigen. 

In humans, inhalation of zinc chloride causes greater damage to respiratory tissue than inhalation of zinc oxide. Reported lesions included acute pneumonitis, ulceration of mucous membranes, subpleural hemorrhage, and pulmonary fibrosis. Exposed individuals have died from respiratory distress syndrome (Evans 1945 Hjortso et al. 1988 Johnson and Stonehill 1961 Matarese and Matthews 1966 Milliken et al. 1963 Schenker et al. 1981). 

Recent reports suggest that denudation of the pleural surface allows for subpleural fibroblasts to be activated. Activated pleural fibroblasts also have been demonstrated to produce the chemokines from both the C-C and the C-X-C group of chemokine families (66). 

In the rabbit, subpleural pulmonary lesions were the preferential reactions after an intravenous injection of Freund s adjuvant (Amemori and Alt-SCHUL 1963). Initial granulamas resemble normal soUtary folhcles. Later they grow and exceed the lymph folhcles by size. EpitheUoid cells appear. Advanced granulomas gain a considerable size and undergo central necrosis. 

The perivenous plexus accompanies the veins into the perilobular septa and even reaches the visceral pleura to supply the subpleural alveolar walls. Spencer and Leof (1964) have described twigs of the venous plexus reaching and ramifying in the subendothelial space. A few ganglia are present in the perivenous plexus near the hilus. 

Fig. 26.5a,b. Axial CT image ina61-year-oldmanwithNSIP shows bilateral subpleural irregular linear opacities (arrowhead) and ground-glass opacities (arrow) (a). Follow-up CT... 

The most important differential diagnoses for LAM are Langerhans cell histiocytosis, idiopathic pulmonary fibrosis, and panlobular emphysema. In contrast to LAM, in Langerhans cell histiocytosis, the costophrenic sulci are usually spared, the cysts can be thick-waUed and irregularly outlined, and nodules are predominant in the early stage of disease. Idiopathic pulmonary fibrosis shows a volume loss in contrast to LAM, and the honeycomb cysts are predominantly located in the lower lobes and subpleural (Bonelli et al. 1998). Panlobular emphysema is associated with alpha-1-antiprotease deficiency. The most distinct feature of emphysema is the absence of defined walls in the areas of low attenuation, whereas cysts in LAM almost invariably present with walls (Johnson 1999). 

As the disease progresses, subpleural emphysema and the formation of thin-waUed subpleural cysts are pathognomonic findings in PAM and might represent early lung fibrosis. The subpleural cysts are accountable for the black subpleural line on chest X-rays (Korn et al. 1992). The main differential diagnoses include miliary tuberculosis, sarcoidosis, metastatic pulmonary calcification associated with hemodialysis, sihcosis, and pulmonary hemosiderosis. 

Fig. 26.21. A 37-year-old man with pulmonary alveolar microlithiasis. Axial CT image shows miliary distributed calcified micronodules predominantly located in the middle and lower zones of both lungs. Also note the formation of small subpleural cysts and subpleural emphysema and the formation of the pathognomonic black subpleural line (white arrows)...

Fig. 26.22. Chronic hypersensitivity pneumonitis in a 52-year-old man, related to mold exposure. Axial CT image shows patchy ground-glass opacities with associated centrilob-ular nodules (inset magnified view of centrilobular nodules). Also note mild subpleural reticular opacities (black arrowheads) indicating fibrosis, and subtle mosaic attenuation (white arrowhead)...

Fig. 26.24. A 50-year-old woman with interstitial pneumonia (lP)/nonspecific interstitial pneumonia (NSIP) after bleomycin chemotherapy for Hodgkin s lymphoma. Axial CT image shows irregular linear and reticular opacities (arrowheads) with subtle ground-glass opacities (arrow) in subpleural distribution...

Fig. 26.25. A 63-year-old man with organizing pneumonia (OP). The patient was receiving amiodarone for cardiac arrhythmia. Coronal CT image shows bilateral areas of ground-glass opacities in subpleural distribution (arrowheads)...

Pnemnocystis Allogeneous transplantation GGO left out subpleural space intralobular septa (late phase)... 

Fig. 27.11a-c. Bilateral pneimionia caused by Pneumocystis jiroveci (PcP) at different stages of immunosuppression. The subpleural space is typically left out. Diffuse ground glass opacification appears typically in the early phase of infection... 

Fig. 37.2a,b. Patient (prone position) with multiple lung me-tastases. A subpleural nodule in the left lower lobe was chosen for aspiration biopsy under CT-fluoroscopic guidance with a 19-G (10 cm) needle (a). Postinterventional CT (supine posi-... 

Fig. 5.2.3. a Peripheral subpleural lesion (arrow). Lateral decubitus position with the patient lying on the same side of the lesion, b Posterior access to reach the lesion in a shorter distance. The applicator (arrow) is placed with an acute angle relative to the lesion and pleural surface, c Follow-up non-contrast CT in the supine position. The lesion is completely ablated leaving a gaseous collection in place and overlying minimal pneumothorax (arrows)... 

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