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complete white out lung, what could be diagnosis?

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hi all,

I had baby 36 weeks  completed gestation, on admission severe respirstory distress,given surfactan , distress not setteled after 24hrs of ventilation (invasiveSIMV ). Xray still shwing complete white out, repaeat surfactant given still no improvent CT chest done its normal. Sepsis screen negative.

what could be reason for complete white out and not improving lung fields?

thanking you.


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Are you able to elaborate on the chest CT and/or share images?  I find it quite hard to fathom how a CXR showed total white out at the same time that a chest CT was completely normal.  Also, more clinical information would be helpful: blood gases, response to surfactant, vent settings, etc.

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Was there a transient improvement in SaO2 and FiO2 after surfactant administration, say for 2-4 hours? If so, I would consider a surfactant protein mutation such as heterogenous SPB mutation or homogenous/heterogenous ABCA3 mutation. Also SPC mutations are highly variable in their presentation(s). 

Homogenous SPB mutations may have a brief response to surfactant, but will inevitably return to a severe RDS clinical picture. Heterogeneous SPB mutations may be survivable if the baby is full term. Heterogeneous ABCA3 mutations are survivable if not premature while homogenous ABCA3 mutations are often fatal, even in full-term babies. 

Recommend searching papers by N. Nogee and A. Hamvas

Another thought, the penetration of the Xrays may not have been optimized for the type of CXR; thus the CXR looks abnormal while the CT is normal. Does the "whiteness" of the stomach bubble correspond to the "whiteness" of the lung? if so, the CXR was probably under penetrated. if the stomach bubble is much blacker than the lung fields, there is a problem with the lungs. 

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