Imaging Pearls ❯ Chest ❯ Parenchymal Lung Disease: HRCT
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- Histoplasmosis: CT Findings
- Pulmonary nodules
- Broncholithiasis
- Adenopathy
- Fibrosing mediastinitis - Histoplasmosis: CT Findings
CT scanning is helpful in detecting calcification in a lung nodule (histoplasmoma) and in evaluating patients with fibrosing mediastinitis and broncholithiasis. CT may define the extent of the fibrous mass in the mediastinum/hilum and demonstrate its obstructing effect . - Histoplasmosis: Clinical Findings
- fever
- malaise
- cough
- headache
- chest pain
- chills
- myalgias - Histoplasmosis: Complications
- Mediastinal granuloma
- Fibrosing mediastinitis
- Broncholithiasis
- Cavitary pulmonary histoplasmosis - “In the article that accompanies this editorial, Mikhael et al report that an artificial intelligence and deep learning model, called Sybil, may predict an individual’s future lung cancer risk after one baseline computed tomography chest scan. This model is an important first step toward a precision approach to lung cancer screening, but understanding who would truly benefit from this technology will require significantly more investment in prospective studies targeting groups with differing risk profiles.”
The Intersection of Lung Cancer creening, Radiomics, and Artificial Intelligence: Can One Scan Really Predict the Future Development of Lung Cancer?
Gerard A. Silvestri and James R. Jett
American Society of Clinical Oncology 2023 (in press)
- “Oleothorax, the intrapleural or extrapleural instillation of mineral or vegetable oil into the pleural space, was widely used from the early decades of the 20th century until the late 1940s. Oleothorax was a form of collapse therapy used to inhibit the multiplication and dissemination of pulmonary Mycobacterium tuberculosis . In addition to exerting a mass effect on the adjacent lung, such substances were caustic and produced obliterative pleuritis, which justified their use in tuberculous empyemas. The amount of oil used varied widely (100-2,000 mL). The recommended length of therapy was up to 2 years, with removal of the oil thereafter. However, asymptomatic patients were often lost to follow-up, and the oil was never removed, as in our case.”
An uncommon chest mass: oleothorax.
Hochhegger B, Zanetti G, Marchiori E. J
Bras Pneumol. 2016 Sep-Oct;42(5):391. - “Plombage is a surgical treatment method used to treat cavitary TB of the upper lobe of the lung.1 It was a historical treatment during 1930–50s prior to the introduction of anti-TB drug therapy,1 where TB treatment relied upon rest, proper nutrition and isolation. The word Plombage derived from Latin word ‘plumbum’ which means, ‘lead’. Plombage is also known as extra-periosteal or extra-pleural pneumonolysis. The theory behind Plombage treatment is that, if the diseased lobe of the lung is physically forced to collapse, then it would heal quickly. The technique involves creating a cavity surgically under the ribs in the upper chest wall and filling the space with inert material.1 The materials used in this procedure are Lucite (acrylic) balls, Ping-Pong balls, mineral oil (oleothorax), air, fat, paraffin wax and rubber sheath.”
Historical TB treatment—Plombage,
V. Namana, S.S. Gupta, R. Sarasam, P. Mathur,
QJM: An International Journal of Medicine, Volume 110, Issue 3, March 2017, Page 191
- Lymphangioleiomyomatosis: Facts
Synonyms of Lymphangioleiomyomatosis
- LAM
- lymphangioleimyomatosis
- lymphangioleiomatosis
- lymphangiomyomatosis
- pulmonary lymphangiomyomatosis
- sporadic lymphangioleiomyomatosis - Lymphangioleiomyomatosis: Facts
- pulmonary LAM can present with shortness of breath upon exertion, cough, wheezing and chest pain. Sometimes, individuals may cough up small amounts of blood (hemoptysis) and have bleeding in their lungs (pulmonary hemorrhage) due to obstructed blood vessels.
- About 50-60% of individuals with LAM experience a lung collapse (pneumothorax) at some point in their life. In about one third of these patients, the pneumothorax may be the first manifestation that brings the diagnosis of LAM to light. - Lymphangioleiomyomatosis: Facts
- Approximately 30% of individuals with sporadic LAM and up to 80% of individuals with TSC-LAM develop angiomyolipomas, which are benign tumors made up of fat, blood vessels and smooth muscle-like cells. These tumors most commonly affect the kidneys and often do not cause symptoms. In some patients, they may cause flank pain, blood in the urine (hematuria) or bleeding into the abdomen. - Lymphangioleiomyomatosis: Facts
- LAM is associated with the rare genetic disorder known as tuberous sclerosis complex (TSC) as both diseases are caused by changes (mutations) in one of two genes known as the TSC1 gene or TSC2 gene. There are two main types of LAM: sporadic LAM (called S-LAM that may occur without TSC) and LAM associated with TSC (called TSC-LAM). In both cases, abnormal LAM cells circulate in blood and lymphatic vessels and deposit in the lungs, causing cysts and lung damage. In S-LAM, mutations are thought to be somatic mutations (e.g., mutations that occur in peripheral tissues after conception and are not inherited). These mutations are not found in the blood or the normal lung or normal kidney cells of affected individuals. On the contrary, in TSC-LAM, these mutations may occur spontaneously (sporadically) for unknown reasons or be inherited in an autosomal dominant pattern. Most cases represent new (sporadic) gene mutations, with no family history of the disease. - Lymphangioleiomyomatosis: CT Findings
- High resolution CT scan (HRCT) shows characteristic thin-walled cysts in the lungs consistent with LAM and can help rule out other pulmonary conditions. HRCT may also reveal angiomyolipomas or lymphangioleiomyomas in the abdomen that support a diagnosis of LAM. Chest x-rays are not diagnostic for LAM and are often normal early in the disease course. - “Lymphangioleiomyomatosis (LAM) is a rare idiopathic disease that exclusively occurs in women of childbearing age, and this disease is characterized by the proliferation of abnormal smooth muscle cells in the lungs and along the thoracic and abdominal lymphatics. The disease primarily affects the lungs in the majority of cases, but extrapulmonary LAM occasionally occurs with or without subsequent involvement of the lungs.”
CT and MR imaging findings of lymphangioleiomyomatosis involving the uterus and pelvic cavity.
Kim YS, Rha SE, Byun JY, Lee A, Park JS
Korean J Radiol. 2011;12(2):261‐265. doi:10.3348/kjr.2011.12.2.261 - “LAM occurs in about 30% of the women with tuberous sclerosis complex (TSC), which is an autosomal dominant multisystem neurocutaneous disorder of highly variable penetrance, and it is characterized by hamartomas, seizure and mental retardation.”
CT and MR imaging findings of lymphangioleiomyomatosis involving the uterus and pelvic cavity.
Kim YS, Rha SE, Byun JY, Lee A, Park JS
Korean J Radiol. 2011;12(2):261‐265. doi:10.3348/kjr.2011.12.2.261 - Lymphangioleiomyomatosis: Abdominal Findings
- renal angiomyolipomas: most common abdominal finding
- splenic cysts
- chylous ascites
- lymphangioleiomyomas
- uterine fibroids
- abdominal lymphadenopathy
- “IPH is a diagnosis of exclusion and can be considered after underlying diseases resulting in alveolar haemorrhage, including Goodpasture’s syndrome, granulomatosis with polyangiitis, systemic lupus erythematosus, rheumatoid arthritis, coagulation disorders, pulmonary infections, neoplasms, additional disorders such as pulmonary venoocclusive disease and pulmonary capillary haemangiomatosis, and toxins such as cocaine, pesticides, and insecticides, have been excluded.”
Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient
L. Khorashadi et al.
Clinical Radiology 70 (2015) 459-465 - “IPH classically presents as a triad of haemoptysis, iron-deficiency anaemia, and opacities on thoracic imaging (representing pulmonary haemorrhage), and is considered a diagnosis of exclusion. For children with IPH, the disease course is severe and the prognosis is poor. However, adults generally have a longer disease course with milder symptoms and the prognosis is more favourable. However, this condition can progress to pulmonary fibrosis, resulting in respiratory failure and cor pulmonale.”
Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient
L. Khorashadi et al.
Clinical Radiology 70 (2015) 459-465 - “HRCT optimally demonstrates thickening of the interstitium, intralobular lines, and associated findings such as traction bronchiectasis and bronchiolectasis. Honeycomb cysts may be present and are typically identified in the peripheral and basilar regions. Progressive massive fibrosis (PMF), classically described as a complication of silicosis or other. pneumoconiosis, may rarely develop in IPH and is typified by dense mass-like consolidation in the upper and mid-lung zones, architectural distortion, and regions of high attenuation corresponding to iron deposition.”
Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient
L. Khorashadi et al.
Clinical Radiology 70 (2015) 459-465 - “Progressive massive fibrosis (PMF), classically described as a complication of silicosis or other. pneumoconiosis, may rarely develop in IPH and is typified by dense mass-like consolidation in the upper and mid-lung zones, architectural distortion, and regions of high attenuation corresponding to iron deposition.”
Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient
L. Khorashadi et al.
Clinical Radiology 70 (2015) 459-465 - “The clinical course consists of two distinct phases, an acute phase and a chronic phase, during which certain clinical symptoms and imaging features may be present. The acute phase is characterized by ground-glass opacity and consolidation due to alveolar haemorrhage. In the chronic phase, the radiological picture is dominated by features of pulmonary fibrosis and honeycombing. Although imaging features are often non-specific, identification and understanding of the abnormalities that may be present on thoracic imaging examinations is important to guide appropriate clinical management.”
Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient
L. Khorashadi et al.
Clinical Radiology 70 (2015) 459-465
- “Interstitial lung disease and pulmonary hypertension (PH) are the most common cardiopulmonary findings in patients with systemic sclerosis (SSc). About two thirds of patients suffering from SSc develop scleroderma interstitial lung disease. PH is present in about 20% of SSc patients and is typically associated with severe lung disease, although it may be an isolated manifestation of SSc. High-resolution CT scanning is a key method for evaluating chest involvement. There are four roles of imaging in scleroderma interstitial lung disease: 1) detection of lung involvement, 2) identification of patients likely to respond to treatment, 3) assessment of treatment efficacy, and 4) exclusion of other significant diseases to include PH and cardiac and esophageal abnormalities.”
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - “High-resolution CT (HRCT) has been shown to be more accurate than chest radiography in detecting and characterizing diffuse lung diseases, and abnormalities on CT correlate more closely with pulmonary function test (PFT) abnormalities. HRCT is now well-established as a sensitive and noninvasive means of detecting and characterizing SILD CT features of fibrosis are present in 55% to 65% of all patients with SSc and in up to 96% of those with abnormal PFT results. As a result, HRCT has become an important part of the routine evaluation of SILD. Classically, the disease affects juxtapleural, posterior, and basilar portions of the lungs, with initially subtle alterations of increased GGO, defined as increased lung attenuation in the absence of architectural distortion, as well as accentuated reticular markings that may progress to pulmonary fibrosis, defined as architectural distortion with reticular intralobular interstitial thickening, traction bronchiectasis and bronchiolectasis, and honeycomb cystic change.”
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - “It has been incorrectly assumed that SILD is more common and severe in patients with diffuse cutaneous systemic sclerosis (dcSSc). In several recent studies, about 40% of patients with pulmonary involvement have demonstrated cutaneous systemic sclerosis (lcSSc) .In the recent Scleroderma Lung Study, lcSSc and dcSSc patients were indistinguishable with regard to their baseline pulmonary functions, but lcSSc patients presented with more extensive pulmonary fibrosis, possibly reflecting a delay in diagnosis and progression of lung disease prior to study entry. The rate of progression of SILD is similar in lcSSc and dcSSc patients after adjustment for baseline differences in the degree of pulmonary fibrosis.”
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - “HRCT scanning has been used to predict outcome in addition to characterizing the nature and extent of SILD. The absence of lung disease at an initial CT evaluation is a superior predictor of excellent long-term prognosis with regard to SILD. In a serial HRCT study of 90 SSc patients, 40 had no evidence of pulmonary fibrosis on an initial scan; of these 40, 35 (88%) continued to have a normal HRCT scan at follow-up for an average of 5 years. Because many SSc patients have limited pulmonary fibrosis that may not necessarily progress, the decision to start treatment is often a clinical challenge. The estimation of disease extent (using HRCT) and severity (using PFT) is pivotal. Careful prognostic evaluation, including the staging of disease severity and the definition of longitudinal disease behavior (by serial imaging and PFT), is central to the formulation of a logical management plan.”
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - "PH, defined as pulmonary artery pressure greater than 35 mm Hg as estimated by transesophageal echocardiography, affects about 20% (range, 6%–60%) of patients with SSc and is a major cause of SSc-related death. When complicated by PH, systemic sclerosis has a very poor prognosis. About half of patients with PH develop the disease within 5 years of the SSc diagnosis. Primary cardiac involvement from SSc may smolder for years before manifesting as overt cardiomyopathy, pericardial disease, or conduction abnormalities. SSc heart disease has a poor prognosis and may be related to excessive deposition of abnormal collagen that impairs myocardial contractility, and to ischemia from coronary vasculopathy.”
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - Scleroderma involves the gastrointestinal tract in up to 90% of patients, and fibrosis and atrophy may result in motility disorders. Esophageal involvement is often an early and asymptomatic manifestation of SSc. A dilated esophagus containing fluid, gas, and/or debris in the setting of SSc reflects esophageal involvement and may help differentiate ILD due to connective tissue disease from other etiologies. Asymptomatic esophageal dilatation and esophageal dysmotility are detected in up to 80% of patients . Gastroesophageal reflux may play a role in the development and/or progression of SILD. Early detection and treatment of esophageal involvement may forestall complications, which include chronic reflux, aspiration pneumonia, Barrett’s esophagus, and esophageal stricture and malignancy.
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - Scleroderma is a systemic disorder of connective tissues and vasculopathy that involves multiple organ systems, typically the skin, esophagus, and lungs. Symptoms of ILD may frequently overlap with those of PH, aspiration pneumonia, and cardiomyopathy. As patients with limited and diffuse cutaneous scleroderma may exhibit progressive and extensive pulmonary fibrosis, all scleroderma patients should be evaluated for lung involvement. Histopathologic assessment of SILD typically represents overlapping features with NSIP and UIP.
HRCT, in conjunction with PFT results, plays a critical role in the detection and treatment of SILD and in the prediction of outcomes. Visual scoring and computer-based HRCT techniques are comparable in detecting and grading disease severity and progression. On CT, SILD typically manifests as GGO and accentuated reticulations that may progress to pulmonary fibrosis. GGO was recently discredited as a marker of active inflammation and reversible lung injury.
Imaging Lung Disease in Systemic Sclerosis
Diane Strollo and Jonathan Goldin
Curr Rheumatol Rep. 2010 Apr; 12(2): 156–161. - Pneumocystis pneumonia: Facts
- Differential diagnosis of pulmonary infections in immunocompromised patients could be established with the help of high-resolution computed tomography.
- Bronchial wall thickening was a significant indicator for bacterial pneumonia.
- The presence of a mosaic pattern and the absence of nodules were significant indicators for pneumocystis pneumonia. - “Pneumocystis pneumonia (PCP) is one of the most frequent pulmonary infections in immunocompromised patients including those with human immunodeficiency virus infection. The major risk factors for invasive aspergillosis include neutropenia and prolonged corticosteroid therapy. Infections by Candida species and Cryptococcus neoformans as well as mucormycosis may also occur as opportunistic infections. Cytomegalovirus pneumonia (CMV-P) is one of the major complications in transplant recipients.”
Kunihiro Y et al. Differential diagnosis of pulmonary infections in immunocompromised patients using high-resolution computed tomography.
Kunihiro Y et al.
Eur Radiol. 2019 Nov;29(11):6089-6099. - “It is difficult to accurately evaluate the HRCT findings of pulmonary infections in immunocompromised patients because of the nonspecific or atypical imaging patterns. However, our study suggested that the differentiation between the various pulmonary infections in immunocompromised patients might be partially possible by evaluating several HRCT findings.”
Kunihiro Y et al. Differential diagnosis of pulmonary infections in immunocompromised patients using high-resolution computed tomography.
Kunihiro Y et al.
Eur Radiol. 2019 Nov;29(11):6089-6099. - “Patients with PCP frequently exhibit the mosaic pattern, and nodules with or without cavitation are infrequent. Nodules and cystic lesions are relatively common in acquired immunodeficiency syndrome (AIDS) patients. The HRCT findings of PCP and CMV-P are often similar, but the differential diagnosis of these is typified by a mosaic pattern and an apical distribution in PCP and an ill-defined demarcation of GGA, consolidation, and nodules with or without a halo sign in CMV-P.”
Kunihiro Y et al. Differential diagnosis of pulmonary infections in immunocompromised patients using high-resolution computed tomography.
Kunihiro Y et al.
Eur Radiol. 2019 Nov;29(11):6089-6099. - “Our study showed that the presence of nodules could be an indicator for fungal infection. In invasive aspergillosis in immunocompromised patients, nodules with the halo sign in the early phase, and cavitary lesions in the late phase, are common. Nodules and cavitation are common findings in cryptococcosis, and nodules with centrilobular or random distribution are common in candidiasis.”
Kunihiro Y et al. Differential diagnosis of pulmonary infections in immunocompromised patients using high-resolution computed tomography.
Kunihiro Y et al.
Eur Radiol. 2019 Nov;29(11):6089-6099. - “Nodules, tree-in-bud appearance, consolidation, and cavities in the upper lobe are the most common findings observed in TB, but immunocompromised patients show more atypical findings, such as multiple cavities and lower or nonsegmental distribution. Our study identified the presence of nodule as highly suggestive of TB, albeit with very low PPV (7.3%). We found nodules to be the predominant patterns for septic embolism, with pleural effusion identified as an indicator with very low PPV (7.1%).”
Kunihiro Y et al. Differential diagnosis of pulmonary infections in immunocompromised patients using high-resolution computed tomography.
Kunihiro Y et al.
Eur Radiol. 2019 Nov;29(11):6089-6099.
- Primary Ciliary Dyskinesia
- Primary ciliary dyskinesia (PCD) is usually an autosomal recessive genetic condition in which the microscopic organelles (cilia) in the respiratory system have defective function. Ciliary dysfunction prevents the clearance of mucous from the lungs, paranasal sinuses and middle ears. Bacteria and other irritants in the mucous lead to frequent respiratory infections. Kartagener syndrome is a type of PCD associated with a mirror-image orientation of the heart and other internal organs (situs inversus). Rare cases of X-linked and autosomal dominant inheritance have been observed.
- “Lymphangioleiomyomatosis (LAM) is a rare idiopathic disease that exclusively occurs in women of childbearing age, and this disease is characterized by the proliferation of abnormal smooth muscle cells in the lungs and along the thoracic and abdominal lymphatics. The disease primarily affects the lungs in the majority of cases, but extrapulmonary LAM occasionally occurs with or without subsequent involvement of the lungs.”
CT and MR imaging findings of lymphangioleiomyomatosis involving the uterus and pelvic cavity.
Kim YS, Rha SE, Byun JY, Lee A, Park JS
Korean J Radiol. 2011;12(2):261‐265. doi:10.3348/kjr.2011.12.2.261 - “LAM occurs in about 30% of the women with tuberous sclerosis complex (TSC), which is an autosomal dominant multisystem neurocutaneous disorder of highly variable penetrance, and it is characterized by hamartomas, seizure and mental retardation.”
CT and MR imaging findings of lymphangioleiomyomatosis involving the uterus and pelvic cavity.
Kim YS, Rha SE, Byun JY, Lee A, Park JS
Korean J Radiol. 2011;12(2):261‐265. doi:10.3348/kjr.2011.12.2.261 - Lymphangioleiomyomatosis: Abdominal Findings
- renal angiomyolipomas: most common abdominal finding
- splenic cysts
- chylous ascites
- lymphangioleiomyomas
- uterine fibroids
- abdominal lymphadenopathy - Lymphangioleiomyomatosis: Facts
- characteristic or compatible lung HRCT and lung biopsy fitting the pathological criteria for LAM or
- characteristic lung HRCT and any of the following
--- renal angiomyolipoma
--- thoracic or abdominal chylous effusion
--- lymphangioleiomyoma or lymph-node involved by LAM
--- definite or probable tuberous sclerosis
- "Cystic fibrosis (CF) is one of the most common genetic disorders in the white population, with a lethal outcome at a young age. Morbidity and mortality in patients with CF are essentially related to pulmonary disease. Early detection and follow-up of lung disease in CF is crucial to allow prompt treatment adaptation."
Pulmonary Disease in Cystic Fibrosis: Assessment with Chest CT at Chest Radiography Dose Levels
Caroline W. Ernst et al.
Radiology 2014; 273:597–605 - Cystic Fibrosis: Imaging
• Radiation doses in chest CT can be reduced dramatically.
• Findings suggest that, in CF, follow-up chest radiography might be replaced by chest CT without important dose penalty.
• Diagnostic quality for patients with CF can be maintained with use of a lower dose protocol than that used with conventional CT. - "Early detection and follow-up of lung disease in CF is crucial to allow prompt treatment adaptation. Early changes in lung disease can be detected with various methods, such as pulmonary function testing (PFT), radiography, and com- puted tomography (CT)."
Pulmonary Disease in Cystic Fibrosis: Assessment with Chest CT at Chest Radiography Dose Levels
Caroline W. Ernst et al.
Radiology 2014; 273:597–605 - "Cystic fibrosis (CF) is the most common inherited disease in the Western world, affecting more than 30 000 individuals in the United States and 60 000 individuals worldwide. Respiratory failure continues to account for more than 80% of the deaths from this disease. However, advances in treatment have increased the median predicted survival time from 16 years in the 1970s to more than 37 years today. Adults now represent more than 40% of the total CF population."
Emerging Roles for CT Imaging in Cystic Fibrosis
Milene T. Saavedra, David A. Lynch
Radiology 2009; 252:327–329 - "CT serves as an excellent technique with which to depict morphologic abnormalities of CF, including airway wall thickening, bronchi- ectasis, mucoid impaction, centrilobular
nodularity, and expiratory air trapping. Furthermore, several semiquantitative scoring systems of varying complexity have been developed to describe the degree of disease involvement ."
Emerging Roles for CT Imaging in Cystic Fibrosis
Milene T. Saavedra, David A. Lynch
Radiology 2009; 252:327–329
- Patterns of Pulmonary Infections
• lobar or rounded consolidations
• centrilobular nodules or lobular consolidation
• tree-in-bud
• one or more nodules or masses
• cavities, fluid levels, and the “air-crescent sign”
• random nodules
• ground-glass opacity - Primary TB with consolidation
• most typical of children and immunosuppressed pts
• focal/multifocal/lobar consolidation in any lobe (mid to lower lungs most frequent)
• slow resolution (months)
• lymphadenopathy more common in children (90%) than adults (25%) and in immunosuppressed pts; nodes > 2 cm show low attenuation center
• cavitation uncommon
• miliary or endobronchial spread may occur
- “The pulmonary manifestation of tuberous sclerosis is lymphangioleiomyomatosis, a proliferation of smooth muscle cells in the lymphatics accompanied by cystic changes in the lung parenchyma. Lymphangioleiomyomatosis can be observed as multiple thin-walled cysts scattered diffusely and surrounded by normal lung parenchyma. There are two forms of lymphangioleiomyomatosis: sporadic and associated with tuberous sclerosis. The sporadic form predominates (85% of all cases) and occurs almost exclusively in women. The tuberous sclerosis–associated form also has a female predominance, and women are more severely affected by the disease than are men. Lymphangioleiomyomatosis exists in as many as 26–39% of women with tuberous sclerosis.” Comprehensive imaging manifestations of tuberous sclerosis. Manoukian SB, Kowal DJ. AJR Am J Roentgenol. 2015 May;204(5):933-43
- “ Pulmonary coccidioidomycosis is a fungal disease endemic to the desert regions of the southwestern United States, Mexico, Central America, and South America. The incidence of reported disease increased substantially between 1998 and 2011, and the infection is encountered beyond the endemic areas because of a mobile society. The disease is caused by inhalation of spores of Coccidioides species. Individuals at high risk are those exposed to frequent soil aerosolization. The diagnosis is established by direct visualization of mature spherules by using special stains or cultures from biologic specimens. Serologic testing of anticoccidioidal antibodies is used for diagnosis and treatment monitoring.”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “The infection is self-limited in 60% of cases. When the disease is symptomatic, the lung is the primary site of involvement. On the basis of clinical presentation and imaging abnormalities, pulmonary involvement is categorized into acute, disseminated, and chronic forms, each with a spectrum of imaging findings. In patients with acute disease, the most common findings are lobar or segmental consolidation, multifocal consolidation, and nodules. Adenopathy and pleural effusions are also seen, usually in association with parenchymal disease. Disseminated disease is rare and occurs in less than 1% of patients. Pulmonary findings are miliary nodules and confluent parenchymal opacities. Acute respiratory distress syndrome is an infrequent complication of disseminated disease.”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “The acute findings resolve in most patients, with chronic changes developing in approximately 5% of patients. Manifestations of chronic disease include residual nodules, chronic cavities, persistent pneumonia with or without adenopathy, pleural effusion, and regressive changes. Unusual complications of chronic disease are mycetoma, abscess formation, and bronchopleural fistula. Patients in an immunocompromised state, those with diabetes mellitus, pregnant women, and those belonging to certain ethnic groups may show severe, progressive, or disseminated disease.”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “ A solitary pulmonary nodule or mass indistinguishable from primary lung malignancy may also be demonstrated. Most nodules seen at CT were multiple and bilateral, with ill-defined borders, and ranged from 0.5 cm and 3 cm in diameter. Cavitation occurred in most nodules, and a coalescent pattern was often noted.”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “Suppression of cellular immunity is a major risk factor for increased disease severity and dissemination. The most substantial risk factors are HIV infection, immunosuppressive medications, and high-dose glucocorticoid administration. For HIV-infected individuals, the risk increases substantially in patients with a CD4 lymphocyte count less than 0.25 × 109/L or a diagnosis of AIDS . Hematologic malignancies, pregnancy, diabetes, cardiopulmonary disease, old age, smoking, and male sex are additional risk factors.”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “Acute symptomatic infection is also known as primary coccidioidal infection. After an incubation period of 7–21 days, patients present with symptoms that vary from mild influenza-like illness to acute pneumonia. The most common symptoms are cough, fever, headache, and chest pain, each occurring in more than 70% of patients. Helpful clinical symptoms are night sweats and prolonged fatigue, which may take months to resolve. Approximately 25% of white women and 4% of white men develop “valley fever,” an allergic syndrome characterized by hypersensitive skin lesions, such as erythema multiforme or erythema nodosum, and polyserositis. Primary coccidioidal infection is typically a self-limited process of 3–6 weeks’ duration, with complete recovery in 85%–95% of cases .”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “Acute symptomatic infection is also known as primary coccidioidal infection. After an incubation period of 7–21 days, patients present with symptoms that vary from mild influenza-like illness to acute pneumonia. The most common symptoms are cough, fever, headache, and chest pain, each occurring in more than 70% of patients. Helpful clinical symptoms are night sweats and prolonged fatigue, which may take months to resolve.Primary coccidioidal infection is typically a self-limited process of 3–6 weeks’ duration, with complete recovery in 85%–95% of cases .”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - “Chronic pulmonary coccidioidomycosis is diagnosed when clinical symptoms or imaging abnormalities persist beyond 6 weeks and occurs in approximately 5% of patients. Seventy-five percent of cases of chronic infection occur in patients who did not have classic symptoms of acute disease.”
Pulmonary coccidioidomycosis: pictorial review of chest radiographic and CT findings.
Jude CM et al.
Radiographics. 2014 Jul-Aug;34(4):912-25 - CT Appearance of Pulmonary Coccidioidomycosis
- Pulmonary nodule(s) which are usually 0.5 -2.5 cm in size
- May be multiple or solitary and simulate metastatic disease or a primary lung cancer
- Cavitation of lung nodules is common - CT Appearance of Pulmonary Coccidioidomycosis
- Parenchymal abnormalities (75% of cases)
- Intrathoracic adenopathy (20% of cases)
- Pleural effusion (15-20% of cases)
- Disseminated disease (<1% of cases) - “ Probably the greatest risk associated with low-dose CT for lung cancer screening is a false positive result, defined as detection of a nodule that proves to be benign, which can lead to unnecessary testing and patient and family anxiety. In the cohort of the NLST screened with low dose CT, 39% of subjects had at least one positive screen result, and just over 96% of positive low dose CT screens were false-positives.”
Screening for Lung Cancer: What Have We Learned?
Kanne JP
AJR 2014;202:530-535
- Bronchiectasis: Etiologies
Infections
- Bacterial; fungal, mycobacterial, viral
Congenital
- Alpha-1 anti-trypsin; cystic fibrosis; ciliary defects
Immunodeficiencies
- Primary ( Chronic granulonmatous dx; complement deficiencies; hypogammaglobulinemias
- Secondary (HIV+, immunosuppressive drug therapy)
Congenital structural defects
- Yellow nail, Wm Campbell, Meunier Kuhn, Marfans
- Airway obstruction - Bronchiectasis: Direct Findings
- Internal diameter > adj pulmonary artery
Contour abnormalities
- Signet ring sign
- Tram tracks
- String of pearls
- Lack of tapering ( > 2 cm distal bifurcation)
- Within 1 cm costal/ adj mediastinal pleura - Bronchiectasis: Indirect Findings
Bronchial wall thickening
- > 0.5 x diameter adj vertical pulm artery
Fluid/mucus-filled bronchi
- Tubular or Y shaped central airways
- Branching or rounded opacities
- Air-fluid levels
- Bronchiolitis (tree-in-bud/ centrilobular nodules)
Mosaic perfusion (air-trapping on expiration)
Atelectasis (consolidation) - Bronchiectasis: Accuracy of HRCT
Overall correct dx = 61% of cases
- Cystic fibrosis = 68%; Prior TB = 67%; Childhood infection = 43%; ABPA = 56%; Misc. causes = 57%
- Moderate agreement correct dx (k = .53)
- Good agreement presence/absence of disease (k= .71)
- Conclusion: Pattern and distribution relates to underlying cause
- Ground-Glass Opacity: significance
- morphologic abnormalities below the resolution of HRCT
- histology nonspecific
- air space disease in 14%
- interstitial disease in 54%
- mixed disease in 32%
- acute or chronic symptoms?
Leung et al. Radiology 1993; 188:219-214 - Ground-Glass Opacity:
acute symptoms
1. distribution of GGO doesn’t help much
2. differential diagnosis
- » pulmonary edema
- » hemorrhage
- » atypical pneumonia (e.g. PCP, viral)
- » diffuse alveolar damage (DAD, ARDS)
3. evaluation based on clinical suspicion - Ground-Glass Opacity with chronic symptoms
- hypersensitivity pneumonitis
- interstitial pneumonias (e.g. NSIP, DIP)
- organizing pneumonia (OP, BOOP)
- eosinophilic pneumonia
- bronchioloalveolar carcinoma (BAC); now invasive mucinous adenocarcinoma
- lipoid pneumonia (rare)
- alveolar proteinosis (rare)
- Per R. Webb Orlando 2012 - Hypersensitivity Pneumonitis (HP)
- a common disease
- caused by inhalation of organic antigens
- acute, subacute, and chronic stages
- usually presents in the subacute stage
- repeated exposures produce fever, chills, dry cough, dyspnea
- progressive symptoms over months or years
- Per R. Webb Orlando 2012 - Subacute Hypersensitivity Pneumonitis: histology predicts the HRCT findings
- alveolitis: diffuse or patchy GGO (50-75%)
- peribronchiolar granulomas: ill-defined centrilobular nodules (50%), usually GGO
- cellular bronchiolitis: mosaic perfusion with air trapping on expiratory scans
- GGO + mosaic perfusion and/or air trapping
- diffuse or predominant in mid lung zones
- involves the entire cross section of lung
- Per R. Webb Orlando 2012 - Ground-Glass Opacity with chronic symptoms: distribution of disease
1. diffuse or patchy (geographic) opacities:
- » hypersensitivity pneumonitis most likely
2. concentric subpleural and lower lobe opacities:
- » interstitial pneumonia most likely
- (e.g. nonspecific interstitial pneumonia, NSIP)
- >> subpleural sparing, lower lobe predominance strongly suggest NSIP - (Idiopathic) Interstitial Pneumonias
- reactions to lung injury, not diseases
- several different patterns
- variable inflammation and fibrosis
- variable response to treatment
- sometimes idiopathic
- may be associated with collagen-vascular diseases, drugs, inhalation,
- other causes most common: NSIP, organizing pneumnia (OP), usual interstitial pneumonia (UIP)
- Per R. Webb Orlando 2012 - Nonspecific Interstitial Pneumonia (NSIP) Travis et al. Am J Respir Crit Care Med 2008; 177:1338
- less common than usual interstitial pneumonia (UIP)
- despite its name, it is a specific entity
- cellular (inflammatory) and fibrotic forms
- associated with collagen disease, drugs, idiopathic
- good response to Rx; 5-year survival 80-90%
- Per R. Webb Orlando 2012 - NSIP: HRCT findings
Johkoh et al. Radiology 2002; 225:199
Travis et al. Am J Respir Crit Care Med 2008; 177:1338
- concentric, basal, and subpleural distribution
- ground-glass opacity in 80-90%; usually indicates cellular NSIP
- reticular opacities in 50%, often fine in appearance
- traction bronchiectasis suggests fibrotic NSIP
- honeycombing uncommon (1-5%) and minimal in extent = fibrotic NSIP
- sparing of immediate subpleural lung in 50% - NSIP: Utility of HRCT
- suggest NSIP if a basal and subpleural distribution of ground-glass opacity or fine reticulation is unassociated with honeycombing
- biopsy is not usually performed if the patient has a history of collagen vascular disease (CVD)
- in a patient with CVD, NSIP is most common ILD
- biopsy often performed if the patient has no known underlying disease
- Per R. Webb Orlando 2012 - Organizing Pneumonia (OP)
- OP is a histologic pattern associated with the syndrome known as OP or BOOP
- the term cryptogenic OP (COP) is used for idiopathic OP
- common
- idiopathic, infection, drugs, C-V diseases, fumes
- several months of cough, dyspnea, low-grade fever
- responds to steroids, good prognosis
- Per R. Webb Orlando 2012 - Organizing Pneumonia: HRCT findings
- air space consolidation - 90%
- ground-glass opacity - 60%
- large nodules - 15%
- focal consolidation - 5%
- opacities often irregular in shape
- patchy peribronchial and subpleural opacities are typical - Perilymphatic Nodules: differential diagnosis
- sarcoidosis (common)
- lymphangitic spread of tumor (uncommon)
- silicosis and CWP (uncommon)
- amyloidosis (rare)
- lymphoid interstitial pneumonia (LIP; rare) - Centrilobular Nodules: differential diagnosis
- bronchopneumonia or endobronchial spread of infection (bacteria, TB, MAC, fungi, virus, PCP)
- hypersensitivity pneumonitis
- respiratory bronchiolitis (RB-ILD) in smokers
- other bronchiolitis (e.g. follicular bronchiolitis)
- endobronchial spread of tumor (mucinous adeno)
- edema, hemorrhage, vasculopathy (uncommon)
- HRCT: GGO or solid? diffuse or patchy? acute or chronic?
- Per R. Webb Orlando 2012 - Centrilobular Nodules: GGO
- chronic symptoms with diffuse GGO nodules strongly suggests HP: with a history of exposure, this is often considered diagnostic
- caveat: in a smoker, think of respiratory bronchiolitis (RB-ILD)
- with chronic symptoms and patchy GGO nodules think of mucinous adenocarcinoma (BAC)
- with acute symptoms: consider atypical infection (PCP, CMV), hemorrhage, or edema - Centrilobular Nodules: solid
- with solid (i.e. soft-tissue) CL nodules, the most likely diagnosis is infection (e.g. TB or bacteria); often patchy or focal
- mucinous adenocarcinoma
- history may help in diagnosis - Honeycombing: differential diagnosis
- it usually reflects the histologic pattern termed usual interstitial pneumonia (UIP); common, UIP results in 25-50% of IP cases
- if no know associated disease or exposure: likely idiopathic pulmonary fibrosis (IPF) (60-70% cases)
- rheumatoid arthritis, scleroderma, other CVD
- drug-related fibrosis
- chronic hypersensitivity pneumonitis
- asbestosis (uncommon) - UIP: HRCT findings
- subpleural, posterior, lower lobe predominance
- irregular reticulation, often patchy
- traction bronchiectasis
- honeycombing in many (70%)
- ground-glass opacity rare as an isolated finding - Idiopathic Pulmonary Fibrosis (IPF)
- most common cause of UIP
- IPF --> UIP
- patients > 50 years of age
- progressive dyspnea
- mean survival 3 years
- no recognized treatment
- gradual progression in most
- Scleroderma of the Chest : Facts
- Bibasilar pulmonary fibrosis
- Productive cough common
- Hematemesis
-Pericarditis
- Dilated esophagus
- Aspiration pneumonia not uncommon - Scleroderma: CREST
- Calcinosis of the skin
- Raynaud Phenomenon
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia - Scleroderma: HRCT Findings
- Areas of ground glass attenuation
- Poorly defined subpleural nodules
- Reticular pattern of attenuation
- Traction bronchiectasis
- Honeycombing "Pulmonary artery diameter is not a reliable indicator of pulmonary hypertension in patients with pulmonary fibrosis.."
The Effect of Diffuse Pulmonary Fibrosis on the Reliability of CT Signs of Hypertension
Devaraj A et al.
Radiology 2008;249;1042-1049" Pulmonary artery dilatation occurs in the absence of pulmonary hypertension in patients with pulmonary fibrosis and is therefore an unreliable sign of pulmonary hypertension in these patients."
The Effect of Diffuse Pulmonary Fibrosis on the Reliability of CT Signs of Hypertension
Devaraj A et al.
Radiology 2008;249;1042-1049- Ernheim Chester Disease
- Triad of diffuse septal interstitial lung disease, pleural thickening , perirenal encasement and sclerotic bone lesions.
- Also known as Non-Langerhans cell histiocytosis of unknown etiology - Erdheim Chester Disease: Pleural Changes
- Smooth thickening of the pleural surfaces is usually bilateral and often symmetric - Erdheim Chester Disease: Parenchymal Changes
- Septal thickening often in association with visceral pleural thickening
- Septal thickening is often smooth and uniform
- Prominent centrilobular nodules
- Usually uniform throughout the lungs - Differential Diagnosis: Septal Lines
- Congestive heart failure
- Langerhans Cell Granulomatosis
- LCG and Erdheim Chester may co-exist
- Retroperitoneal fibrosis
- Congestive heart failure - Differential Diagnosis: Septal Lines
- Congestive heart failure
- Pulmonary edema
- Sarcoidosis
- Lymphangitic tumor
- Pulmonary veno-occlusive disease
- Diffuse pulmonary lymphangiomatosis - Erdheim Chester Disease: Renal Changes
- Perirenal fat effaced or infiltrated by soft tissue
- Usually bilateral and symmetric
- Infiltration of para-aortic regions is also common - Erdheim Chester Disease: Vascular Changes
- Periaortic infiltration which is usually circumferential and nonocclusive
- May involve aorta from root thru iliac vessels - Erdheim Chester Disease: Skeletal Changes
- Bilateral symmetric osteosclerosis of metaphyses and diaphyses especially in long bone. - Sarcoidosis: Key Facts
- Multiorgan granulomatous disease with multi-organ involvement
- Classic pathology is a noncaseating granuloma
- Usually affects young to middle age adults
- Highest prevalence in blacks
- More common in women than men - Sarcoidosis: Clinical Outcome
- Spontaneously remits in 1/3 of patients
- Chronic and progressive in 30% of patients
- Will prove fatal in 1-5% of patients (pulmonary or cardiac complcations) - Sarcoidosis: Key Facts
- Multiorgan granulomatous disease with multi-organ involvement
- Classic pathology is a noncaseating granuloma
- Usually affects young to middle age adults
- Highest prevalence in blacks
- More common in women than men - Sarcoidosis: Clinical Outcome
- Spontaneously remits in 1/3 of patients
- Chronic and progressive in 30% of patients
- Will prove fatal in 1-5% of patients (pulmonary or cardiac complcations) - "The spectrum of HRCT manifestations varies from typical findings that allow confident diagnosis to atypical patterns mimicking other disease, including predominance of ground glass opacity, consolidation, nodules, and typical distribution of lesions."
Idiopathic Pulmonary Fibrosis:Spectrum of High Resolution CT Findings
Souza CA et al.
AJR 2005; 185:1531-1539 - Idiopathic Pulmonary Fibrosis: Facts
- Symmetric bilateral reticulation
- Honeycombing involving subpleural regions especially in the lower lobes
- Architectural distortion of the lung parenchyma
- Increased incidence of lung cancer