Chest: Systemic Conditions · Sarcoidosis HRCT • Bilateral, symmetric • Small nodular/reticular...
Transcript of Chest: Systemic Conditions · Sarcoidosis HRCT • Bilateral, symmetric • Small nodular/reticular...
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Approach to Diagnosis: Case-based Imaging Review
Chest: Systemic Conditions
Tan-Lucien H. Mohammed, M.D., FCCPDepartment of Radiology
University of Florida
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38-year-old woman with cough and dyspnea
Case 1 - Radiography
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Case 1 - HRCT
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Case 1 - Imaging Findings
• Reticulonodular opacities• mid-lungs• upper lungs
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Case 1 - Imaging Findings (HRCT)
• Multifocal micronodules• Perilymphatic distribution
Bronchovascular bundlesJuxtapleural regionsInterlobular septae
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Case 1 - Imaging Findings (HCRT)
• Multifocal micronodules• Perilymphatic distribution
Bronchovascular bundlesJuxtapleural regionsInterlobular septae
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Perilymphatic Distribution
Courtesy of Jud W. Gurney, MD
• Axial (bronchoarterial)• Subpleural• Interlobular septa
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Case 1 - Differential Diagnosis
• Lymphangitic carcinomatosis• Sarcoidosis• Silicosis• Lymphoproliferative disorder
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Case 1 - Diagnosis
SARCOIDOSIS
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Sarcoidosis HRCT • Bilateral, symmetric • Small nodular/reticular opacities• Upper-lung and mid-lung zones predominantly• (Nodular sarcoid: multifocal nodules/masses with or without air bronchograms)
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Lymphangitic carcinomatosisHRCT• Unilateral or Bilateral• Patchy or diffuse• Smooth or nodular thickening• Peribronchovascular• Interlobular septa• Interlobar fisures
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Lymphangitic carcinomatosis
HRCT• Unilateral or bilateral• Patchy or diffuse• Smooth or nodular thickening• Peribronchovascular• Interlobular septa• Interlobar fisures
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SilicosisHRCT• Small (2-5mm) nodules• Ill-defined or well-defined• Centrilobular or juxtapleural• Conglomerate masses• Upper lobe or posterior
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62 year old woman with cough
Case 2
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Case 2 - Imaging Findings• Irregular, cavitary nodule in left upper lobe• Focal consolidation in right upper lobe (angiocentric)
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Case 2 - Differential Diagnosis
Multifocal cavitary nodules• Multifocal neoplasia (primary or secondary)• Multifocal bacterial pneumonia• Bland or septic emboli• Vasculitis (Wegener granulomatosis, Churg-Strauss)• Cryptogenic organizing pneumonia (COP)
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Case 2 - Diagnosis
WEGENER’S GRANULOMATOSIS
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Wegener GranulomatosisImaging features• Nodules or masses (44%) • Consolidations (24%)• Cavitation (5-25%)• Diffuse consolidation (5%)• Airway abnormalities (9%)
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Metastases or Septic Emboli• Hematogenous dissemination• Predominantly lower lungs• Reflects increased blood supply
Metastatic colon caSeptic Emboli
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Septic emboliImaging features
• Multiple pulmonary opacities• Variable shape and size • Subpleural/wedge-shaped
• Frequent cavitation/air bronchograms• Predominant in lower lungs
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50-year-old man with dyspneaCase 3
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Case 3 - Imaging Findings
• Bilateral, patchy ground-glass opacity• Focal areas of traction bronchiectasis
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Case 3 - Differential DiagnosisBibasilar Ground Glass Opacities• Usual interstitial pneumonia (UIP)• Nonspecific interstitial pneumonia (NSIP)• Acute interstitial pneumonia (AIP)• Cryptogenic organizing pneumonia (COP)
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Case 3 - Diagnosis
Nonspecific interstitial pneumonia (NSIP)
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NSIP Imaging Features• Ground glass opacity• Evidence of fibrosis• Volume loss• Reticulation• Traction bronchiectasis
• Honeycombing (rare)• Basal predominance• Subpleural or peribronchovascular
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HRCT Features
UIP NSIP DIPGGO + +++ +++
Honeycombing +++ + +
Traction bronchiectasis
+++ + +
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UIP versus NSIP - HRCT
UIP NSIP
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28 year old man with dry cough and mild dyspnea
Case 4
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Case 4
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Case 4 - Imaging Findings (CXR)
• Bilateral, symmetric • Airspace or reticular opacities• No lymphadenopathy • No pleural effusion
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Case 4 - Imaging Findings
• Bilateral patchy ground-glass opacities• Superimposed interlobular septal thickening• “Crazy paving” pattern
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Case 4 - Differential Diagnosis
“Crazy Paving” Pattern• Pneumonia
(infectious, eosinophilic, lipoid, organizing)• Pulmonary alveolar proteinosis (PAP)• Diffuse alveolar damage (ARDS)• Pulmonary edema• Multifocal neoplasia (BAC, Lymphoma)
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Case 4 - Diagnosis
Pulmonary alveolar proteinosis (PAP)
Accumulation of lipid-rich granular eosinophilic material in alveoli
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Pulmonary Alveolar Proteinosis (PAP) - CT/HRCT
• Diffuse, patchy bilateral GGO• Superimposed smooth thickening of interlobular septa (“crazy-paving” pattern)• GGO, airspace nodules, confluent consolidations• Geographic demarcation between affected lung and normal parenchyma
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“Crazy Paving” HRCT
• Ground-glass opacity• Thickened interlobular septa
Crazy Paving masonry
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“Crazy-Paving” Pattern Differential Diagnosis
Most Likely:• Pulmonary alveolar proteinosis• Lipoid pneumonia• Bronchioloalveolar carcinoma• Pneumocystic jiroveci pneumonia
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25 year old man with wheezing, dyspnea and productive cough
Case 5
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Case 5 - Radiography
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Case 5 - HRCT
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Case 5 - Radiography
• Hyperinflation• RUL atelectasis• Parallel linear opacities (tram tracks)• Tubular and nodular opacities emanating from left hilum
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Case 5 - HRCT• Extensive bronchiectasis• Predominantly upper lungs• RUL atelectasis
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Case 5 - Differential Diagnosis(Bronchiectasisis)
• Cystic fibrosis • Allergic bronchopulmonary aspergillosis (ABPA)• Williams-Campbell syndrome• Other causes of bronchiectasis
(chronic aspiration, healed TB, radiation Rx)
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Case 5 - Diagnosis
CYSTIC FIBROSIS
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Cystic Fibrosis -Radiography
• Large lung volumes• Atelectasis (mucous plugs)• Widespread bronchiectasis(upper>lower)• Nodular or tubular opacities (mucoid impaction)• Recurrent consolidation• Lymphadenopathy
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Cystic FibrosisHRCT
• Bronchiectasis• Diffuse, bilateral upper lobes • “Tree-in-bud” appearance• Geographic lung attenuation• Air-trapping• Mucous plugs in dilated airways
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Bronchiectasis Distribution
ABPA
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Bronchiectasis DistributionABPA Central bronchiectasis
Cystic fibrosis Upper lung predominance
Post-infectious Lower lobes (LLs), dependent lung
Ciliary dyskinesia Lower lobes (LLs)
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54-year-old man with dyspnea and nonproductive cough
Case 6
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Case 6 - Radiography
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Case 6 - CT/HRCT
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Case 6 Radiography
• Bilateral perihilar and upper lobe • Nonsegmental consolidations
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Case 6 - CT/HRCT
• Bilateral consolidations • Ground-glass opacities• Peribronchial and subpleural distribution
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Case 6 - Differential Diagnosis
• Chronic eosinophilic pneumonia• Cryptogenic organizing pneumonia (COP)• Multifocal bronchioloalveolar carcinoma (BAC)
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Case 6 - Diagnosis
Cryptogenic organizing pneumonia
(COP)
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Cryptogenic organizing pneumonia Radiography
• Nonspecific• Bilateral, peripheral, basal patchy consolidation
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Cryptogenic organizing pneumonia (CT/HRCT)
• Patchy, uni/bilateral• Air-space consolidation• Ground-glass opacity• Crazy-paving pattern• Subpleural/peribronchial• Centrilobular nodules
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Cryptogenic organizing pneumonia (CT/HRCT)• Unusual HRCT finding• “Atoll sign”• Resembles an atoll
ATOLL: massive coral growth on a submerged mountain range or volcano; low islands encircling a seawater lagoon.
Courtesy of Elizabeth Moore, MD
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Chronic eosinophilic pneumonia Imaging
• Bilateral non-segmental airspace consolidations• GGO and consolidations• Subpleural distribution (60%)• Upper/mid lung predominance
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Approach to Diagnosis: Case-based Imaging Review
Chest: Systemic Conditions
Tan-Lucien H. Mohammed, M.D., FACR Department of Radiology
University of Florida