Radiologic Findings in Bronchiectasis · L. Renata Thronson, HMS III Gillian Lieberman, MD...
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L. Renata Thronson, HMS III Gillian Lieberman, MD Radiologic Findings in Radiologic Findings in Bronchiectasis Bronchiectasis L. Renata Thronson, Harvard Medical School Year III Gillian Lieberman, MD Oct/Nov 2003
Transcript of Radiologic Findings in Bronchiectasis · L. Renata Thronson, HMS III Gillian Lieberman, MD...
L. Renata Thronson, HMS IIIGillian Lieberman, MD
Radiologic Findings in Radiologic Findings in BronchiectasisBronchiectasis
L. Renata Thronson, Harvard Medical School Year IIIGillian Lieberman, MD
Oct/Nov 2003
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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BronchiectasisBronchiectasis
Bronchiectasis is an irreversible, chronic dilatation of diseased airways.
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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A 64 yearA 64 year--old male old male with recurrent with recurrent
pneumoniapneumoniaandand
A 44 yearA 44 year--old old woman with woman with
cough and cough and ralesrales
PACS, BIDMC PACS, BIDMC
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Pathogenesis of Pathogenesis of BronchiectasisBronchiectasis
Colonization
Tissue damage
Defective mucociliaryclearance
Microbes persist inbronchi
Environmentalinsult
Geneticsusceptibility
ChronicinflammationProgressive
lung damage
Adapted from Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
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Menu of testsMenu of tests
• Bronchography– The “gold standard”
• High-resolution CT– 1-2 mm collimation– Grenier et al: Se 96%; Sp 93%– Young et al: Se 98%; Sp 99%
• Chest x-ray– Inferior sensitivity and specificity
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BronchographyBronchography
• Requires local anesthetic and bronchographic medium potential for allergic reaction
• Exam limited to airways http://radiology.rsnajnls.org
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CXR: FindingsCXR: Findings
• Indistinct vessel margins
• Tram lines• Ring shadows• Volume loss
– Elevated left hemidiaphragm
PACS, BIDMC
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HRCT: FindingsHRCT: Findings
• Dilatation– Signet ring sign– Non-tapering airways
• Indirect signs– Mucous plugging– Lobar volume loss– Wall thickening
PACS, BIDMC
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Signet Ring SignSignet Ring Sign
PACS, BIDMC
Airway
Pulmonary artery
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NonNon--tapering airwaystapering airways
• Airways visible within 1 cm of the visceral pleura
• Tram lines• Flaring
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Mucous pluggingMucous plugging
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
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DDX of DDX of BronchiectasisBronchiectasis• Postinfectious
– Bacterial– Mycobacterial– Viral– Fungal
• Post-transplantation– Chronic rejection– GVHD
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DDX of Bronchiectasis
• Postinflammatory– Aspiration– Toxic inhalation
• Postobstructive– Tumor– Foreign body– Stricture
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DDX of DDX of BronchiectasisBronchiectasis
• Impaired mucociliary clearance– Dyskinetic cilia syndromes– Cystic Fibrosis
• Inherited cellular or molecular defects– Alpha-1-antitrypsin deficiency– Cystic Fibrosis
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DDX of DDX of BronchiectasisBronchiectasis• Immune deficiency
– Inherited– Acquired
• Collagen Vascular Disease– Rheumatoid arthritis– Sjogren’s syndrome– Ankylosing spondylitis– Marfan syndrome– IBD
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DDX of DDX of BronchiectasisBronchiectasis
• Congenital bronchial abnormalities– Mounier-Kuhn syndrome– Williams-Campbell syndrome– Bronchopulmonary sequestration
• Miscellaneous– Asthma– Yellow-nail syndrome– Sarcoidosis
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Diagnostic PitfallsDiagnostic Pitfalls
PACS, BIDMC http://www.hospitalist.net/case1.html
Bronchiectasis Interstitial disease
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Diagnostic PitfallsDiagnostic Pitfalls
Signet ring? Tram lines?
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126
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Diagnostic PitfallsDiagnostic Pitfalls
Branching airway
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126
Double shadow: heart and vessels
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64 year64 year--old man with recurrent old man with recurrent pneumoniapneumonia
PACS, BIDMC
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64 year64 year--old man with recurrent old man with recurrent pneumoniapneumonia
PACS, BIDMC
Ring shadow Tram lines
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64 year64 year--old man with recurrent old man with recurrent pneumoniapneumonia
Varicoiddilatation
Airways visible at pleural margin
PACS, BIDMC
Mucous plugging
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44 year44 year--old woman with coughold woman with cough
Varicoid dilatation Cystic dilatation
PACS, BIDMC PACS, BIDMC
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44 year44 year--old woman with coughold woman with cough
Tracheal margins
Tracheal margins
PACS, BIDMC
PACS, BIDMC
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MounierMounier--Kuhn syndromeKuhn syndrome
• Congenital bronchial abnormality
• ?Autosomal recessive• Findings
– Tracheomegaly– Bronchomegaly
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BronchiectasisBronchiectasis and and SitusSitus InversusInversus
Courtesy of Phillip Boiselle, MD
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KartagenerKartagener syndromesyndrome
• Primary ciliary dismotility– Recurrent respiratory
infections– Decreased fertility
• Findings on CXR– Bronchiectasis– Situs inversus Courtesy of Phillip Boiselle, MD
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Cystic FibrosisCystic Fibrosis
• Upper lobe predilection
• Panlobar disease• Marked cystic
dilatation– Air-fluid levels
may be seen within cysts Courtesy of Phillip Boiselle, MD
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Cystic FibrosisCystic Fibrosis
• Upper lobe predilection
• Panlobar disease• Marked cystic
dilatation– Air-fluid levels
may be seen within cysts Courtesy of Phillip Boiselle, MD
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PostinfectiousPostinfectious VaricoidVaricoid BronchiectasisBronchiectasis
Focal bronchiectasis
PACS, BIDMC
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SummarySummary• DDX of bronchiectasis is broad, but the diseases
share a common pathogenesis• Morphologies reflect degrees of severity
– Cylindrical– Cystic– Varicoid
• Tests available– Bronchography– CXR– HRCT
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SummarySummary
• Radiologic findings– CXR
• Volume loss• Mucous plugging
– “gloved finger”
• Inflammation– Indistinct vessel margins– Tram lines– Ring shadows
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SummarySummary
• Radiologic findings– HRCT
• Wall thickening• Mucous plugging• Crowded bronchilobar volume loss• Airway dilatation
– Signet ring sign– Non-tapering small airways
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ReferencesReferences• Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.• McGuinness G, Naidich DP. CT of Airways Disease and Bronchiectasis. Radiologic Clinics of
North America 2002; 40:1-19.• Friedman, PJ. Chest Radiographic Findings in Adults with Cystic Fibrosis. Seminars in
Roentgenology 1987; 22:114-124.• Grenier P, Maurice R, Musset D, et al. Bronchiectasis: Assessment by thin-section CT.
Radiology 1986; 161:95-99.• Young K, Aspestrand F, Kolbenstvedt. High resolution CT and bronchography in the
assessment of bronchiectasis. Acta Radiology 1991; 32:439-441.
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Acknowledgements
• Andru Bageac, MD• Eric Niendorf, MD• Phillip Boiselle, MD• Gillian Lieberman, MD• Larry Barbaras• Pamela Lepkowski
