Non-Resolving Consolidation

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1 Non-Resolving Consolidation Archana Laroia, MD Usual course of pneumonia -subjective improvement within three to five days of treatment. Archana Laroia, MD University of Iowa Hospitals and Clincs, Iowa city, USA Chest x-ray and hospitalization be considered for outpatients with pneumonia who fail to improve after 48 hours of treatment (2009 British Thoracic Society guidelines) Slow or incomplete resolution of pneumonia despite treatment - 15 percent of inpatient pulmonary consultations and 8 percent of bronchoscopies Approximately 20 percent of presumed non responding community-acquired pneumonia is due to noninfectious causes - Homogeneous increase in pulmonary parenchymal attenuation that obscures the margins of vessels and airway walls. Air bronchogram may be present Non- specific misdiagnosis of the pathogen or the presence of a resistant pathogen - development of complications from the initial infection -20 percent

2 Day 1 6 weeks later CT day 8 Day 4 Complicated by Lung abscess!! Day 7 Patient with bone marrow transplant presented with fever. UNUSUAL INFECTIONS Pulmonary aspergillosis Histoplasmosis INFLAMMATORY Chronic eosinophilic pneumonia Cryptogenic organizing pneumonia Sarcoidosis Wegener's granulomatosis Alveolar proteinosis Lipoid pneumonia NEOPLASTIC Bronchioloalveolar carcinoma Lymphoma TREATMENT RELATED DISEASES Radiation pneumonitis Amiodarone lung toxicity Initial CT Aspergillosis is a mycotic disease- most frequent species A fumigatus, A flavus and A niger Three months later Five categories of pulmonary aspergillosis have been classically described: Saprophytic aspergillosis (aspergilloma) Allergic bronchopulmonary aspergillosis Semi-invasive or chronic necrotizing aspergillosis Airway-invasive aspergillosis Angioinvasive aspergillosis Two weeks later Semi-invasive and angioinvasive aspergillosis can cause chronic slowly resolving consolidation

3 Almost exclusively seen in immunocompromised patients Radiological Findings Halo sign Air-crescent sign Histologic confirmation is not usually needed. Initial CT Three weeks later Historyimmunocompetent History Initial CT 4 weeks later Six months later Course CRYPTOGENIC ORGANIZING PNEUMONIA History typically peripheral and peri bronchovascular in distribution Radiologic characteristics Migrating nature of the consolidations Reverse halo sign % of cases Initial CT 4 weeks later Fleeting character Reverse halo

4 45 F H/o asthma presents with 4 weeks of SOB, no fever, constant cough, not productive Another 35 F with history of asthma. No response to treatment for infection. Labs- Eosinophils BAL- 40% Eosinophils!! BAL revealed >25 eosinophilia. Chronic eosinophilic pneumonia Idiopathic condition characterized by chronic infiltration of the lung with eosinophils Peripheral blood eosinophilia, if present, usually mild or moderate Increased IgE levels are seen in 2/3rd. Eosinophils in the BAL fluid are high Female preponderance, association with asthma -50% Reverse pulmonary edema- peripheral consolidations -when associated with blood eosinophilia, this characteristic allows a confident diagnosis Less common findings include ground-glass opacities, nodules, and reticulation Oct 2012 BAL- noncaseating granulomas Sarcoidosis July 2013 March 2013 Systemic disorder of unknown cause that is characterized by noncaseating granulomas with proliferation of epithelioid cells Thoracic involvement -90% of patients Five radiological stages are described: Stage 0 - Normal chest radiograph Stage 1 - Lymphadenopathy only Stage 2 - Lymphadenopathy with parenchymal infiltration Stage 3 - Parenchymal disease only Stage 4 - Pulmonary fibrosis Bilateral hilar and right paratracheal lymph node enlargement +/_ calcification is characteristic

5 35 M with h/o smoking for 20 years minimal sob Small nodules in a perivascular distribution and with irregular thickening of bronchovascular bundles and septa with a upper lobes predominancemost common Many atypical variants- Irregular areas of high attenuation that may contain air bronchogram True alveolar consolidation and ground-glass opacities Crazy Paving Predominant ground-glass opacity and consolidation patterns seen on initial CT scan - worse prognosis /susceptible to developing severe respiratory insufficiency Characterized by abnormal intraalveolar accumulation of surfactant-like material Idiopathic form accounts for more than 90% of cases with an incidence of 0.36 new cases per million per year Strong association with smoking (up to 75% of patients are smokers) CXR usually reveals bilateral central and symmetric opacifications with relative sparing of apices and costophrenic angles Clinicoradiologic discrepancy in these patients with mild symptoms and an eye-catching imaging CT appearance of "crazy-paving", defined as a network of smoothly thickened septal lines superimposed on areas of ground-glass opacity often with sharply marginated areas of geographic or lobular sparing - 75% of the patients left heart failure pneumocystis pneumonia alveolar hemorrhage bronchoalveolar carcinoma lymphangitic carcinomatosis adult respiratory distress syndrome radiation- or drug reaction Non resolving infiltrates in a a 83 F with life long h/o constipation Accumulation of lipids in the alveoli Exogenous- inhalation or aspiration of animal fat or vegetable or mineral oil. Endogenous -associated with bronchial obstruction Chronic exogenous lipoid pneumonia - Repeated episodes of aspiration in older patients, swallowing impairment, anorexia nervosa or bulimia or in children Ass. with chronic use of mineral oil lubricants or decongestants such as Vaseline, Vicks Vapo Rub, lip gloss and laxatives CT -Consolidations with predominant involvement of the lower lobes. With areas of fat attenuation as low as -30 HU

6 August 2011 Jan 2012 March 2012 May 2012 Open lung biopsy- mucinous adenocarcinoma previously called Bronchioloalveolar carcinoma Nodules and chronic consolidations predominantly peripheral distribution Bronchioloalveolar carcinoma 75 F with weight loss, fever, cough. Bronchioloalveolar carcinoma (BAC) represents 1.5%-6.5% of all primary pulmonary neoplasms May 2013 Middle-aged, women (30-50%). Jun /3rd are smokers BAC manifests radiologically in three different ways: Solitary nodule (45%) Consolidation (30%) Multiple nodules (25%) Jun 2013 Bronchoscopic biopsy- Atypical cells CD 30 + Pulmonary lymphoma Initial CT Jan 2011 March 2011 Primary non-hodgkin's pulmonary lymphomas are rare extranodal lymphomas ( <1% of all lymphoma) April 2011 August 2011 Secondary pulmonary lymphoma Hodgkin's disease 12% Non-Hodgkin's lymphoma 4% CXR and CT: Bronchovascular or lymphangitic with thickening of bronchovascular bundles and interlobular septa (41%), pulmonary nodules (39%),pulmonary consolidation (14%), and hematogenous or miliary with disseminated micro-nodules (6%) AIDS and organ transplant recipients- higher prevalence of pulmonary lymphoma Increasing nodular consolidations in both lungs Pulmonary lymphoma

7 45 F with stage 4 breast cancer - multiple bony metastatic lesions Slowly resolving lung infiltrate in post lung transplant patient after Sirolimus Amiodarone lung toxicity Amiodarone is an antiarrhythmic agent Pulmonary toxicity develops in around 6% High attenuation lung infiltrates Increased attenuation in the liver-90% Radiation pneumonitis CT 3 months post radiation Acute phase of radiation pneumonitis manifests radiologically as ground-glass opacities and consolidation in the irradiated area. May occur 6 weeks to 6 months after radiation Gradually resolves or progression to radiation fibrosiswith severe injury Key radiological fact -relatively sharp border that conforms to the treatment zone rather than to anatomic boundaries Non resolving lung consolidation has a wide of differential diagnosis ranging from infectious to neoplastic causes, including some rare conditions as alveolar proteinosis or lipoid pneumonia. Some radiological signs that may point to a correct diagnosis Correlating the radiological findings with the history is an important at arriving at a diagnosis in this not so uncommon problem. Thanks for your attention!!

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