HRCT of Common Lung Diseases. W. Richard Webb MD
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1 HRCT of Common Lung Diseases W. Richard Webb MD
2 Common Lung Diseases: HRCT Infections (pneumonia, airways disease) Sarcoidosis Hypersensitivity pneumonitis UIP and idiopathic pulmonary fibrosis (IPF) Nonspecific interstitial pneumonia (NSIP) Organizing pneumonia (OP or BOOP)
3 Sarcoidosis microscopic noncaseating granulomas in clusters 60-70% have characteristic plain film findings 10% have normal chest radiographs HRCT abnormal in most with normal radiographs
4 Sarcoidosis: HRCT findings small nodules, usually well-defined are typical patchy distribution upper lobe predominance in most the nodules show a perilymphatic distribution typical lymph node enlargement or calcification in some patients is suggestive, but is not necessary for diagnosis
5 Sarcoidosis: Nodules perilymphatic nodules predominate in relation to the peripheral pleural surfaces and fissures, and the peribronchovascular interstitium interlobular septal nodules are less frequent and less numerous centrilobular nodules can be seen involving the centrilobular peribronchovascular interstitium in rare patients, the nodules appear random in distribution
6 Sarcoidosis Subpleural and peribronchovascular nodules
7 . Perilymphatic nodules in sarcoidosis: peribronchovascular and subpleural
8 . Perilymphatic nodules in sarcoidosis: peribronchovascular and subpleural
9
10 . Perilymphatic nodules in sarcoidosis: peribronchovascular and subpleural
11 . Sarcoidosis: interlobular septal nodules
12 . Sarcoidosis with interlobular septal nodules
13 . interlobular septal nodules with atypical basal distribution
14 . Centrilobular (peribronchovascular) nodules
15 . Sarcoidosis: centrilobular opacities mimicking tree-in-bud
16 Sarcoidosis: centrilobular nodules
17 . Sarcoidosis: nodules with a random distribution
18 Sarcoidosis: additional findings large nodules or masses %» often upper lobe, parahilar (peribronchovascular)» air bronchograms (i.e. consolidation)» confluence of granulomas» satellite nodules ( galaxy sign )» alveolar sarcoid ground-glass opacity» confluence of small granulomas
19 Sarcoidosis: subpleural and peribronchovascular nodules confluent nodules: masses with satellites.
20 Sarcoidosis: subpleural and peribronchovascular nodules confluent nodules: masses with satellites.
21 Sarcoidosis: subpleural and peribronchovascular nodules confluent nodules: masses with satellites the galaxy sign.
22 . confluent nodules: masses with satellites
23 . Sarcoidosis: confluent nodules with air bronchograms
24 Sarcoidosis: confluent nodules with air bronchograms
25 . Sarcoidosis: clustered small nodules with satellites and ground-glass opacity
26 . Sarcoidosis: nodules and ground-glass opacity
27 . Sarcoidosis: ground-glass opacity
28 Sarcoidosis: airway abnormalities obstruction of large airways endobronchial granulomas small airway obstruction with mosaic perfusion and/or air trapping on expiratory scans
29 Sarcoid: airway abnormalities
30 45 year old with dyspnea. bronch: sarcoidosis
31 . 1 year later
32 Sarcoidosis: nodules and air trapping dynamic expiration.
33 . Sarcoidosis: subpleural and peribronchovascular nodules
34 Sarcoidosis: air trapping dynamic expiration inspiration.
35 Sarcoidosis: air trapping dynamic expiration.
36 Sarcoidosis: late or fibrotic nodules decrease (but often remain visible) distortion of fissures, reticulation interlobular septal thickening peribronchovascular fibrosis, usually upper lobe conglomerate masses of fibrous tissue traction bronchiectasis subpleural honeycombing in a few percent emphysema and cysts
37 . Sarcoidosis: early fibrosis with reticulation and distortion of fissures
38 . Sarcoidosis: fibrosis with reticulation and septal thickening
39 . Sarcoidosis: conglomerate fibrosis, traction bronchiectasis, posterior displacement of the hila
40 . Sarcoidosis: fibrosis with traction bronchiectasis
41 . Sarcoidosis: peribronchovascular fibrosis with traction bronchiectasis, mild honeycombing
42 . Sarcoidosis: traction bronchiectasis and cysts
43 . Sarcoidosis: traction bronchiectasis and cysts
44 . Sarcoidosis: fibrosis with cysts
45 . Sarcoidosis: traction bronchiectasis, cysts, emphysema, aspergilloma
46 . Sarcoidosis: traction bronchiectasis and honeycombing
47 Hypersensitivity Pneumonitis
48 Hypersensitivity Pneumonitis (HP) common caused by inhalation of organic antigens responsible antigen identified in only 50% acute, subacute, and chronic stages repeated exposures produce fever, chills, dry cough, dyspnea progressive symptoms over months or years
49 Hypersensitivity Pneumonitis: subacute stage ongoing exposure progressive symptoms over weeks to months ill-defined peribronchiolar granulomas alveolitis and interstitial infiltration cellular bronchiolitis
50 Hypersensitivity Pneumonitis: subacute stage ill-defined centrilobular nodules (50-60%), usually of ground-glass opacity (granulomas) patchy ground-glass opacity (75-90%) (alveolitis) patchy mosaic perfusion; air trapping on expiratory scans (bronchiolitis) diffuse or predominant in mid lung zones; entire cross section of lung involved; no subpleural predominance a few lung cysts in a few patients
51 . Subacute hypersensitivity pneumonitis
52 . Subacute hypersensitivity pneumonitis
53 .
54 . Subacute hypersensitivity pneumonitis
55
56
57
58 . Subacute hypersensitivity pneumonitis
59 Subacute HP: patchy GGO
60 Hypersensitivity pneumonitis post-treatment ground-glass opacity.
61 ground-glass opacity + mosaic perfusion ground-glass opacity = interstitial infiltration mosaic perfusion = bronchiolitis. Headcheese sign
62 Headcheese sign. Hypersensitivity pneumonitis
63 Hypersensitivity Pneumonitis Headcheese sign lobular (geographic) ground-glass opacity and mosaic perfusion (air trapping) indicative of mixed infiltrative disease and bronchiolitis
64
65 . mosaic perfusion
66 . expiration
67 66 year old bird fancier with progressive dyspnea. Hypersensitivity pneumonitis
68 dynamic expiration. Hypersensitivity pneumonitis
69 Subacute HP: air trapping
70 . Biopsy proven HP
71 . expiratory scan
72 Hypersensitivity pneumonitis expiration air-trapping with lung cyst.
73 HRCT Diagnosis: Chronic HP, IPF, NSIP chronic HP: lobular areas of low attenuation, centrilobular ground-glass opacity nodules, absence of lower lobe predominance IPF: basal predominance of honeycombing, absence of subpleural sparing and nodules NSIP: subpleural sparing, absence of honeycombing and lobular low attenuation confident diagnosis in 53%; correct in 94% Silva et al. Radiology 2008; 246:288
74 48 year old man with dyspnea
75
76
77 Hot tub lung
78 Hot tub lung Immunocompetent subjects symptoms within hours of hot tub use dyspnea, cough, hypoxemia, fever nonnecrotizing granulomas, often bronchiolocentric MAC (mycobactium avium) found on culture, less often on biopsy, and in the hot tube likely a hypersensitivity reaction resolution without antibiotic treatment
79 Hypersensitivity Pneumonitis: chronic stage long term or repeated exposure irregular fibrosis: coarse scars, septal thickening, traction bronchiectasis, honeycombing in some patchy, lacks a subpleural distribution in most diffuse or predominantly involving mid lung zones upper lobe involvement (atypical for IPF) superimposed findings of subacute disease in some: ground-glass opacity or nodules headcheese sign with findings of fibrosis
80 Hypersensitivity Pneumonitis: progression. 6 month follow-up
81 . Chronic HP
82 . Chronic HP
83
84
85
86
87 . chronic HP: reticulation and traction bronchiectasis
88 . chronic hypersensitivity pneumonitis
89 subacute HP: ground-glass opacity chronic HP: reticulation and traction bronchiectasis.
90 HRCT of Common Lung Diseases W. Richard Webb
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