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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