International Journal of Current Medical And Applied Sciences, volume 5, Issue 1, December: PP: 41-46

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1 International Journal of Current Medical And Applied Sciences, volume 5, Issue 1, December: PP: Etiological Classification and HRCT Features of Diffuse Interstitial Lung Disease at Katuri Tertiary Referral Center. Ramakrishna Narra*, Naganarasimharaju Jukuri**, Bhimeswarao Pasupaleti*** & Teja Naidu **** *Associate Professor, **Assistant Professor, ***Professor & ****Senior Resident, Department of Radiodiagnosis, Katuri Medical College Guntur Corresponding Research Article Abstract: Background: Interstitial lung diseases comprise a group of disorders characterized by inflammation and scarring of alveoli and the pulmonary interstitium. Interstitial lung disorders represent a group with diverse etiology and characteristic HRCT features. The purpose of the present study is to etiologically classify various interstitial lung disorders and to describe their characteristic HRCT features among the patients referred to our tertiary center. Methods: The study is a prospective study done in department of Radiodiagnosis at KATURI MEDICAL College and Hospital. A total of 50 patients referred to the department for an HRCT scan with interstitial lung disease confirmed clinically, by laboratory analysis or by biopsy were studied. The various etiological subtypes and their corresponding HRCT features were analyzed and described. HRCT was performed using GE 16 SLICE MDCT scanner. Results: The study comprised of 50 patients who were etiologically classified into fourteen subgroups. Characteristic imaging features of interstitial lung disorders such as reticular opacities, nodular opacities, ground glass opacities, were analyzed and their characteristic distribution, location were noted. Each subgroup had characteristic HRCT features. Idiopathic pulmonary fibrosis was the most common etiological subgroup observed in our study. Conclusion: HRCT is a useful tool for diagnosis and management of diffuse interstitial lung disease and an unnecessary biopsy could be avoided for etiological classification of interstitial lung disorders. Introduction: Interstitial lung diseases are a group of disorders caused by inflammation and scarring of Subject: Radiodiagnosis alveoli and the pulmonary interstitium. Pulmonary interstitium is the network of connective tissue fibers that supports the lung. It includes alveolar walls, interlobular septa and the peribronchovascular interstitium [1]. Interstitial lung diseases are characterized by alveolar septal thickening, fibroblast proliferation, collagen deposition and if the process remains unchecked, it will lead to pulmonary fibrosis. To have a probable diagnosis, the clinical assessment of a patient with suspected interstitial lung disease can be a difficult and perplexing problem. Plain chest radiograph is an inexpensive, excellent and indispensable modality on the investigation of such disease. However the radiographic pattern of diffuse lung disease has often been nonspecific and is subject to considerable observer variations. Due to poor contrast resolution and superimposition of structures, the plain chest radiograph has limited diagnostic accuracy. These limitations of plain chest film in the assessment of lung disease especially diffuse interstitial lung disease and difficulties of characterizing lung morphology precisely became even more evident when computed tomography was introduced as a new tool in radiographic imaging. High resolution computed tomography (HRCT) was introduced in 1985 by Zerhouni et al [2], the perfect imaging modality for characterization and diagnosis of interstitial lung diseases. It differs from conventional CT by using thin collimation with high spatial frequency algorithm (Bone algorithm). It has enabled imaging of the lung with excellent spatial resolution proving anatomical details similar to that available from gross pathologic specimens of lungs. In accordance with diffuse interstitial lung diseases HRCT plays major role in finding out Presence of disease in the lung Type of disease 2014 Logic Publications, IJCMAAS,E-ISSN: ,P-ISSN: Page I 41

2 Ramakrishna Narra, Naganarasimharaju Juluri, Bhimeswarao Pasupaleti & Teja Naidu Changes of active lung disease From which site and which type of biopsy should be performed if required Change in disease activity following treatment. Aim and Objectives: To evaluate the importance of high resolution computed tomography in the diagnosis of interstitial lung diseases. To study the various high resolution computed tomographic patterns of interstitial lung diseases. Materials and Methods: A total number of 50 patients with suspected or known interstitial lung disease were Scanning Parameters: Position : Supine Scanner settings : KV(p): mas : Collimation : 1mm Scan time : 1 second. Matrix size : 512 x 512 Superior extent : Lung apices. Inferior extent : Domes of diaphragm Reconstruction : High spatial frequency algorithm Windows setting Window width : 1200 to 1600 HU. Window level : -600 to -800 HU. Technique: The CT machine used was GE 16 slice MDCT scanner. 1) Patient was placed on gantry table in the supine position with both arms above the head and no gantry tilt was done. 2) A digitized AP scanogram was obtained in suspended full inspiration. studied by high-resolution computed tomography (HRCT) over a period of 24 months. The study group consisted of 50 patients, of which 26 were males (52%) and 24 were females (48%). The age group of patients varied from 4 years to 75 years. Selection Criteria: Patients were selected on the basis of:-- 1) Clinical history suggestive of interstitial lung disease. 2) Known cases of interstitial lung disease. 3) Abnormal chest radiographs (with an interstitial pattern) 4) Abnormal restrictive pulmonary function tests. Data collected from these patients included their name, age, sex, occupation, clinical history and relevant investigation reports. Image Analysis -Image analysis done based on morphological pattern on HRCT Reticulations,nodularity,groundglassopacity,consoli dation,bronchiectasis,emphysema,fibrotic strands, cystic spaces, fissural thickening, pleural thickening. -Reticular thickening was analysed depending on smoothness and irregularity, interface sign, peribronchovascular septal thickening, interlobular septal thickening, parenchymal bands, subpleural interstitial thickening, intralobular interstitial thickening, honeycombing, irregular linear opacities, subpleural lines, honeycombing indicating end stage lung disease. -Nodularity was analysed based on size, appearance, attenuation, distribution of nodules- Centrilobular, Perilymphatic or Random. -Increased Lung Opacity i.e. ground-glass opacity, consolidation, crazy - paving pattern was analysed on the basis of distribution and pattern. -Honeycombing, emphysema, bronchiectasis,mosaic perfusion were analysed based on pattern and distribution. -Cystic spaces and cavities were analysed based on size and distribution. -Pleural involvement and fissural thickening were assessed. -Associated features like pleural effusion and mediastinal lymphadenopathy were also assessed. 3) The patients were taught prior to procedures to hold breath in deep inspiration and expiration wherever required. 4) Axial scans of 1mm thickness were obtained at 10 mm intervals from lung apices to bases in suspended full inspiration Logic Publications, IJCMAAS,E-ISSN: ,P-ISSN: Page 42

3 Logic 2014, IJCMAAS, E-ISSN: ,P-ISSN: ) Modifications in the above technique were done if indicated:- Prone scan were taken to determine whether opacities in the dependent lung are abnormal or not. Observations and Results: Scans were also taken at the end of deep expiration to detect any air trapping. The study included 50 patients.the age, sex distribution etiological subgroups and HRCT patterns include Table 1: Patients according to Age-Group & Gender: Age- Group Total No.of patients Male Female No. % No. % < Total Table 2: Distribution of cases according to etiological diagnosis Diagnosis No. of Cases Percentage Idiopathic pulmonary fibrosis Lymphangitic carcinomatosis Hypersensitivity pneumonitis 9 18 Rheumatoid arthritis 6 12 Miliary tuberculosis 4 8 Nonspecific interstitial pneumonia 2 4 Acute interstitial pneumonia 1 2 Pneumocystis carinii pneumonia 1 2 Cardiogenic pulmonary edema 1 2 Systemic lupus erythematosus 1 2 Progressive systemic sclerosis 1 2 Welder s pneumoconiosis 1 2 Sarcoidosis 1 2 Silicosis 1 2 Table 3 : Distribution of Fifty cases according to lung involvement. No. of patients Percentage Unilateral involvement 01 02% Bilateral involvement 49 98% Total % International Journal of Current Medical And Applied Sciences [IJCMAAS], volume.5. Issue 1.

4 IPF LC HP RA Miliary TB NSIP AIP PCP CPE SLE PSS WP SAR Silicosis Total % Ramakrishna Narra, Naganarasimharaju Juluri, Bhimeswarao Pasupaleti & Teja Naidu Table 4: HRCT findings of interstitial lung diseases observed in 50 patients HRCT Findings Discussion: Reticular Nodular Ground-glass opacity Honeycombing Cysts/cystic air spaces Consolidation Bronchiectasis Fissural thickening Emphysema Cavity Fibrotic strands Pleural thickening Pleural effusion Lymphadenopa thy The various imaging features of interstitial lung disease which can be used to etiologically classify into various subgroups are HRCT Findings In Interstitial Lung Diseases [3,14]: 1.Lines and Reticular Opacities: This is a result of thickening of the interstitial fiber network of the lung by fluid or fibrous tissue, or because of infiltration by cells or other material and is manifested as: Interface sign referring to the presence of irregular interfaces between the aerated lung parenchyma, bronchi, vessels or pleural surface, peribronchovascular septal thickening, interlobular septal thickening, parenchymal bands, subpleural interstitial thickening, intralobular interstitial thickening,honeycombing indicating end stage lung disease, irregular linear opacities, subpleural lines, septal thickening can be smooth or irregular. 2.Nodules and Nodular Opacities The term nodule is defined as a rounded opacity, at least moderately well defined and no more than 3 cm in diameter. Assessment of nodules on HRCT is based on-- Size: Small nodules are less than 1cm in diameter and larger are 1cm or more in diameter. Micronodules are less than 3mm or 7mm in diameter. Appearance: Interstitial nodules are well defined and air space nodules are ill-defined. Attenuation: Soft tissue attenuation nodules obscure the edges of vessels and soft tissues that they touch. Ground-glass nodules are hazy and less dense than adjacent vessels. Distribution of nodules which can be: Perilymphatic, Centrilobular or Random. Tree-inbud appearance is due to centrilobular branching opacities indicating endobronchial disease 3. Increased Lung Opacity: It is also termed as parenchymal opacification and is manifested as: 2014 Logic Publications, IJCMAAS,E-ISSN: ,P-ISSN: Page 44

5 Logic 2014, IJCMAAS, E-ISSN: ,P-ISSN: Ground-glass opacity: referring to the hazy increase in lung opacity without obscuration of underlying vessels. Crazy - paving pattern: Crazy - paving pattern is ground-glass opacity with superimposed reticular pattern. Consolidation: Consolidation is increased lung attenuation with obscuration of underlying pulmonary vessels and may show air bronchogram. 4. Decreased Lung Opacity, Cysts And Airway Abnormalities: a. Honeycombing: Due to alveolar disruption, dilatation of alveolar ducts and bronchiolar dilatation, appearing as multiple layers of small cystic spaces with discrete well defined walls b. Lung Cysts: well-defined, rounded, circumscribed lesions with thin wall (less than 3mm) c. Emphysema: which can be classified as centrilobular, panlobular, paraseptal, irregular or cicatricial emphysema and bullous emphysema. d. Pneumatocele e. Cavitary nodule f. Bronchiectasis: which can be cylindrical, varicose, cystic and traction bronchiectasis. g. Mosaic perfusion: due to airway disease or pulmonary vascular disease. Depending on the presence of various patterns and lobar distribution the subgroups include. Idiopathic Pulmonary Fibrosis : HRCT findings of bibasilar reticular abnormalities with honeycombing and absence of findings suggestive of other diseases are characteristic features of idiopathic pulmonary fibrosis. In addition the additional criteria should include age greater than 45 years and exclusion of other potential causes of interstitial lung disease (ILD), such as relevant environmental and occupational exposures, use of fibrogenic drugs, and collagen vascular diseases [7,8]. Pulmonary Lmphangitic Carcinomatosis: Lymphangitic lung metastases can result from pulmonary and extra pulmonary tumors alike. Common extrathoracic origins include breast, stomach, pancreas, and prostate. HRCT findings include nodular peribronchovascular interstitium and also thickening of subpleural interstitium, nodular thickening of interlobular septa giving reticular pattern without distortion of lung architecture.ground-glass opacities, pneumothorax and associated findings of hematogeneous metastasis, mediastinal lymphadenopathy and pleural effusion [4,5]. Hypersensitivity Pneumonitis: Subacute type showed small poorly defined centrilobular nodules and patchy areas of ground-glass opacities and variable perfusion [14]. Chronic type shows patchy or diffuse areas of ground-glass opacities.in addition fibrosis, predominently in subpleural and peribronchovascular distribution and Subpleural honeycombing can be seen. Rheumatoid Arthritis:Patchy or diffuse areas of ground-glass opacity and subpleural honeycombing with reticular pattern and bronchial abnormalities such as a bronchiectasis and wall thickening representing small airways diseases and bronchial obstruction small nodular opacities and pleural effusions can be seen [7,9]. Miliary Tuberculosis:Randomly distributed nodules, majority of them ranging between 1 to 3 mm few of them seen up to 5mm, commonly involving perivascular and subpleural regions and associated pleural effusion and mediastinal lymphadenopathy can be seen [11]. Nonspecific Interstitial Pneumonia:Patchy ground-glass opacities and reticulations which correspond pathologically to the areas of interstitial thickening caused by interstitial inflammation, thickening of intralobular septa and adjacent patchy ground-glass opacities and traction bronchiectasis predominantly distributed in middle and lower zones can be seen [10,14]. Acute Interstitial Pneumonia:Diffuse ground-glass opacity with discrete areas of alveolar consolidation [3,10,14]. Pneumocystis Carinii Pneumonia:Predominant perihilar distribution of ground-glass opacities, cystic spaces along with bronchial wall thickening with sparing of subpleural regions and patchy areas of consolidation can be seen [13]. Cardiogenic Pulmonary Edema: Patchy areas of ground-glass opacities with smooth and uniform interlobular septal thickening pleural effusion, increased vascular calibre can be seen in addition to other findings of cardiac failure [12,14]. Systemic Lupus Erythematosus:Thickening of interlobular septa and peribronchovascular interstitial thickening subpleural areas of interstitial pneumonitis (Lupus Pneumonitis) can be seen [3,7]. Progressive Systemic Sclerosis (Scleroderma):Diffuse ground-glass opacity with cysts representing changes of fibrosing alveolitis in subpleural regions and lower zone can be observed [3,7]. Welder s Pneumoconiosis (Siderosis):Small centrilobular micronodules and few branching International Journal of Current Medical And Applied Sciences [IJCMAAS], volume.5. Issue 1.

6 Ramakrishna Narra, Naganarasimharaju Juluri, Bhimeswarao Pasupaleti & Teja Naidu centrilobular nodules in peripheral subpeural regions can be seen [14]. Sarcoidosis: Small nodules representing confluence of epitheloid granulomas were seen along bronchi, vessels in centrilobular regions and in subplueral regions nodular thickening of interlobar fissures predominantly in upper zones can be seen [5]. Silicosis : Conglomerated nodular opacities predominantly distributed in subpleural regions, mediastinal lymphnodes with calcification in addition to occupational history can be noted [6]. Conclusion: HRCT is an important tool in the evaluation of interstitial lung disease for diagnosis and etiological classifications and together with clinical and laboratory analysis can avoid an unnecessary biopsy in those patients. References: 1. Grainger and Allison s Diagnostic Radiology,Interstitiall Lung Disease, Fourthedition,2001,VOL 1 pg no: Zerhouni EA, Naidich DP, Stitik FP et al. Computed Tomography of pulmonary parenchyma: part--2: Interstitial disease. J Thorac imag 1985; 1: W.Richard Webb,Nestor Muller,David P. Naidich, High Resolution Computed Tomography of the lung fourth edition, 2009, technical aspects of High Resolution Computed Tomography pg no:2,3. 4. Munk PL, Muller NL et al. Pulmonary lymphangitic Carcinomatosis: CT and pathologic findings.radiology 1988; 166: Hondo O, Johkoh T, Ichikado K, Yoshida S, Mihara N et al. Comparison of high resolution CT findings of sarcoidosis, lymphoma and lymphongitic carcinoma: Is there any difference in involved 6. interstitium? J Comput Assist Tomogr 1999; 23(3): Ferreira AS, Mareiva VB, Ricardo HM, Coutinho R, Gabetto JM et al. Progressive massive fibrosis in silica exposed workers high resolution computed tomography findings, J Bras Pneumol 2006;32(6): Lim MK, Im JG, Ahn JM, Kim JH, Lee SK, Yeon KM. Idiopathic pulmonary fibrosis versus pulmonary involvement of collagen vascular disease: HRCT findings. J Korean Med Sci. 1997; 12(6): Battista G, Zompatori M et al. Progressive worsening of idiopathic pulmonary fibrosis. High resolution computed tomography (HRCT) study with functional correlation: Radiol Med.2003; 105: Remy Jardin M, Remy J, Cortet B et al. Lung changes in rheumatoid arthritis: CT findings. Radiology 1994 :193: Muller NL,Colby TV. Idiopathic interstitial pneumonias: HRCT and histologic findings.radiographics 1997; 17: Hong SH, Im JG, Lee IS et al. High resolution CT findings of miliary tuberculosis. J Comput Assist Tomogr 1998; 22: Ribeiro CM, Marchiori E, Rodrigues R et al. Hydrostatic pulmonary edema: high-resolution computed tomography aspects. J Bras Pnemo 2006; 32(6): Bergin CJ, Wirth RL, Berry GJ et al. Pneumocystis carinii pneumonia: CT and HRCT observations. J Comput Assist Tomogr.1999; 14(5): Mehnert F, Pereira PL, Dammann F, Erdtmann B, Hahn U, Kopp AF. High resolution multislice CT of the lung: Comparison with sequential HRCT slices. RoFo 2000; 172(12): Images : FIG 1: 65 years old male presented with dyspnoea. A- HRCT at the level of carina shows bilateral reticulation and honeycombing mainly in subpleural lung regions.b-hrct at the level of lung bases shows bilateral reticulation and honeycombing. s/o idiopathic pulmonary fibrosis FIG 2: The high resolution chest CT shows multiple,randomly distributed 1-3 mm nodules throughout the lung s/o military TB Fig.: 3 66 years female known case of carcinoma breast presented with cough and dyspnoea HRCT shows thickening of interlobular septa s/o lymphangitis carcinomatos Logic Publications, IJCMAAS,E-ISSN: ,P-ISSN: Page 46

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