Approach to Diagnosis: Case-based Imaging Review

Chest: Systemic Conditions

Tan-Lucien H. Mohammed, M.D., FCCPDepartment of Radiology

University of Florida

38-year-old woman with cough and dyspnea

Case 1 - Radiography

Case 1 - HRCT

Case 1 - Imaging Findings

• Reticulonodular opacities• mid-lungs• upper lungs

Case 1 - Imaging Findings (HRCT)

• Multifocal micronodules• Perilymphatic distribution

Bronchovascular bundlesJuxtapleural regionsInterlobular septae

Case 1 - Imaging Findings (HCRT)

• Multifocal micronodules• Perilymphatic distribution

Bronchovascular bundlesJuxtapleural regionsInterlobular septae

Perilymphatic Distribution

Courtesy of Jud W. Gurney, MD

• Axial (bronchoarterial)• Subpleural• Interlobular septa

Case 1 - Differential Diagnosis

• Lymphangitic carcinomatosis• Sarcoidosis• Silicosis• Lymphoproliferative disorder

Case 1 - Diagnosis

SARCOIDOSIS

Sarcoidosis HRCT • Bilateral, symmetric • Small nodular/reticular opacities• Upper-lung and mid-lung zones predominantly• (Nodular sarcoid: multifocal nodules/masses with or without air bronchograms)

Lymphangitic carcinomatosisHRCT• Unilateral or Bilateral• Patchy or diffuse• Smooth or nodular thickening• Peribronchovascular• Interlobular septa• Interlobar fisures

Lymphangitic carcinomatosis

HRCT• Unilateral or bilateral• Patchy or diffuse• Smooth or nodular thickening• Peribronchovascular• Interlobular septa• Interlobar fisures

SilicosisHRCT• Small (2-5mm) nodules• Ill-defined or well-defined• Centrilobular or juxtapleural• Conglomerate masses• Upper lobe or posterior

62 year old woman with cough

Case 2

Case 2 - Imaging Findings• Irregular, cavitary nodule in left upper lobe• Focal consolidation in right upper lobe (angiocentric)

Case 2 - Differential Diagnosis

Multifocal cavitary nodules• Multifocal neoplasia (primary or secondary)• Multifocal bacterial pneumonia• Bland or septic emboli• Vasculitis (Wegener granulomatosis, Churg-Strauss)• Cryptogenic organizing pneumonia (COP)

Case 2 - Diagnosis

WEGENER’S GRANULOMATOSIS

Wegener GranulomatosisImaging features• Nodules or masses (44%) • Consolidations (24%)• Cavitation (5-25%)• Diffuse consolidation (5%)• Airway abnormalities (9%)

Metastases or Septic Emboli• Hematogenous dissemination• Predominantly lower lungs• Reflects increased blood supply

Metastatic colon caSeptic Emboli

Septic emboliImaging features

• Multiple pulmonary opacities• Variable shape and size • Subpleural/wedge-shaped

• Frequent cavitation/air bronchograms• Predominant in lower lungs

50-year-old man with dyspneaCase 3

Case 3 - Imaging Findings

• Bilateral, patchy ground-glass opacity• Focal areas of traction bronchiectasis

Case 3 - Differential DiagnosisBibasilar Ground Glass Opacities• Usual interstitial pneumonia (UIP)• Nonspecific interstitial pneumonia (NSIP)• Acute interstitial pneumonia (AIP)• Cryptogenic organizing pneumonia (COP)

Case 3 - Diagnosis

Nonspecific interstitial pneumonia (NSIP)

NSIP Imaging Features• Ground glass opacity• Evidence of fibrosis• Volume loss• Reticulation• Traction bronchiectasis

• Honeycombing (rare)• Basal predominance• Subpleural or peribronchovascular

HRCT Features

UIP NSIP DIPGGO + +++ +++

Honeycombing +++ + +

Traction bronchiectasis

+++ + +

UIP versus NSIP - HRCT

UIP NSIP

28 year old man with dry cough and mild dyspnea

Case 4

Case 4

Case 4 - Imaging Findings (CXR)

• Bilateral, symmetric • Airspace or reticular opacities• No lymphadenopathy • No pleural effusion

Case 4 - Imaging Findings

• Bilateral patchy ground-glass opacities• Superimposed interlobular septal thickening• “Crazy paving” pattern

Case 4 - Differential Diagnosis

“Crazy Paving” Pattern• Pneumonia

(infectious, eosinophilic, lipoid, organizing)• Pulmonary alveolar proteinosis (PAP)• Diffuse alveolar damage (ARDS)• Pulmonary edema• Multifocal neoplasia (BAC, Lymphoma)

Case 4 - Diagnosis

Pulmonary alveolar proteinosis (PAP)

Accumulation of lipid-rich granular eosinophilic material in alveoli

Pulmonary Alveolar Proteinosis (PAP) - CT/HRCT

• Diffuse, patchy bilateral GGO• Superimposed smooth thickening of interlobular septa (“crazy-paving” pattern)• GGO, airspace nodules, confluent consolidations• Geographic demarcation between affected lung and normal parenchyma

“Crazy Paving” HRCT

• Ground-glass opacity• Thickened interlobular septa

Crazy Paving masonry

“Crazy-Paving” Pattern Differential Diagnosis

Most Likely:• Pulmonary alveolar proteinosis• Lipoid pneumonia• Bronchioloalveolar carcinoma• Pneumocystic jiroveci pneumonia

25 year old man with wheezing, dyspnea and productive cough

Case 5

Case 5 - Radiography

Case 5 - HRCT

Case 5 - Radiography

• Hyperinflation• RUL atelectasis• Parallel linear opacities (tram tracks)• Tubular and nodular opacities emanating from left hilum

Case 5 - HRCT• Extensive bronchiectasis• Predominantly upper lungs• RUL atelectasis

Case 5 - Differential Diagnosis(Bronchiectasisis)

• Cystic fibrosis • Allergic bronchopulmonary aspergillosis (ABPA)• Williams-Campbell syndrome• Other causes of bronchiectasis

(chronic aspiration, healed TB, radiation Rx)

Case 5 - Diagnosis

CYSTIC FIBROSIS

Cystic Fibrosis -Radiography

• Large lung volumes• Atelectasis (mucous plugs)• Widespread bronchiectasis(upper>lower)• Nodular or tubular opacities (mucoid impaction)• Recurrent consolidation• Lymphadenopathy

Cystic FibrosisHRCT

• Bronchiectasis• Diffuse, bilateral upper lobes • “Tree-in-bud” appearance• Geographic lung attenuation• Air-trapping• Mucous plugs in dilated airways

Bronchiectasis Distribution

ABPA

Bronchiectasis DistributionABPA Central bronchiectasis

Cystic fibrosis Upper lung predominance

Post-infectious Lower lobes (LLs), dependent lung

Ciliary dyskinesia Lower lobes (LLs)

54-year-old man with dyspnea and nonproductive cough

Case 6

Case 6 - Radiography

Case 6 - CT/HRCT

Case 6 Radiography

• Bilateral perihilar and upper lobe • Nonsegmental consolidations

Case 6 - CT/HRCT

• Bilateral consolidations • Ground-glass opacities• Peribronchial and subpleural distribution

Case 6 - Differential Diagnosis

• Chronic eosinophilic pneumonia• Cryptogenic organizing pneumonia (COP)• Multifocal bronchioloalveolar carcinoma (BAC)

Case 6 - Diagnosis

Cryptogenic organizing pneumonia

(COP)

Cryptogenic organizing pneumonia Radiography

• Nonspecific• Bilateral, peripheral, basal patchy consolidation

Cryptogenic organizing pneumonia (CT/HRCT)

• Patchy, uni/bilateral• Air-space consolidation• Ground-glass opacity• Crazy-paving pattern• Subpleural/peribronchial• Centrilobular nodules

Cryptogenic organizing pneumonia (CT/HRCT)• Unusual HRCT finding• “Atoll sign”• Resembles an atoll

ATOLL: massive coral growth on a submerged mountain range or volcano; low islands encircling a seawater lagoon.

Courtesy of Elizabeth Moore, MD

Chronic eosinophilic pneumonia Imaging

• Bilateral non-segmental airspace consolidations• GGO and consolidations• Subpleural distribution (60%)• Upper/mid lung predominance

Approach to Diagnosis: Case-based Imaging Review

Chest: Systemic Conditions

Tan-Lucien H. Mohammed, M.D., FACR Department of Radiology

University of Florida