radiographic evaluation of interstitial lung disease laura e. heyneman, md duke university medical...
TRANSCRIPT
Radiographic Evaluation of Interstitial Lung
Disease
Laura E. Heyneman, MD
Duke University Medical Center
Case 1
Case 2
Case 3
Case 4
Approach to ILD• What is the pattern?• Acute vs chronic?• Any clues?
– distribution– lung volumes
Approach to ILD• What is the pattern?• Acute vs chronic?• Any clues?
– low volumes: fibrosis– ↑ volumes: obstruction
Approach to ILD• What is the pattern?• Acute vs chronic?• Any clues?
– distribution, volumes– associated findings
Patterns of ILD• Nodular
• Reticular
• Septal lines
• Cystic
Nodular• Acute
– atypical infection• miliary tuberculosis• disseminated fungal
Nodular• Chronic
– Mets– Sarcoid– Silicosis / Coal worker’s– Eosinophilic granuloma– Hypersensitivity: subacute
Nodular: CluesDiffuse / lower distribution
• hematogenous- miliary infection- metastases
Nodular: CluesUpper lung distribution
– Sarcoid– Silicosis / Coal worker’s– Eosinophilic granuloma– Hypersensitivity: subacute
Case 1
Multiple small nodules
Lower lobe predominant: hematogenous
Acute: infection
1 month earlier
Miliary TB
Upper lobe predominant
Clues to etiology? nodules: central lucencies
Eosinophilic Granuloma
Upper lobe predominant
Clues to etiology? lymphadenopathy
Sarcoid
Clues to etiology? calcified nodes (“egg shell”)
Clues to etiology? silicosis vs sarcoid (vs TB)
Sarcoid
Clues to etiology? calcified nodules
Silicosis
Reticular• Acute
– interstitial edema– atypical infection
• Pneumocystis• viral infection
Reticular• Chronic
– fibrosis
Reticular• Chronic
– fibrosis– emphysema– cystic lung disease– bronchiectasis
Reticular: CluesNormal lung volumes
– acute: edema / infection– bronchiectasis
Reticular: CluesIncreased lung volumes
– cystic lung disease– emphysema– (bronchiectasis)
Reticular: CluesDecreased lung volumes
– fibrosis
FibrosisUpper lobe distribution
– sarcoid– chronic hypersensitivity– cystic fibrosis– XRT (head and neck)– prior tuberculosis– ankylosing spondylitis
FibrosisLower lobe distribution– UIP, NSIP– (chronic aspiration)
Normal volumes: not fibrosis
Acute perihilar reticulation
2 months earlier
Pneumocystis jirovecii
Case 2
Low volumes: fibrosis upper lobe predominant
Clues to etiology? lymphadenopathy
Sarcoid
Low volumes, upper lobe fibrosis
Clues to etiology? Osseous findings
Clues to etiology? Osseous findings
Ankylosing spondylitis
Upper lobe fibrosis, perihilar confluent masses
Progressive massive fibrosissilicosis vs sarcoid
PMF: Clues to etiology? parallel chest wall: silicosis
PMF: Clues to etiology? noncalcified LAN: sarcoid
Case 3
Low volumes, lower lobe
Fibrosis: UIP or NSIP
Clues to etiology? Calcified pleural plaques
Clues to etiology? Asbestosis
Clues to etiology? osseous changes?
Clues to etiology? Rheumatoid Arthritis
Clues to etiology? soft tissue calcification?
Courtesy of Charles White, MD
Clues to etiology? soft tissue calcification?
Courtesy of Charles White, MD
Clues to etiology? Connective Tissue Disease
Courtesy of Charles White, MD
Clues to etiology?
Clues to etiology? esophageal dilation
Clues to etiology? esophageal dilation
Clues to etiology? Scleroderma
Septal Lines• Acute
– edema
– atypical infection
Septal Lines• Chronic
– lymphangitic ca
– (amyloid)
– (Kaposi’s sarcoma)
Acute
6 weeks earlier
Edema
6 weeks earlier
Acute, heart bigger
6 weeks earlier
Clues to etiology? signs cardiac, renal disease
Case 4
chronic septal thickening
follow-up film 2 weeks
Lymphangitic carcinomatosis
Clues to etiology? mastectomy, lung mass,
surgical clips, biliary stent
Clues to etiology? mastectomy, lung mass,
surgical clips, biliary stent
Clues to etiology? linitis plastica
Cysts/ Ring Lucencies• Acute
– Pneumocystis pneumonia
– (necrotizing pneumonia)
• Chronic– honeycombing– bronchiectasis– eosinophilic granuloma– lymphangioleiomyomatosis– emphysema
Cysts/ Ring Lucencies
Cystic: CluesUpper lobe distribution
– Pneumocystis– eosinophilic granuloma– cystic fibrosis– honeycombing: sarcoid, chronic EAA
Cystic: CluesLower lobe distribution
– honeycombing: UIP– alpha-1 antitrypsin– bronchiectasis: aspiration
Cystic: CluesNo lobar distribution– lymphangioleiomyomatosis
Normal volumes: not fibrosisupper lobe cystic change
Acute
2 months earlier
Pneumocystis jirovecii
Low volumes: fibrosis Cysts stacked upon cysts
Honeycombing
Lower lobe: UIP Upper: sarcoid, chronic HP
Normal volumes: not fibrosis cysts stacked on cysts
tubular lucencies converge toward hila
Bronchiectasis
Clues to etiology? lower lobe: chronic aspiration
Clues to etiology? upper lobe, ↑volumes, young pt
Cystic Fibrosis
Increased volumes: obstructive
Increased volumes: obstructive upper lobe cysts, spares lower
Eosinophilic granuloma
Increased volumes: obstructive
Increased volumes, diffuse thin walled cysts
Lymphangioleiomyomatosis
Increased volumes: obstructive
Increased volumes: obstructive lower lobe bulla
Alpha-1 antitrypsin dz
Patterns may overlap septal lines + nodules
Septal Lines + Nodules• Acute
– atypical infection
• Chronic
– lymphangitic carcinoma
Lymphangitic carcinomatosis
Patterns• Acute vs chronic
• Distribution, volumes– Low volumes: fibrosis
– Increased volumes: obstructive
• Other clues?