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    RADIOLOGICAL SIGN OF CHEST DISEASE

    BY:Dr.Deepak Adhikari,MBBS

    1st Year Resident

    Department of Radiology

    JRRMMC

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    Increased Lung density

    1.Air space disease /Parenchymal air space

    2.Interstitial Disease

    3.Combined air space and interstitial

    disease

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    Predominantly air space disease

    Radiological Findings:Margins of the opacities are poorly outlined expect when

    consolidation abuts the pleura.

    Air containing bronchi /Air bronchogram are evident

    Air space nodule :A localized are of consolidaton measuring

    10 mm in diameter or less may also be identified.

    Tendency to coalesce

    On HRCT scan area of airspace consolidation are often

    marginated by interlobular septa.

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    Air Bronchogram Sign This sign refers to a branching, linear, tubular

    lucency representing a bronchus or bronchiole

    passing through airless lung parenchyma .

    Indicates that the underlying opacity must beparenchymal rather than pleural or mediastinal in

    location.

    Does not differentiate nonobstructive

    atelectasis from other abnormal parenchymal

    opacities such as pneumonia.

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    Distribution characteristics

    1.Focal /Nonsegmental/Lobar

    2.Patchy /Segmental/

    Lobular/Broncho

    3.Extensive or diffuse bilateral

    consolidation

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    Segmental consolidation

    Pneumonia

    Endobronchial obstruction

    Pulmonary infraction

    Aspiration

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    Patchy/ Lobular/Nonsegmental

    Broncho pneumonia

    Focal hemorrhage

    Neoplasm

    Irradiation

    Lofflers syndrome

    Chronic eosinophilic pneumonia

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    DIFFUSE BILATERAL CONSOLIDATION

    Causes:

    Hydrostatic pulmonary edema

    Acute respiratory distress syndrome

    Diffuse pulmonary hemorrhage

    Pneumocystic Pneumonia

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    PREDOMINANTLY INTERSTITIAL DISEASE

    5 radiological pattern

    Septal

    Reticular

    Nodular

    Reticulonodular

    Ground glass

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    SEPTAL/LINEAR

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    Septal Pattern

    Effectively restrict diagnosis :1.Hydrostatic Pulmonary edema

    2.Malignancy-either lymphangitic spread of carcinoma orlymphoma

    Not as main abnormality1.Idiopathic pulmonary fibrosis

    2.Sarcoidosis

    3.Asbestosis

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    Fine Reticular Pattern

    Acute Hydrostatic pulmonary edema

    Viral pneumonia

    Mycoplasm pneumonia

    Chronic Interstitail pulmonary edema associated with

    mitral stenosis

    Idiopathic pulmonary fibrosis

    pulmonary fibrosis associated with connectivetissue disease

    Asbestosis

    Sarcoidosis

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    Medium reticulation/HoneycombingRefers to reticular interstitial opacities where the

    intervening spaces are 3 to 10 mm in diameter.

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    Honeycomb Pattern

    Honeycombing is characterized by the

    presence of cystic airspaces with thick, clearly

    definable fibrous walls lined by bronchiolarepithelium.

    It results from destruction of alveoli and

    loss of acinar architecture and is associated

    with pulmonary fibrosis.

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    Causes Usual interstitial pneumonitis (UIP)(idiopathic pulmonary fibrosis,

    cryptogenic alveolitis) asbestosis

    Collagen vascular disease

    Hypersensitivity pneumonic (chronic)

    Pneumonia or pneumonitis (chronic)

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    Coarse reticular opacitiesRefers to spaces greater than 1

    cm in diameter are seen most

    commonly in diseases that

    produce cystic spaces as a result

    of parenchymal destruction.

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    Cystic Pattern

    The term cyst is nonspecific and refers to athin-walled (usually less than 3 mm thick),

    well-defined, well-circumscribed, air- or fluid-

    containing lesion, 1 cm or more in diameter,

    that has an epithelial or fibrous wall. A cystic pattern results from a

    heterogeneous group of diseases that have in

    common the presence of focal, multifocal, ordiffuse parenchymal lucencies and lung

    destruction

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    CYSTIC Vs HONEYCOMB

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    Nodular pattern

    Miliary (

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    Micro Nodules (Synonym:miliary nodules)

    Tiny, sharp, discreet nodules (

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    Macro Nodules (Synonym: small nodules)

    Causes:Metastatic cancer

    Septic emboli

    Diffuse granulomatous infections

    Langerhans histiocytosis (eosinophilic granuloma)

    Vasculitis

    Sarcoidosis

    Silicosis

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    Nodular Pattern in CT

    A nodular pattern refers to multiple round opacities,generally ranging in diameter from 1 mm to 1 cm.

    Nodular opacities may be described as miliary , small,

    medium, or large as the diameter of the opacity

    increases. Nodules can be further characterized according to

    their margins (e.g., smooth or irregular),

    Presence or absence of cavitation,

    Attenuation characteristics (such as ground-glassopacity [GGO] or calcification),

    Distribution (e.g., centrilobular, perilymphatic, or

    random)

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    Peribronchial (also known as Perilymphatic)

    Peribronchial nodules are usually well defined and

    have a patchy or asymmetric distribution. They caninvolve parahilar areas, interlobular septa, and pleural

    surfaces and fissures

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    Centrilobular Nodules

    Centrilobular nodules are distributed predominantlywithin the center of the secondary pulmonary

    lobule.

    They spare the pleural surfaces, usually being

    centered 5 to 10 mm away from the pleural surfaceand interlobar fissures.

    They can range in size from a few millimeters to

    >1 cm

    May be well defined or ill defined.

    They tend to be evenly spaced and of similar size.

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    Tree-in-Bud Pattern The CT pattern of centrilobular nodular and

    branching linear opacities has been likened to

    the appearance of a budding tree.

    All processes producing the tree-in-bud

    pattern are (a)bronchiolar dilatation and (b)impaction of bronchioles with mucus, pus, or

    other material

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    Random Nodules

    Random nodules show no definite

    relationship to the secondary lobule or other

    structures of the lung (i.e., interlobular septa,small vessels, pleura).

    They usually are well defined, diffuse, and

    symmetric in distribution. Subpleural nodulesare common.

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    i l d l

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    The presence of interconnecting linear opacities result

    in a reticular pattern. Orientation of some linear

    opacities parallel to the x-ray beam causes additional

    nodular component that result in reticulonodular

    pattern.

    Reticulonodular pattern

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    Ground-Glass Opacification/ foggy/hazy/semiopaque

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    Ground Glass Pattern

    A ground glass pattern is considered to bepresent when there is a hazy increase in opacity

    unassociated with obscuration of the underlying

    vascular markings.(If vessel are obscured theterm consolidation is used)

    Acute

    1.Pneumocystis Jiroveci pneumonia

    2.Pulmonary hemorrhage3.Acute interstitial pneumonia

    Subacute

    Extrinsic allergic alveolitis

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    Crazy paving patternThe abnormality consists mainly of filling

    of airspaces with proteinaceous material,

    interlobular septal thickening is frequentlyidentified on CT in the areas of GGO,

    creating a crazy paving pattern

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    Fibrosis (Synonym: scarring)

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    Causes: scarring from any cause

    Sarcoidosis

    Tuberculosis

    Silicosis

    Radiation

    Pneumonitis

    late stage ARDS

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    Cavitation

    A cavity is defined radiographically as agas containing space within the lung

    surrounded by a wall whose thickness is

    greater than 1 mm.

    There is necrosis of centaral portion of a

    lesion an drainage of the resultant partially

    liquefied material via a communicating

    airway.

    Cavity Vs Abscess

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    B ll

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    Bullae

    A bullae is a sharplydemarcated air

    containing space that

    measures 1 cm ormore in diameter

    and possesses a

    smooth wall 1mm orless in thickness.

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    Belbs

    A belb is a localized collection of air in the

    immediate subpleural lung or within the

    pleura.It develops maost commonly inlung apices and seldom exceeds 1 cm in

    diameter.

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    Pneumatocele

    A pneumatocele is a thin walled gas

    filled space within the lung that

    characteristically increases in the size

    over a period of days to week and

    almost invariably resolves , typically

    occurs in association with infection.

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    Silhouette Sign Felson and Felson popularized the term

    silhouette sign to indicate an obliteration of

    the borders of the heart, other mediastinal

    structures, or diaphragm by an adjacent

    opacity of similar density.

    An intrathoracic lesion not anatomically

    contiguous with a border of one of these

    structures will not obliterate that border.

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    Air Crescent SignA mass growing within a pre-existing

    cavity, or an area of pneumonia that

    undergoes necrosis and cavitates, may

    form a peripheral crescent of air

    between the intracavitary mass and the

    cavity wall, resulting in the air crescent

    sign.

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    Bulging Fissure SignHistorically, the bulging fissure sign wasseen as a result of pneumonia caused by

    Klebsiella pneumoniae involving the

    right upper lobe.The disease is often confined to one

    lobe, with consolidation spreading

    rapidly, causing lobar expansion andbulging of the adjacent fissure inferiorly.

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    Continuous Diaphragm Sign

    This sign is seen as a continuous

    lucency outlining the base of the heart,

    representing pneumomediastinum.Air in the mediastinum tracks

    extrapleurally, between the heart and

    diaphragm .

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    Deep Sulcus Sign This sign refers to a deep, sometimesfingerlike collection of intrapleural air

    (pneumothorax) in the costophrenic sulcus

    as seen on the supine chest radiograph.

    When present, this sign may represent a

    pneumothorax that is much larger thaninitially expected.

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    Fallen Lung Sign

    This sign refers to the appearance of the

    collapsed lung occurring with a fractured

    bronchus.

    The bronchial fracture results in the lung

    falling away from the hilum, either inferiorly

    and laterally in an upright patient orposteriorly, as seen on CT in a supine patient.

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    Flat Waist Sign

    This sign refers to flattening of the

    contours of the aortic knob and adjacent

    main pulmonary artery .

    It is seen in severe collapse of the left

    lower lobe and is caused by leftwarddisplacement and rotation of the heart.

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    Finger-in-Glove Sign In allergic bronchopulmonary aspergillosis, aclinical disorder secondary to Aspergillus

    hypersensitivity, the bronchi become impacted

    with mucus, cellular debris, eosinophils, andfungal hyphae.

    The impacted bronchi appear radiographically

    as opacities with distinctive shapes ,variouslydescribed as gloved finger.

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    Golden S Sign

    When a lobe collapses around a large central

    mass, the peripheral lung collapses and the

    central portion of lung is prevented from

    collapsing by the presence of the mass.

    The relevant fissure is concave toward the lung

    peripherally but convex centrally, and the shapeof the fissure resembles an S or a reverse S.

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    L ft i h l Si

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    Luftsichel Sign

    In left upper lobe collapse, the superiorsegment of the left lower lobe, which is

    positioned between the aortic arch and the

    collapsed left upper lobe, is hyperinflated. This

    aerated segment of left lower lobe is hyperlucent

    and shaped like a sickle, where it outlines the

    aortic arch on the frontal chest radiograph.

    This peri-aortic lucency has been termed theluftsichel sign, derived from the German words

    luft (air) and sichel (sickle) .

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    Halo Sign

    This sign refers to ground-glassattenuation on CT scanning that

    surrounds, or forms a halo around, a

    denser nodule or area of consolidation.

    Most hemorrhagic pulmonary nodules

    produce this sign.

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    Hampton Hump Sign

    Pulmonary infarction secondary to pulmonary

    embolism produces an abnormal area of

    opacification on the chest radiograph, which is

    always in contact with the pleural surface.

    The opacification may assume a variety of

    shapes. When the central margin is rounded, ahump is produced.

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    Westermark Sign

    This sign refers to oligemia of the lung

    beyond an occluded vessel in a patient

    with pulmonary embolism.

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    M lti I C b Si

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    Melting Ice Cube Sign

    This sign refers to the appearance of a

    resolving pulmonary infarct on a chest

    radiograph or CT scan, which looks like an ice

    cube that is melting peripherally to internally.

    This is distinguished from the pattern of

    resolving pneumonia, where the opacification

    disappears in a patchy fashion .

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    h i k Si

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    Juxtaphrenic Peak Sign

    This sign refers to a small triangular shadow

    that obscures the dome of the diaphragm,

    secondary to upper lobe atelectasis.

    The shadow is caused by traction on the

    lower end of the major fissure, the inferior

    accessory fissure, or the inferior pulmonaryligament.

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    S i Si

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    Spine Sign

    Lower lobe pneumonia may be poorly

    visualized on a posteroanterior (PA)

    chest radiograph. Spine sign, which is progressive

    increase in lucency of the vertebral

    bodies from superior to inferior.

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    PLEURAL EFFUSION Vs ASCITES

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    PLEURAL EFFUSION Vs ASCITES

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    Mediastinal mass

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    Mediastinal mass

    A mediastinal mass displaces the medialpleura toward the lung.The interface with the

    lung has sharp Margin & Convex Margin.

    May also displace,compress or invase adjacentstructure i.e trachea

    May obscure a adjacent structure of same

    density,the silhouette sign.

    Absence of air bronchogram

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    Pleural/Extrapleural mass

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    Pleural/Extrapleural mass

    The borders are generally sharp andconvex.

    The margin forms an obtuse anglewith the chest wall.

    Air bronchgram is absent.

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