Approach to ILD • What is the pattern? • Acute vs chronic? • Any clues? – distribution – lung volumes

1. Radiographic Evaluation
of Interstitial Lung
Disease
Laura E. Heyneman, MD
Duke University Medical Center

2. Case 1

3. Case 2

4. Case 3

5. Case 4

6. Approach to ILD
• What is the pattern?
• Acute vs chronic?
• Any clues?
– distribution
– lung volumes

7. Approach to ILD
• What is the pattern?
• Acute vs chronic?
• Any clues?
– low volumes: fibrosis
– ↑ volumes: obstruction

8. Approach to ILD
• What is the pattern?
• Acute vs chronic?
• Any clues?
– distribution, volumes
– associated findings

9. Patterns of ILD
• Nodular
• Reticular
• Septal lines
• Cystic

10. Nodular
• Acute
– atypical infection
• miliary tuberculosis
• disseminated fungal

11. Nodular
•Chronic
– Mets
– Sarcoid
– Silicosis / Coal worker’s
– Eosinophilic granuloma
– Hypersensitivity: subacute

12. Nodular: Clues
Diffuse / lower distribution
• hematogenous
- miliary infection
- metastases

13. Nodular: Clues
Upper lung distribution
– Sarcoid
– Silicosis / Coal worker’s
– Eosinophilic granuloma
– Hypersensitivity: subacute

14. Case 1

15. Multiple small nodules

16. Lower lobe predominant:
hematogenous

17. Acute: infection
1 month earlier

18. Miliary TB

20. Upper lobe predominant

21. Clues to etiology?
nodules: central lucencies

22. Eosinophilic Granuloma

24. Upper lobe predominant

25. Clues to etiology?
lymphadenopathy

26. Sarcoid

27. Clues to etiology?
calcified nodes (“egg shell”)

28. Clues to etiology?
silicosis vs sarcoid (vs TB)

29. Sarcoid

30. Clues to etiology?
calcified nodules

31. Silicosis

32. Reticular
• Acute
– interstitial edema
– atypical infection
• Pneumocystis
• viral infection

33. Reticular
• Chronic
– fibrosis

34. Reticular
• Chronic
– fibrosis
– emphysema
– cystic lung disease
– bronchiectasis

35. Reticular: Clues
Normal lung volumes
– acute: edema / infection
– bronchiectasis

36. Reticular: Clues
Increased lung volumes
– cystic lung disease
– emphysema
– (bronchiectasis)

37. Reticular: Clues
Decreased lung volumes
– fibrosis

38. Fibrosis
Upper lobe distribution
– sarcoid
– chronic hypersensitivity
– cystic fibrosis
– XRT (head and neck)
– prior tuberculosis
– ankylosing spondylitis

39. Fibrosis
Lower lobe distribution
– UIP, NSIP
– (chronic aspiration)

41. Normal volumes: not fibrosis

42. Acute perihilar reticulation
2 months earlier

43. Pneumocystis jirovecii

44. Case 2

45. Low volumes: fibrosis
upper lobe predominant

46. Clues to etiology?
lymphadenopathy

47. Sarcoid

49. Low volumes,
upper lobe fibrosis

50. Clues to etiology?
Osseous findings

51. Clues to etiology?
Osseous findings

52. Ankylosing spondylitis

54. Upper lobe fibrosis,
perihilar confluent masses

55. Progressive massive fibrosis
silicosis vs sarcoid

56. PMF: Clues to etiology?
parallel chest wall: silicosis

57. PMF: Clues to etiology?
noncalcified LAN: sarcoid

58. Case 3

59. Low volumes, lower lobe

60. Fibrosis: UIP or NSIP

61. Clues to etiology?
Calcified pleural plaques

62. Clues to etiology?
Asbestosis

63. Clues to etiology?
osseous changes?

64. Clues to etiology?
Rheumatoid Arthritis

65. Clues to etiology?
soft tissue calcification?
Courtesy of Charles White, MD

66. Clues to etiology?
soft tissue calcification?
Courtesy of Charles White, MD

67. Clues to etiology?
Connective Tissue Disease
Courtesy of Charles White, MD

68. Clues to etiology?

69. Clues to etiology?
esophageal dilation

70. Clues to etiology?
esophageal dilation

71. Clues to etiology?
Scleroderma

72. Septal Lines
• Acute
– edema
– atypical infection

73. Septal Lines
• Chronic
– lymphangitic ca
– (amyloid)
– (Kaposi’s sarcoma)

75. Acute
6 weeks earlier

76. Edema
6 weeks earlier

77. Acute, heart bigger
6 weeks earlier

78. Clues to etiology?
signs cardiac, renal disease

79. Case 4

80. chronic septal thickening
follow-up film 2 weeks

81. Lymphangitic carcinomatosis

82. Clues to etiology?
mastectomy, lung mass,
surgical clips, biliary stent

83. Clues to etiology?
mastectomy, lung mass,
surgical clips, biliary stent

84. Clues to etiology?
linitis plastica

85. Cysts/ Ring Lucencies
• Acute
– Pneumocystis pneumonia
– (necrotizing pneumonia)

86. • Chronic
– honeycombing
– bronchiectasis
– eosinophilic granuloma
– lymphangioleiomyomatosis
– emphysema
Cysts/ Ring Lucencies

87. Cystic: Clues
Upper lobe distribution
– Pneumocystis
– eosinophilic granuloma
– cystic fibrosis
– honeycombing: sarcoid,
chronic EAA

88. Cystic: Clues
Lower lobe distribution
– honeycombing: UIP
– alpha-1 antitrypsin
– bronchiectasis: aspiration

89. Cystic: Clues
No lobar distribution
– lymphangioleiomyomatosis

92. Normal volumes: not fibrosis
upper lobe cystic change

93. Acute
2 months earlier

94. Pneumocystis jirovecii

97. Low volumes: fibrosis
Cysts stacked upon cysts

98. Honeycombing

99. Lower lobe: UIP
Upper: sarcoid, chronic HP

101. Normal volumes: not fibrosis
cysts stacked on cysts

102. tubular lucencies
converge toward hila

103. Bronchiectasis

104. Clues to etiology?
lower lobe: chronic aspiration

105. Clues to etiology?
upper lobe, ↑volumes, young pt

106. Cystic Fibrosis

108. Increased volumes: obstructive

109. Increased volumes: obstructive
upper lobe cysts, spares lower

110. Eosinophilic granuloma

112. Increased volumes: obstructive

113. Increased volumes,
diffuse thin walled cysts

114. Lymphangioleiomyomatosis

116. Increased volumes: obstructive

117. Increased volumes: obstructive
lower lobe bulla

118. Alpha-1 antitrypsin dz

119. Patterns may overlap
septal lines + nodules

120. Septal Lines + Nodules
• Acute
– atypical infection
• Chronic
– lymphangitic carcinoma

121. Lymphangitic carcinomatosis

122. Patterns
• Acute vs chronic
• Distribution, volumes
– Low volumes: fibrosis
– Increased volumes: obstructive
• Other clues?