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Radiological Presentation of Pulmonary Pathology
This document discusses various radiographic signs seen on chest x-rays and CT scans related to different types of lung collapse and cystic lung lesions. It describes signs such as the flat waist sign seen in left lower lobe collapse, the juxtaphrenic peak sign seen in upper lobe collapse, and the fallen lung sign seen with bronchial fractures. It also discusses cystic lung patterns seen in conditions like lymphangioleiomyomatosis (LAM), Langerhans cell histiocytosis, and lymphocytic interstitial pneumonia. Different characteristics of cysts such as their size, distribution and appearance on imaging are described for these various conditions.
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Radiological Presentation of Pulmonary Pathology
- 2. Gamal Rabie Agmy,MD, FCCP Professor of Chest Diseases, Assiut University
- 14. Types of Collapse 6-CompressionAtelectasis
- 36. Flat waist Sign Thissign 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 leftward displacement and rotation of the heart
- 38. Juxtaphrenic peak sign Thejuxtaphrenic peak sign refers to the peaked or tented appearance of a hemidiaphragm which can occur in the setting of lobar collapse. It is caused by retraction of the lower end of diaphragm at an inferior accessory fissure (most common), major fissure or inferior pulmonary ligament. It is commonly seen in upper lobe collapse but may also be seen in middle lobe collapse.
- 40. Fallen Lung Sign Thissign refers to the appearance of the collapsed lung occurring with a fractured bronchus . The bronchial fracture results in the lung to fall away from the hilum, either inferiorly and laterally in an upright patient or posteriorly, as seen on CT in a supine patient. DD: Pneumothorax causes a lung to collapse inward toward the hilum.
- 42. Luftsichel Sign •German forsickle of air (luft: air sichel: crescent) •Paramediastinal lucency due to interposition of lower lobe apex between mediastinum and shrunken upper lobe •Occurs more commonly on the left than in the right
- 43. Comet Tail Sign •Seenon CT of the chest •Consists of curvilinear opacity extending from subpleural mass toward hilum •Produced by the distortion vessels and bronchi that lead to adjacent rounded atelectasis
- 45. (posterioranterior) position. Note thatthe x-ray tube is 72 inches away. the supine AP (anteriorposterior) position the x-ray tube is 40 inches from the patient.
- 47. Dee method forapproximating the position o f the carina can be used. This involves defining the aortic arch and then drawing a line Inferomedially through the middle of the arch at a 45 degree angle to t he midline
- 48. The Ideal positionfor endotracheal tubes is in the mid trachea, 5cm from the carina, when the head is neither flexed nor extended. This allows for movement of the tip with head movements. The minimal safe distance from the carina is 2cm.
- 51. Notice the increasedlucency of the cardiophrenic sulci in this patient with inferior anteromedial pneumothoraces. A CT scan confirms the diagnosis
- 52. a hyperlucentupper quadrant with visualization of the superior surface of the diaphragm and visualization of the inferiorvena cava. double-diaphragm sign
- 53. Antero lateralair may increase the radiolucency at the costo phrenicsulcus. This is called the deep sulcus sign.
- 54. Apicolateral pneumothorax (arrows) withright upper lobe collapse (arrowheads)
- 55. shifting ofthe heart border, the superior vena cava, and the inferior vena cava. The shifting of these structures can lead to decreased venous return.
- 56. •Mediastinal shifT is usually seenin a tension pneumothorax. •The most reliable sign of tension pneumothorax is depression of a hemidiaphragm.
- 57. Radiographic Signs ofPneumomediastinum Subcutaneous emphysema Thymic sail sign Pneumoprecardium Ring around the artery sign Tubular artery sign Double bronchial wall sign Continuous diaphragm sign Extrapleural sign
- 65. Ginkgo leaf sign •The ginkgo leaf sign is a chest plain radiography appearance which is seen at extensive subcutaneous emphysema of the chest wall. Air outlines the fibers of the pectoralis major muscle and creates a branching pattern that resembles the branching pattern in the veins of a ginkgo leaf.
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- 68. The terminal bronchiolein the center divides into respiratory bronchioles with acini that contain alveoli. Lymphatics and veins run within the interlobular septa Centrilobular area in blue (left) and perilymphatic area in yellow (right)
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- 71. ARE NODULES INCONTACT WITH PLEURA NO CENTRILOBULAR YES PERILYMPHATIC RANDOM
- 73. Size, Distribution, Appearance Nodulesand Nodular Opacities Size Small Nodules: <10 mm Miliary - <3 mm Large Nodules: >10 mm Masses - >3 cms Appearance Interstitial opacity: Well-defined, homogenous, Soft-tissue density Obscures the edges of vessels or adjacent structure Air space: Ill-defined, inhomogeneous. Less dense than adjacent vessel – GGO small nodule is difficult to identify
- 74. Interstitial nodules Air space opacity Miliarytuberculosis sarcoidosis in a lung transplant patient with bronchopneumonia
- 75. RANDOM: no consistentrelationship to any structures PERILYMPHATIC: corresponds to distribution of lymphatic CENTRILOBULAR: related to centrilobular structuresDistribution 75
- 76. Disseminated histoplasmosis andnodular ILD. CT scan shows multiple bilateral round circumscribed pulmonary nodules.
- 77. Notice the nodulesalong the fissures indicating a perilymphatic distribution (red arrows). The majority of nodules located along the bronchovascular bundle (yellow arrow).
- 78. Sarcoidosis The majority ofnodules located along the bronchovascular bundle (yellow arrow).
- 79. PERILYMPHATIC NODULES Perilymphatic andRandom distribution of nodules , seen in sarcoidosis.
- 80. Centrilobular distribution Hypersensitivity pneumonitis Respiratorybronchiolitis in smokers infectious airways diseases (endobronchial spread of tuberculosis or nontuberculous mycobacteria, bronchopneumonia) Uncommon in bronchioloalveolar carcinoma, pulmonary edema, vasculitis
- 81. Random distribution Small randomnodules are seen in: Hematogenous metastases Miliary tuberculosis Miliary fungal infections Sarcoidosis may mimick this pattern, when very extensive Langerhans cell histiocytosis (early nodular stage)
- 82. Langerhans cell histiocytosis:early nodular stage before the typical cysts appear.
- 83. Differential diagnosis ofa nodular pattern of interstitial lung disease SHRIMP Sarcoidosis Histiocytosis (Langerhan cell histiocytosis) Hypersensitivity pneumonitis Rheumatoid nodules Infection (mycobacterial, fungal, viral) Metastases, Miliary TB Microlithiasis, alveolar Pneumoconioses (silicosis, coal worker's, berylliosis)
- 84. Cystic Lung Lesions By GamalRabie Agmy , MD , FCCP Professor of Chest Diseases ,Assiut University
- 85.
- 86. Lung Cysts Pulmonary fibrosis(Honeycombing) Lymphangiomyomatosis Langerhanscell histiocytosis Lymphocytic Interstitial Pneumonia (LIP) Differential Diagnosis
- 87. Rough Reticular FineReticular Traction Bronchiectasis and Interface sign Honey combing UIP UIP or NSIP
- 88. Usual Interstitial PneumoniaUIP HRCT Findings Reticular opacities, thickened intra- and interlobular septa Irregular interfaces Honey combing and parenchymal distorsion Ground glass opacities (never prominent) Basal and subpleural predominance
- 89. Basal and subpleuraldistribution UIP
- 90. Inconsistent with UIP pattern(any one of seven features Possible UIP pattern (all three features) UIP pattern (all four features) •Upper or mid lung predominance subpleural basal predominance •subpleural basal predominance •peribronchovascular predominance reticular abnormality•reticular abnormality •extensive ground glass abnormality (extent > reticular abnormality) •honeycombing with or without traction bronchiectasis •profuse micronodules (bilateral, predominantly upper lobes Absence of features listed as inconsistent with UIP pattern Absence of features listed as inconsistent with UIP pattern •discrete cysts (multiple bilateral, away from areas of honeycombing) •diffuse mosaic attenuation/air trapping (bilateral in three or more lobes) •consolidation in broncho- pulmonary segment(s)/lobe(s) Radiological features of idiopathic pulmonary fibrosis: 2011
- 91. Lymphangioleiomyomatosis (LAM) HRCT Morphology Thin-walledcysts (2mm - 5cm) Uniform in size / rarely confluent Homogeneous distribution Chylous pleural effusion Lymphadenopathy in young women
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- 96. Langerhans Cell Histiocytosis HRCTFindings Small peribronchiolar nodules (1-5mm) Thin-walled cysts (< 1cm), Bizarre and confluent Ground glass opacities Late signs: irreversible / parenchymal fibrosis Honey comb lung, septal thickening, bronchiectasis
- 97. 1 year later PeribronchiolarNodulesCavitating nodules and cysts Langerhans Cell Histiocytosis
- 98.
- 99. Langerhans Cell Histiozytosis KeyFeatures Upper lobe predominance Combination of cysts and noduli Characteristic stages Increased Lung volume Sparing of costophrenic angle S M O K I N G
- 100.
- 101. Langerhans Cell Histiocytosis DifferentialDiagnosis Only small nodules Sarkoidosis, Silikosis Only cysts idiopathic Fibrosis LAM Destruktive emphysema
- 102. Benign lymphoproliferative disorder Diffuse interstitialinfiltration of mononuclear cells Not limited to the air ways as in follicular Bronchiolitis LIP = Lymphocytic Interstitial Pneumonia
- 103.
- 104. LIP = Lymphocytic InterstitialPneumonia Rarely idiopathic In association with: Sjögren’s syndrome Immune deficiency syndromes, AIDS Primary biliary cirrhosis Multicentric Castlemean’s disease
- 105. Sjoegren disease Dry eyeand dry mouth Fibrosis, bronchitis and bronchiolitis LIP Overlap Sarcoid, DM/PM, MXCT SLE, RA (pleural effusion) Up to 40 x increased risk for lymphoma (mediastinal adenopathy) and 2 x times increased risk for neoplasma
- 106. Young woman Drymouth Smoker LAM LIP Histiocytosis
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- 110. Honeycombing and tractionbronchiectasis in UIP.
- 111. Typical UIP withhoneycombing and traction bronchiectasis in a patient with idiopathic pulmonary fibrosis (IPF)
- 112.
- 114. Reticular Pattern Gamal RabieAgmy, MD, FCCP Professor of chest Diseases, Assiut university
- 115. Linear Pattern A linearpattern is seen when there is thickening of the interlobular septa, producing Kerley lines. Kerley B lines Kerley A lines The interlobular septa contain pulmonary veins and lymphatics. The most common cause of interlobular septal thickening, producing Kerley A and B lines, is pulmonary edema, as a result of pulmonary venous hypertension and distension of the lymphatics. Kerley B lines Kerley A lines
- 116. DD of KerlyLines: Pulmonary edema is the most common cause Mitral stenosis Lymphangitic carcinomatosis Malignant lymphoma Congenital lymphangiectasia Idiopathic pulmonary fibrosis Pneumoconiosis Sarcoidosis
- 117. HRCT of thelung Reticular pattern – HRCT numerous, clearly visible interlobular septa outlining lobules of characteristic size and shape interlobular septal thickening very fine network of lines within visible lobules intralobular interstitial thickening several layers of air-filled cysts, 3-10 mm in diameter, with thick walls (1-3 mm) honeycombing
- 118. Reticular pattern Interlobular septalthickening – dd smooth thickening pulm. edema pulm. hemorrhage lymphangitic carc. lymphoma nodular thickening lymphangitic carc. sarcoidosis amyloidosis irregular thickening fibrosis
- 119. Reticular pattern Interlobular septalthickening – pulmonary edema smooth septal thickening, isolated or in combination with ground-glass opacity peribronchovascular and subpleural interstitial th. perihilar and gravitational distribution, bilateral findings of CHF
- 120. Reticular pattern Interlobular septalth. – lymphangitic carcinomatosis smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular interstitium and fissures thickening of the intralobular axial interstitium focal or asymmetric distribution
- 121. Reticulation or notreticulation …… “crazy paving”
- 122. Reticular pattern Honeycombing –significance air-containing cystic spaces having thick, fibrous walls lined by bronchiolar epithelium fibrosis is present UIP is likely the histologic pattern IPF is very likely, in the absence of a known disease
- 123. Reticular pattern Honeycombing –differential diagnosis basal distribution middle/upper distribution chronic HP sarcoidosis IPF collagen vasc. dis. asbestosis drugs
- 124. Reticular pattern adapted from:Webb RW – HRCT of the lung, III ed; 2001 interlobular septal thickening irregular, lung distorsion nodularsmooth •fibrosis (sarcoidosis, asbestosis) •pulm. edema •linf. carc. •hemorrhage •sarcoidosis •linf. carc.
- 125. Reticular pattern adapted from:Webb RW – HRCT of the lung, III ed; 2001 honeycombing •IPF (60%) •collagen vascular dis. •drug reaction •asbestosis (uncommon) subpleural, posterior LL predominance •sarcoidosis •chronic HP •radiation other distribution (UL; parahilar)
- 126. Head cheese sign Itrefers to mixed densities which includes # consolidation # ground glass opacities # normal lung # Mosaic perfusion • Signifies mixed infiltrative and obstructive disease
- 127. Head cheese sign Commoncause are : 1. Hypersensitive pneumonitis 2. Sarcoidosis 3. DIP 127
- 128. Headcheese sign Headcheese signin hypersensitivity pneumonitis. HRCT scan shows lung with a geographic appearance, which represents a combination of patchy or lobular ground-glass opacity (small arrows) and mosaic perfusion (large arrows).
- 129. Mosaic Patternitie By Gamal RabieAgmy , MD , FCCP Professor of Chest Diseases ,Assiut University
- 130.
- 131. Where is thepathology ??????? in the areas with increased density meaning there is ground glass in the areas with decreased density meaning there is air trapping
- 132. Pathology in blackareas Airtrapping: Airway Disease Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic, connective tissue diseases, drug reaction, after transplantation, after infection Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall Sarcoidosis granulomatous inflammation of bronchiolar wall Asthma / Bronchiectasis / Airway diseases
- 133.
- 134. Pathology in whiteAreas Alveolitis / Pneumonitis Ground glass desquamative intertitial pneumoinia (DIP) nonspecific interstitial pneumonia (NSIP) organizing pneumonia In expiration both areas (white and black) decrease in volume and increase in density DECREASE IN CONTRAST DIFFERENCES
- 135. Mosaic Perfusion Chronic pulmonaryembolism LOOK FOR Pulmonary hypertension idiopathic, cardiac disease, pulmonary disease
- 136. CTEPH = Chronic thrombembolic pulmonaryhypertension