Radiological Presentation of Pulmonary Pathology

Radiology of collapse ; interstitial lung diseases; calcification and cavitary lung lesions

2. Gamal Rabie Agmy, MD, FCCP
Professor of Chest Diseases, Assiut University

14. Types of Collapse
6-Compression Atelectasis

36. 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 leftward
displacement and rotation of the heart

38. Juxtaphrenic peak sign

The juxtaphrenic 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
This sign 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 for sickle 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

•Seen on 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
that the 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 for approximating 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 position for 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 increased lucency of the cardiophrenic sulci in this patient
with inferior anteromedial pneumothoraces. A CT scan confirms the
diagnosis

52.  a hyperlucent upper
quadrant with
visualization of the
superior surface of the
diaphragm and
visualization of the
inferiorvena cava.

double-diaphragm
sign

53. Antero lateral air may
increase the
radiolucency at the
costo phrenicsulcus.
This is called the deep
sulcus sign.

54. Apicolateral
pneumothorax
(arrows) with right
upper lobe collapse
(arrowheads)

55. shifting of the 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
seen in a tension
pneumothorax.

•The most reliable sign of
tension pneumothorax is
depression of a
hemidiaphragm .

57. Radiographic Signs of Pneumomediastinum




Subcutaneous emphysema
Thymic sail sign
Pneumoprecardium
Ring around the artery sign
Tubular artery sign
Double bronchial wall sign
Continuous diaphragm sign
Extrapleural sign
Air in the pulmonary ligament

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.

66. Nodular Patternitie

67. Secondary pulmonary lobular
anatomy

68. The terminal bronchiole in 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)

69. Nodular Pattern

70. Perilymphatic distribution
Centrilobular distribution
Random distribution

71. ARE NODULES IN CONTACT
WITH PLEURA
NO
CENTRILOBULAR
YES
PERILYMPHATIC RANDOM

73. Size, Distribution, Appearance
Nodules and 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
Miliary tuberculosis
sarcoidosis
in a lung transplant patient
with bronchopneumonia

75. RANDOM: no consistent relationship to any structures
PERILYMPHATIC: corresponds to distribution of lymphatics
CENTRILOBULAR: related to centrilobular structures Distribution
75

76. Disseminated histoplasmosis and nodular ILD.
CT scan shows multiple bilateral round circumscribed
pulmonary nodules.

77. Notice the nodules along the fissures indicating a
perilymphatic distribution (red arrows).
The majority of nodules located along the bronchovascular
bundle (yellow arrow).

78. Sarcoidosis
The majority of nodules located
along the bronchovascular bundle
(yellow arrow).

79. PERILYMPHATIC NODULES
Perilymphatic and Random distribution of
nodules , seen in sarcoidosis.

80. Centrilobular distribution
Hypersensitivity pneumonitis
Respiratory bronchiolitis in
smokers
infectious airways diseases
(endobronchial spread of
tuberculosis or
nontuberculous
mycobacteria,
bronchopneumonia)
Uncommon in
bronchioloalveolar
carcinoma, pulmonary
edema, vasculitis

81. Random distribution
Small random nodules
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 of a 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
Gamal Rabie Agmy , MD , FCCP
Professor of Chest Diseases ,Assiut University

85. DECREASED
LUNG
ATTENUATION

86. Lung Cysts
Pulmonary fibrosis (Honeycombing)
Lymphangiomyomatosis
Langerhanscell histiocytosis
Lymphocytic Interstitial Pneumonia (LIP)
Differential Diagnosis

87. Rough Reticular Fine Reticular
Traction
Bronchiectasis
and
Interface
sign
Honey
combing
UIP UIP or NSIP

88. Usual Interstitial Pneumonia UIP
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 subpleural distribution
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-walled cysts (2mm - 5cm)
Uniform in size / rarely confluent
Homogeneous distribution
Chylous pleural effusion
Lymphadenopathy
in young women

94. Lymphangioleiomyomatosis (LAM)

95. Tuberous Sclerosis (young man)

96. Langerhans Cell Histiocytosis
HRCT Findings
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
Peribronchiolar Nodules Cavitating nodules and cysts
Langerhans Cell Histiocytosis

98. Langerhans Cell Histiocytosis

99. Langerhans Cell Histiozytosis
Key Features
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. Langerhans Cell Histiocytosis

101. Langerhans Cell Histiocytosis
Differential Diagnosis
Only small nodules
Sarkoidosis, Silikosis
Only cysts
idiopathic Fibrosis
LAM
Destruktive emphysema

102. Benign lymphoproliferative
disorder
Diffuse interstitial infiltration of
mononuclear cells
Not limited to the air ways as
in follicular Bronchiolitis

LIP
= Lymphocytic Interstitial Pneumonia

103. Sjögren: LIP

104. LIP
= Lymphocytic Interstitial Pneumonia
Rarely idiopathic

In association with:
Sjögren’s syndrome
Immune deficiency syndromes, AIDS
Primary biliary cirrhosis
Multicentric Castlemean’s disease

105. Sjoegren disease
Dry eye and 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 Dry mouth Smoker
LAM LIP Histiocytosis

107. Wegener‘s disease

108. Rheumatoid Arthritis

109. Honeycombing
HRCT showing
subpleural
broncheolectasis

110. Honeycombing and traction bronchiectasis in UIP.

111. Typical UIP with honeycombing and traction
bronchiectasis in a patient with idiopathic
pulmonary fibrosis (IPF)

112. Distribution within the lung

114. Reticular Pattern
Gamal Rabie Agmy, MD, FCCP
Professor of chest Diseases,
Assiut university

115. Linear Pattern
A linear pattern 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 Kerly Lines:
Pulmonary edema is the most common cause
Mitral stenosis
Lymphangitic carcinomatosis
Malignant lymphoma
Congenital lymphangiectasia
Idiopathic pulmonary fibrosis
Pneumoconiosis
Sarcoidosis

117. HRCT of the lung
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 septal thickening – dd
smooth
thickening
pulm. edema
pulm. hemorrhage
lymphangitic carc.
lymphoma
nodular
thickening
lymphangitic carc.
sarcoidosis
amyloidosis
irregular
thickening
fibrosis

119. Reticular pattern
Interlobular septal thickening – 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 septal th. – 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 not reticulation ……
“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
nodular smooth
•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
It refers to mixed
densities which includes
# consolidation
# ground glass
opacities
# normal lung
# Mosaic perfusion

•Signifies mixed
infiltrative and
obstructive disease

127. Head cheese sign
Common cause are :

1.Hypersensitive pneumonitis

2.Sarcoidosis

3.DIP
127

128. Headcheese sign
Headcheese sign in
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 Rabie Agmy , MD , FCCP
Professor of Chest Diseases ,Assiut University

130. Mosiac pattern

131. Where is the pathology ???????
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 black areas
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. Bronchiolitis
obliterans

134. Pathology in white Areas
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 pulmonary embolism
LOOK FOR
Pulmonary hypertension
idiopathic, cardiac disease, pulmonary
disease

136. CTEPH =
Chronic thrombembolic
pulmonary hypertension