Causes and Imaging Patterns Associated with...

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Causes and Imaging Patterns of Tree-in-Bud Opacities

Wallace T. Miller, Jr. MD Associate Professor of Radiology

University of Pennsylvania Medical Center Perelman School of Medicine

[email protected]

Conflicts of Interest

RoyaltiesMcGraw Hill

Diagnostic Thoracic ImagingDiagnostic Abdominal Imaging

Wolters Kluwer Field Guide to the Chest X-ray

DoRadiologyThoracic Imaging: a Primer for Physicians Thoracic Imaging: a Case Series

Objectives

To learn the causes and relativefrequencies of TIBTo learn how patterns of TIB cannarrow the differential diagnosis.

Causes and Imaging Patterns of Tree-in-bud Opacities

All cases with TIB in 2010406 examinations3.0% (406/13,540) of all thoracic CTs

Causes established in 40.9%(166/406)

Jill Panosian MD Miller and Panosian, Chest. 2013 Aug 15. [Epub ahead of print]

Causes of Tree-In-Bud Opacities

Respiratory infections 72% Aspiration 25% DPAI 14%

CF/PCD/ABPAImmune Def

Other 7%

Bronchiectasis a cause orcontributor in 34%

Causes of Tree-In-Bud Opacities: Infections

Mycobacteria 56% MAC 84%* M. Abscessus 9% M. chelonae 4% M. fortuitum 6% M. kansasii 3% M. massilense 1% M. terrae 1%

M. Tuberculosis 1%

Viruses 4% RSV 40% Parainfluenza 60%

Fungi 0%

Bacteria 40% Pseudomonas aeruginosa 58% Staphlococcus aureus 38% Klebsiella pneumonia 6% Escherichia coli 4% Moraxella catarrhalis 4% Haemophilus influenza 4% Enterobacter cloacae 2% Acinetobacter baumannii 2% Achromobacter xylosoxidans 2% Streptococcus agalactiae 2% Stenotrophomonas maltophilia 2% Burkholderia cepacia complex 2% Bordetella bronchiseptica 2% Klebsiella oxytoca 2% Actinomyces israelii 2%

Sums of the organisms exceed the total number of cases because some individuals had multiple organisms recovered. *

Causes and Imaging Patterns Associated with Tree-in-BudWallace T. Miller, Jr., MD

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M. Tuberculosis 1%


Fungi 0%


Sums of the organisms exceed the total number of cases because some individuals had multiple organisms recovered. *

Few case reports primarily: Airway invasive Aspergillus sp.

J Mycol Med. 2013 Mar;23(1):64-9 J Heart Lung Transplant. 2014 Oct;33(10):1034-40 Transpl Infect Dis. 2010 Feb;12(1):60-3



M. Tuberculosis 1%


Fungi 0%


Sums of the organisms exceed the total number of cases because some individuals had multiple organisms recovered.*



M. Tuberculosis 1%


Fungi 0%





M. Tuberculosis 1%


Fungi 0%



3% - 11%

Causes of Tree-In-Bud Opacities Aspiration

57% with a predisposing conditionHead and neck Ca / XRT Esophagectomy AchalasiaAltered MS

43% no predisposing conditionDetected by BA swallow

Causes of Tree-In-Bud Opacities Bronchiectasis

39% NTMB 4113% DPAI

CF/PCD/ABPA/Immune Def

8% Aspiration 1

41% Idiopathic3% Bacteria 18/141

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Causes of Tree-In-Bud Opacities Miscellaneous

BO/BOSGraft vs host diseaseBOOPObstructing lesions

Pulmonary lymphoma

Folicular bronchiolitis

Patterns of Tree-In-Bud Opacities*

Without bronchiectasisFocal bronchiolitis 25% Widespread bronchiolitis 14% Bronchopneumonia 23%

With bronchiectasisRandom small airways disease 21% Widespread bronchiectasis 6% Apical bronchiectasis / cavitation 2%

*All cases in 2010

Patterns: Focal Bronchiolitis

CharacteristicsSingle small zone of TIBSometimes resolves / sometimes persists

Most common pattern seen (25%)Least common with a proven diagnosis (9%)(p<.0001)Frequently asymptomatic In most cases

clinically irrelevant

Fig 1 A6846029am

No respiratory symptoms. No diagnosis.

70 woman with RCC. R/O metastasis

Patterns: Widespread Bronchiolitis

CharacteristicsWidespread TIB

Non-specific patternAll causes of TIB produce this pattern

Mycobacteria > bacteria > virusesAspiration > DPAI > micelaneous

Parainfluenza Bronchiolitis

54 man in methadone clinic complained of cough and fever

Fig 2A a6717561gs

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05285342JO

49 man with leukemia sp alloBMT with GVHD of liver. Now with fever and cough

Fig

6801562 6561481 6197282

Haemophilus Influenzae Bronchiolitis MAC Bronchiolitis

56 man with asthma and chronic cough

1002847543 deakr

7097158 6811004 6695212 6509276 6388380 6224616

30 woman with acute promyelocytic leukemia sp ATRA with neutropenia. Now with fever, cough and dyspnea.

Fig 6 a6808448mmw

Silent Aspiration proven by BA swallow

79 woman with mantle cell lymphoma and fevers

Fig 2B a6693797hbk

Pulmonary Lymphoma

Patterns: Bronchopneumonia

Characteristics TIB with consolidation or GGO

Associated with

Bacterial infection specificity 0.84 Aspiration specificity 0.80

52 man with multiple myeloma now with fever & cough.

Fig 5A A6384258ab

Stenotrophomonas maltophilia Bronchopneumonia

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46 man sp lung transplant with cough dyspnea

Fig 5B A7077746dm

Pseudomonas & E coli Bronchopneumonia Aspiration by BA Swallow

31 man with history of polysubstance abuse now with fever and cough after crack cocaine use

1003915200ca 31M polysubstance abuse hx prior pneumonia now fever cough post crack cocaine Dx Dilated esophagus poss achalasia aspiration pneumonia

Aspiration Pneumonia

53 man with relapsed AML and neutropenic fever.

05821432whz Dx RSV pneumonia 2010-01-28 cct

RSV Bronchopneumonia No bacteria recovered Patterns: Random Small Airways

Characteristics Multifocal zones of bronchiectasis / TIB

RML / lingula / post segment RUL Superimposed on regions of normal lung

Highly associated with Atypical mycobacteria specificity 0.94 MAC specificity 0.92 Older (>50) women

60 woman with a chronic cough

Fig 3AB a5935032jas 60F with chronic cough

Moderate Primary MAC Infection

57woman with cough, dyspnea and fever

Fig 3CD a6695212jlla

Mild Primary MAC Infection

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79 woman with chronic cough and intermittent fever

6001125ss 79Fchronic cough intermittent fever Dx MAI RSmAir

Another Primary MAC Infection

68 woman head and neck CA

04366833 grayom

Random Small Airways due to Aspiration

RSA due to asp 6290461 6793847 6207214 6697806 6189434

RSA due to ABPA 6644900 5939243

Patterns: Widespread Bronchiectasis

Characteristics Nearly uniform distribution bronchiectasis across lungs with scattered TIB

Associated with DPAI specificity 0.92

CF upper lobe predominance ABPA / dysmotile cilia / immunodef lower lobe

22 woman with CF and acute exacerbation

Fig 4A a6209967amm

Disease Predisposing to Airway Infection : CF

30 man with chronic cough

1004565437lar

Disease Predisposing to Airway Infection : Dysmotile Cilia Syndrome

Patterns: Apical Predominant Disease

Characteristics Apical Bronchiectasis Cavitation Dependent spread of TIB

Associated with

TB NTMB (MAC, M kansasii, M xenopi, etc) Bacteria

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50 man with involuntary weight loss and chronic sinusitis

05342717SP 50M involotary wt loss, chronic sinusitis Dx reactivation TB ctlw 1-06

Apical Predominant Disease: Tuberculosis

64 woman with chronic productive cough and intermittent fever

1001291662 dziadozscr 64F chronic productive cough intemittent fever Dx TB mimic apperearacne M. abscessus

Apical Predominant Disease: M. Abscessus

63 man with COPD and recurrent fevers and dyspnea unresponsive to antibiotic therapy.

01703920lg 63M COPD recurrent fevers dyspnea unresponsive to ABx Dx Persistent bacterial pneumonia looks like TB 05-05 cct

Apical Predominant Disease: Bacterial Pneumonia Patterns: Dependent Predominant Disease

Characteristics TIB / Bronchiectasis LL > RML-lingula > UL

Associated with

Aspiration specificity 0.79

68 man with head and neck CA sp XRT with brain metastasis. No pulmonary symptoms

6238049 garofaloj

Aspiration with Dependent Predominant Bronchiolitis

Bronchiolitis 7115086 6211574 6238049

Bronchopneumonia 6755159 7050661 6774524 6354635 6287395 6192346

Brnchiolitis with bronchiectasis 6336976

65 man with head and neck cancer and fever

8000058278 demeritteg

Aspiration with Dependent Predominant Bronchopneumonia

Bronchiolitis 7115086 6211574 6238049

Bronchopneumonia 6755159 7050661 6774524 6354635 6287395 6192346

Brnchiolitis with bronchiectasis 6336976

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73 man with achalasia cough and dyspnea

8000067932 shawl

Aspiration with Dependent Predominant Bronchiectasis and TIB Causes of Tree-In-Bud Opacities

Respiratory infections 72% Mycobacteria = Bacteria > Viruses

Aspiration 25% Bronchiectasis 34%

Idiopathic Mycobacteria DPAI (CF, ABPA, PCD, Im def)

Other 7% BO / GVHD / BOOP / lymphoma

Tree-in-bud opacity

Bronchiectasis No Bronchiectasis

Random Small Airways Pattern

Widespread Bronchiectasis

Pattern

Consolidation or GGO

No consolidation or GGO

Alternating diseased

regions with normal lung

Diffuse bronchiectasis

Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB

Widespread Bronchiolitis Pattern

Focal Bronchiolitis Pattern

Clinically insignificant

Everything Bacteria Aspiration

DPAI Less often

mycobacteria

Mycobacteria Less often aspiration

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erytnica acter PAIbact

Basilar distribution Esophagus abnormal

ar distributiori

Aspiration pira

Tree-in-bud opacity




Pattern






Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB





DPAI Less often

mycobacteria


s B

n ting D

cal W

om desponchesprl

erytnica acte PAIbact


ar distributiori

Aspiration pira

Tree-in-bud opacity




Pattern






Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB





DPAI Less often

mycobacteria


s B

n ting D

cal W

om desponchesprl



ar distributiori

Aspiration pira

Tree-in-bud opacity




Pattern






Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB





DPAI Less often

mycobacteria


s B

n ting D

cal W

om desponchesprl



ar distributiori

Aspiration pira

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Tree-in-bud opacity



WidespreadBronchiectasis

Pattern






Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB





DPAI Less often

mycobacteria


s B

n ting D

cal W

om desponchesprl



ar distributiori

Aspiration pira

Tree-in-bud opacity



WidespreadBronchiectasis

Pattern






Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB





DPAI Less often

mycobacteria


s B

n ting D

cal W

om desponchesprl



ar distributiori

Aspiration pira

Tree-in-bud opacity




Pattern






Broncho-pneumonia

Pattern

Focal TIB

Widespread TIB





DPAI Less often

mycobacteria


s B

n ting D

cal W

om desponchesprl



ar distributiori

Aspiration pira

Other Clues

Clinical presentationSex

Primary MAC elderly womenEsophagus

Esophageal abnormality and TIB0.86 specificity for Aspiration

Age

Under 40 Cystic FibrosisABPADysmotile ciliaImmunodeficiency

Common variable

X-linked Hypogamma

MycobacteriaTB MAC

AspirationIdiopathic

Williams Campbell

Over 50

Young Children

Age and Bronchiectasis

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Under 40 Cystic Fibrosis ABPA Dysmotile cilia Immunodeficiency

Common variable

X-linked Hypogamma

Mycobacteria TB MAC

Aspiration Idiopathic

Williams Campbell

Over 50

Young Children



Common variable

X-linked Hypogamma

Mycobacteria TB MAC


Williams Campbell

Over 50

Young Children



Common variable

X-linked Hypogamma

Mycobacteria TB MAC


Williams Campbell

Over 50

Young Children


Causes and Imaging Patterns Associated with...

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