Radiological signs of chest diseases

141

Transcript of Radiological signs of chest diseases

Page 1: Radiological signs of chest diseases

Radiological Signs in Chest Medicine

Gamal Rabie Agmy MD FCCP Professor of chest Diseases Assiut university

S Curve of

Golden

When there is a mass

adjacent to a fissure the

fissure takes the shape

of an S The proximal

convexity is due to a

mass and the distal

concavity is due to

atelectasis Note the

shape of the transverse

fissure

This example represents

a RUL mass with

atelectasis

Pulmonary Artery

Overlay Sign

This is the same concept

as a silhouette sign If

you can recognize the

interlobar pulmonary

artery it means that the

mass seen is either in

front of or behind it

This is an example of a

dissecting aneurysm

Achalasia of esophagus

Inhomogeneous cardiac density

Right half more dense than left

Density crossing midline (right black

arrow)

Right sided inlet to outlet shadow

Right para spinal line (left black

arrow)

Barium swallow below Dilated

esophagus

Feeding vessel sign

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

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 2: Radiological signs of chest diseases

S Curve of

Golden

When there is a mass

adjacent to a fissure the

fissure takes the shape

of an S The proximal

convexity is due to a

mass and the distal

concavity is due to

atelectasis Note the

shape of the transverse

fissure

This example represents

a RUL mass with

atelectasis

Pulmonary Artery

Overlay Sign

This is the same concept

as a silhouette sign If

you can recognize the

interlobar pulmonary

artery it means that the

mass seen is either in

front of or behind it

This is an example of a

dissecting aneurysm

Achalasia of esophagus

Inhomogeneous cardiac density

Right half more dense than left

Density crossing midline (right black

arrow)

Right sided inlet to outlet shadow

Right para spinal line (left black

arrow)

Barium swallow below Dilated

esophagus

Feeding vessel sign

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

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 3: Radiological signs of chest diseases

Pulmonary Artery

Overlay Sign

This is the same concept

as a silhouette sign If

you can recognize the

interlobar pulmonary

artery it means that the

mass seen is either in

front of or behind it

This is an example of a

dissecting aneurysm

Achalasia of esophagus

Inhomogeneous cardiac density

Right half more dense than left

Density crossing midline (right black

arrow)

Right sided inlet to outlet shadow

Right para spinal line (left black

arrow)

Barium swallow below Dilated

esophagus

Feeding vessel sign

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

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 4: Radiological signs of chest diseases

Achalasia of esophagus

Inhomogeneous cardiac density

Right half more dense than left

Density crossing midline (right black

arrow)

Right sided inlet to outlet shadow

Right para spinal line (left black

arrow)

Barium swallow below Dilated

esophagus

Feeding vessel sign

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

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 5: Radiological signs of chest diseases

Feeding vessel sign

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

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 6: Radiological signs of chest diseases

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

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 7: Radiological signs of chest diseases

Incomplete Border Sign

(Pregnant Lady Sign) The incomplete border sign is

useful to depict an

extrapulmonary mass on

chest radiograph

An extrapulmonary mass will

often have a inner well defined

border and an ill-defined outer

margin This can be attributed

to the inner margin being

tangential to the x-ray beam

and has good inherent

contrast with the

adjacent lung On the other

hand the outer margin is

enface or partially enface with

the x-ray beam and merges

with the pleural or chest wall

thus the border is obscured

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 8: Radiological signs of chest diseases

Ginkgo leaf sign bull 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

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 9: Radiological signs of chest diseases

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

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 10: Radiological signs of chest diseases

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT

The vessels are prominently seen

against a background of low-

attenuation material

Associated with

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 11: Radiological signs of chest diseases

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

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 12: Radiological signs of chest diseases

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 13: Radiological signs of chest diseases

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass

opacity (GGO) in both apices resulting from invasive pulmonary

aspergillosis

This halo represents hemorrhage

When seen in leukemic patients is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 14: Radiological signs of chest diseases

CT Halo Sign

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 15: Radiological signs of chest diseases

Reverse Halo Sign

bullCentral ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape at least 2 mm thick

bullFirst described by Voloudaki in 1996

bullKim in 2003 used the term reverse halo

bullFound to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 16: Radiological signs of chest diseases

Reverse Halo Sign

Seen in other conditions

bullWegenerrsquos granulomatosis

bulllymphomatoid granulomatosis

bullparacoccidiodomycosis

bullneoplastic (metastasis)

bullinvasive aspergillosis

bulllipoid pneumonia

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 17: Radiological signs of chest diseases

Tree-in-Bud Sign

bull

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 18: Radiological signs of chest diseases

Pearl ring sign

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 19: Radiological signs of chest diseases

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple The appearance is suggestive

of croup which should be obvious

clinically A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 20: Radiological signs of chest diseases

Cancer Breast

Larger right breast Inverted nipple

Radiation Fibrosis of

Lung

Right lung smaller

Right hemithorax smaller

Paramediastinal fibrosis

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 21: Radiological signs of chest diseases

Mosiac pattern

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 22: Radiological signs of chest diseases

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

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 23: Radiological signs of chest diseases

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

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 24: Radiological signs of chest diseases

Airway Disease

what you seehelliphellip

In inspiration sharply demarcated areas of seemingly increased

density (normal) and decreased density

demarcation by interlobular septa

In expiration bdquoblack‟ areas remain in volume and density

bdquowhite‟ areas decrease in volume and increase in

density

INCREASE IN CONTRAST

DIFFERENCES

AIRTRAPPING

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 25: Radiological signs of chest diseases

Bronchiolitis

obliterans

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 26: Radiological signs of chest diseases

Early Sarcoidosis

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 27: Radiological signs of chest diseases

Chronic EAA

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 28: Radiological signs of chest diseases

Hypersensitivity pneumonitis

Extr Allerg Alveolitis (EAA) HRCT

Morphology

chronic fibrosis

Intra- interlobular septal thickening

Irregular interfaces

Traction bronchiectasis

acute - subacute

acinar (centrilobular) unsharp densities

ground glass (patchy - diffuse)

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 29: Radiological signs of chest diseases

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

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 30: Radiological signs of chest diseases

DI

P

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 31: Radiological signs of chest diseases

Cellular

NSIP

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 32: Radiological signs of chest diseases

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 33: Radiological signs of chest diseases

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 34: Radiological signs of chest diseases

Secondary lobule

Basic anatomic unit of pulmonary

structure and function

1-2 cm and is made up of 5-15

pulmonary acini

Supplied by a small bronchiole

(terminal bronchiole) in the

center that is parallelled by the

centrilobular artery

Pulmonary veins and lymphatics

run in the periphery

Two lymphatic systems

central network

peripheral network

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 35: Radiological signs of chest diseases

The terminal bronchiole in the center divides into respiratory bronchiolies with acini that contain alveoli Lymphatics and veins run within the interlobular septa

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 36: Radiological signs of chest diseases

Centrilobular area in blue perilymphatic area in yellow

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 37: Radiological signs of chest diseases

Raoof S CHEST 2006 129805

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 38: Radiological signs of chest diseases

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 39: Radiological signs of chest diseases

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 40: Radiological signs of chest diseases

Hypersensitivity

pneumonitis

HRCT at the level of the

upper lobes reveals an ldquoill-

defined centrilobular nodular

patternrdquo characterised by

micronodules of ground-

glass opacity that are

diffusely distributed

characteristically in the

centre of the pulmonary

lobules

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 41: Radiological signs of chest diseases

RBILD

HRCT at the level of the upper

lobes exhibits an ldquoill-defined

centrilobular nodular patternrdquo

characterised by micronodules of

ground-glass opacity that are

diffusely distributed

characteristically in the centre of

the pulmonary lobules In this case

the history of smoking favours the

diagnosis of respiratory

bronchiolitis interstitial lung disease

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 42: Radiological signs of chest diseases

Miliary TB HRCT at the level of the upper

lobes exhibits a ldquomiliary nodular

patternrdquo characterised by random

micronodules diffusely and

symmetrically distributed within the

lungs having approximately the

same size

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 43: Radiological signs of chest diseases

Miliary metastatic disease

HRCT at the level of the upper lobes

shows a ldquomilary nodular patternrdquo

characterised by random and

perilymphatic micronodules diffusely

distributed throughout the lungs that

have a more variable size compared

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 44: Radiological signs of chest diseases

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

workers berylliosis)

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 45: Radiological signs of chest diseases

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 46: Radiological signs of chest diseases

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 47: Radiological signs of chest diseases

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 48: Radiological signs of chest diseases

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

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 49: Radiological signs of chest diseases

Basal and subpleural distribution

UIP

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 50: Radiological signs of chest diseases

Lymphangioleiomyomatosis

(LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 51: Radiological signs of chest diseases

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 52: Radiological signs of chest diseases

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 53: Radiological signs of chest diseases

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 54: Radiological signs of chest diseases

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 55: Radiological signs of chest diseases

Langerhans Cell Histiocytosis

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 56: Radiological signs of chest diseases

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

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 57: Radiological signs of chest diseases

after cessation of smoking

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 58: Radiological signs of chest diseases

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 59: Radiological signs of chest diseases

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 60: Radiological signs of chest diseases

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgren‟s syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemean‟s disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 61: Radiological signs of chest diseases

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 62: Radiological signs of chest diseases

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 63: Radiological signs of chest diseases

Wegenerbdquos disease

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 64: Radiological signs of chest diseases

Rheumatoid Arthritis

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 65: Radiological signs of chest diseases

Emphysema

histopathological definition

hellippermanent abnormal enlargement of

airspaces distal to the bronchioles terminales

and

hellipdestruction of the walls of the involved

airspaces

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 66: Radiological signs of chest diseases

Centrilobular Emphysema

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 67: Radiological signs of chest diseases

Panlobular Emphysema

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 68: Radiological signs of chest diseases

CLE and PLE in one Patient

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 69: Radiological signs of chest diseases

Fibrosis and Emphysema

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 70: Radiological signs of chest diseases

LAM Emphysema Fibrosis

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 71: Radiological signs of chest diseases

LCH Emphysema

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 72: Radiological signs of chest diseases

Fibrosis Emphysema

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 73: Radiological signs of chest diseases

Emphysema

Emphysema typically presents as

areas of low attenuation without

visible walls as a result of

parenchymal destruction

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 74: Radiological signs of chest diseases

EMPHYSEMA

Permanent abnormal enlargement of air

spaces distal to the terminal bronchiole

and accompanied by the destruction of

the walls of the involved air spaces

112

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 75: Radiological signs of chest diseases

Centrilobular emphysema

Most common type

Irreversible destruction of alveolar

walls in the centrilobular portion of the

lobule

Upper lobe predominance and

uneven distribution

Strongly associated with smoking

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 76: Radiological signs of chest diseases

Centrilobular (proximal or

centriacinar) emphysema

Found most commonly in the upper lobes

Manifests as multiple small areas of low attenuation without a

perceptible wall producing a punched-out appearance

Often the centrilobular artery is visible within the

centre of these lucencies

114

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 77: Radiological signs of chest diseases

Centrilobular emphysema due to smoking The periphery of

the lung is spared (blue arrows) Centrilobular artery (yellow

arrows) is seen in the center of the hypodense area

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 78: Radiological signs of chest diseases

Panlobular emphysema

Affects the whole secondary lobule

Lower lobe predominance

In alpha-1-antitrypsin deficiency but

also seen in smokers with advanced

emphysema

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 79: Radiological signs of chest diseases

PANLOBULAR EMPHYSEMA

Affects the entire secondary pulmonary

lobule and is more pronounced in the lower

zones

Complete destruction of the entire pulmonary

lobule

Results in an overall decrease in lung

attenuation and a reduction in size of

pulmonary vessels

117

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 80: Radiological signs of chest diseases

PANLOBULAR EMPHYSEMA

118

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 81: Radiological signs of chest diseases

Panlobular emphysema

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 82: Radiological signs of chest diseases

Paraseptal (distal acinar)

emphysema

Affects the peripheral parts of

the secondary pulmonary lobule

Produces subpleural lucencies

120

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 83: Radiological signs of chest diseases

Paraseptal emphysema

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 84: Radiological signs of chest diseases

Cystic lung disease

Lung cysts are defined as radiolucent areas with a

wall thickness of less than 4mm

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 85: Radiological signs of chest diseases

Langerhans cell histiocytosis

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 86: Radiological signs of chest diseases

Lymphangiomyomatosis complicated by pneumothorax

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 87: Radiological signs of chest diseases

Bronchiectasis

Bronchiectasis is defined as localized bronchial

dilatation (signet-ring sign)

bronchial wall thickening

lack of normal tapering with visibility of airways

in the peripheral lung

mucus retention in the broncial lumen

associated atelectasis and sometimes air

trapping

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 88: Radiological signs of chest diseases

ABPA glove-finger shadow due to mucoid impaction in central

bronchiectasis in a patient with asthma

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 89: Radiological signs of chest diseases

Signet-Ring Sign

A signet-ring sign represents an axial cut of a dilated bronchus

(ring) with its accompanying small artery (signet)

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 90: Radiological signs of chest diseases

Tram Tracks

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 91: Radiological signs of chest diseases

Bronchial dilation with lack of tapering

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 92: Radiological signs of chest diseases

HONEYCOMBING

Defined as - small cystic spaces with

irregularly thickened walls composed of

fibrous tissue

Predominate in the peripheral and subpleural

lung regions

Subpleural honeycomb cysts typically occur

in several contiguous layers DD- paraseptal

emphysema in which subpleural cysts usually

occur in a single layer

Indicates the presence of ldquoEND stagerdquo

disease regardless of the cause

131

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 93: Radiological signs of chest diseases

Honeycombing

Honeycombing is defined by the presence of small cystic

spaces with irregularly thickened walls composed of

fibrous tissue

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 94: Radiological signs of chest diseases

Causes

Lower lobe predominance

1 UIP or interstitial fibrosis

2 Connective tissue disorders

3 Asbestosis

4 Drug induced

5 NSIP (rare)

Upper lobe predominance

1 End stage sarcodosis

2 Radiation

3 Hypersensitivity Pneumonitis

4Silicosis

4 End stage ARDS

133

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 95: Radiological signs of chest diseases

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 96: Radiological signs of chest diseases

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 97: Radiological signs of chest diseases

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 98: Radiological signs of chest diseases

Inconsistent with UIP

pattern (any one of

seven features)

Possible UIP

pattern (all

three features)

UIP pattern (all

four features)

bullUpper or mid lung

predominance

bullperibronchovascular

predominance

bullextensive ground glass abnormality (extent gt

reticular abnormality)

bullprofuse micronodules

(bilateral predominantly

upper lobes) bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic

attenuationair trapping (bilateral in three or more

lobes)

bullsubpleural basal

predominance

bullreticular abnormality

bullAbsence of features listed as inconsistent

with UIP pattern

bullsubpleural basal

predominance

bullreticular abnormality

bullhoneycombing with

or without traction

bronchiectasis

bullAbsence of features

listed as inconsistent

with UIP pattern

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 99: Radiological signs of chest diseases

Hydrostatic pulmonary

oedema

ldquoseptal patternrdquo characterised by

thickened smoothly interlobular

septae in the right parahilar area

Right pleural effusion is also seen

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 100: Radiological signs of chest diseases

Lymphangitic carcinomatosis

HRCT of the right lung shows a

ldquoseptal patternrdquo characterised by

diffuse nodular thickening of the

interlobular septae and the right

major fissure

Page 101: Radiological signs of chest diseases