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

Radiographic Evaluation of Interstitial Lung

Disease

Laura E. Heyneman, MD

Duke University Medical Center

Case 1

Case 2

Case 3

Case 4

Approach to ILD• What is the pattern?• Acute vs chronic?• Any clues?

– distribution– lung volumes

Approach to ILD• What is the pattern?• Acute vs chronic?• Any clues?

– low volumes: fibrosis– ↑ volumes: obstruction

Approach to ILD• What is the pattern?• Acute vs chronic?• Any clues?

– distribution, volumes– associated findings

Patterns of ILD• Nodular

• Reticular

• Septal lines

• Cystic

Nodular• Acute

– atypical infection• miliary tuberculosis• disseminated fungal

Nodular• Chronic

– Mets– Sarcoid– Silicosis / Coal worker’s– Eosinophilic granuloma– Hypersensitivity: subacute

Nodular: CluesDiffuse / lower distribution

• hematogenous- miliary infection- metastases

Nodular: CluesUpper lung distribution

– Sarcoid– Silicosis / Coal worker’s– Eosinophilic granuloma– Hypersensitivity: subacute

Case 1

Multiple small nodules

Lower lobe predominant: hematogenous

Acute: infection

1 month earlier

Miliary TB

Upper lobe predominant

Clues to etiology? nodules: central lucencies

Eosinophilic Granuloma

Upper lobe predominant

Clues to etiology? lymphadenopathy

Sarcoid

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

Clues to etiology? silicosis vs sarcoid (vs TB)

Sarcoid

Clues to etiology? calcified nodules

Silicosis

Reticular• Acute

– interstitial edema– atypical infection

• Pneumocystis• viral infection

Reticular• Chronic

– fibrosis

Reticular• Chronic

– fibrosis– emphysema– cystic lung disease– bronchiectasis

Reticular: CluesNormal lung volumes

– acute: edema / infection– bronchiectasis

Reticular: CluesIncreased lung volumes

– cystic lung disease– emphysema– (bronchiectasis)

Reticular: CluesDecreased lung volumes

– fibrosis

FibrosisUpper lobe distribution

– sarcoid– chronic hypersensitivity– cystic fibrosis– XRT (head and neck)– prior tuberculosis– ankylosing spondylitis

FibrosisLower lobe distribution– UIP, NSIP– (chronic aspiration)

Normal volumes: not fibrosis

Acute perihilar reticulation

2 months earlier

Pneumocystis jirovecii

Case 2

Low volumes: fibrosis upper lobe predominant

Clues to etiology? lymphadenopathy

Sarcoid

Low volumes, upper lobe fibrosis

Clues to etiology? Osseous findings

Clues to etiology? Osseous findings

Ankylosing spondylitis

Upper lobe fibrosis, perihilar confluent masses

Progressive massive fibrosissilicosis vs sarcoid

PMF: Clues to etiology? parallel chest wall: silicosis

PMF: Clues to etiology? noncalcified LAN: sarcoid

Case 3

Low volumes, lower lobe

Fibrosis: UIP or NSIP

Clues to etiology? Calcified pleural plaques

Clues to etiology? Asbestosis

Clues to etiology? osseous changes?

Clues to etiology? Rheumatoid Arthritis

Clues to etiology? soft tissue calcification?

Courtesy of Charles White, MD

Clues to etiology? soft tissue calcification?

Courtesy of Charles White, MD

Clues to etiology? Connective Tissue Disease

Courtesy of Charles White, MD

Clues to etiology?

Clues to etiology? esophageal dilation

Clues to etiology? esophageal dilation

Clues to etiology? Scleroderma

Septal Lines• Acute

– edema

– atypical infection

Septal Lines• Chronic

– lymphangitic ca

– (amyloid)

– (Kaposi’s sarcoma)

Acute

6 weeks earlier

Edema

6 weeks earlier

Acute, heart bigger

6 weeks earlier

Clues to etiology? signs cardiac, renal disease

Case 4

chronic septal thickening

follow-up film 2 weeks

Lymphangitic carcinomatosis

Clues to etiology? mastectomy, lung mass,

surgical clips, biliary stent

Clues to etiology? mastectomy, lung mass,

surgical clips, biliary stent

Clues to etiology? linitis plastica

Cysts/ Ring Lucencies• Acute

– Pneumocystis pneumonia

– (necrotizing pneumonia)

• Chronic– honeycombing– bronchiectasis– eosinophilic granuloma– lymphangioleiomyomatosis– emphysema

Cysts/ Ring Lucencies

Cystic: CluesUpper lobe distribution

– Pneumocystis– eosinophilic granuloma– cystic fibrosis– honeycombing: sarcoid, chronic EAA

Cystic: CluesLower lobe distribution

– honeycombing: UIP– alpha-1 antitrypsin– bronchiectasis: aspiration

Cystic: CluesNo lobar distribution– lymphangioleiomyomatosis

Normal volumes: not fibrosisupper lobe cystic change

Acute

2 months earlier

Pneumocystis jirovecii

Low volumes: fibrosis Cysts stacked upon cysts

Honeycombing

Lower lobe: UIP Upper: sarcoid, chronic HP

Normal volumes: not fibrosis cysts stacked on cysts

tubular lucencies converge toward hila

Bronchiectasis

Clues to etiology? lower lobe: chronic aspiration

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

Cystic Fibrosis

Increased volumes: obstructive

Increased volumes: obstructive upper lobe cysts, spares lower

Eosinophilic granuloma

Increased volumes: obstructive

Increased volumes, diffuse thin walled cysts

Lymphangioleiomyomatosis

Increased volumes: obstructive

Increased volumes: obstructive lower lobe bulla

Alpha-1 antitrypsin dz

Patterns may overlap septal lines + nodules

Septal Lines + Nodules• Acute

– atypical infection

• Chronic

– lymphangitic carcinoma

Lymphangitic carcinomatosis

Patterns• Acute vs chronic

• Distribution, volumes– Low volumes: fibrosis

– Increased volumes: obstructive

• Other clues?