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The Egyptian Journal of Radiology and Nuclear Medicine
journal homepage: www.elsevier.com/locate/ejrnm
Original Article
Emphasizing the role of multi-detector computed tomography chest in theetiological diagnosis of pulmonary bronchiectasis
a Diagnostic and Intervention Radiology Department, Cairo University Medical School, Egyptb Pulmonology Department, Cairo University Medical School, Egypt
A R T I C L E I N F O
Keywords:MDCTChestBronchiectasis
A B S T R A C T
In this study we aimed to highlight the role of multi-slice computed tomography (MSCT) and high resolutioncomputed tomography (HRCT) of the chest in the detection of pulmonary bronchiectatic lesions and to displaythe approach used in determining the proper etiological diagnosis.Patients and methods: This study involved 62 patients; 36 females and 26 males, were referred to the radiologydepartment for MSCT of the chest from the pulmonary department in the period from October 2016 – April 2017.Results: Pulmonary bronchiectatic lesions were classified according to bronchiectasis distribution; with bilaterallesions were more common in 62.5% of patients, classification according to morphological type with the cy-lindrical bronchiectasis was the most common shape in 37.5% of case, classification according to bronchiectasisetiology, most of cases were post inflammatory in 42.2% of cases, followed by traction bronchiectasis in 34.4%of cases. Then the diagnostic approach to reach different etiologies was displayed.Conclusion: The role of MDCT imaging in diagnosis and evaluation of bronchiectasis is crucial.
1. Introduction
Bronchiectasis is a permanent irreversible dilatation of the airways[1]. Permanent architectural changes in the airways causing bronchialdilatation attributed to many etiologies mainly resulting from the re-current infection and inflammation [2].
Clinical diagnosis of bronchiectasis is based on a history of dailyviscid excessive sputum production, so it is frequently misdiagnosed asasthma or chronic obstructive pulmonary disease (COPD) due to thesimilarities in clinical findings [2].
It can cause potential morbidity secondary to recurrent infectionsand in severe cases, death could occur from massive hemoptysis [3].Characteristic computed tomography (CT) scan findings is the maindifferentiating factor [2].
Multi detector row computed tomography (MDCT) especially vo-lumetric high resolution computed tomography (HRCT) provides en-hanced quality of multi-planar reconstructed images in axial, coronaland sagittal planes with minimum intensity projection reconstructedimages as well, is the most sensitive imaging modality for the detectionand diagnosis of bronchiectasis [4]. HRCT findings in bronchiectasisinclude bronchial wall thickening with dilatation of the bronchi to adiameter greater than that of the accompanying artery (the signet-ring
sign); lack of normal tapering of bronchi; and visualization of airway inthe outer 1–2 cm of the lung [2].
Bronchiectasis can result from a variety of pathological conditions.Both congenital and acquired conditions can cause bronchiectasis.Acquired causes are more common, such as infection, pulmonary fi-brosis, recurrent or chronic aspiration, stenosis or obstruction of air-ways by neoplasm, granulomatous disease, broncholithiasis, andasthma. Congenital conditions that cause bronchiactasis include, cysticfibrosis, and cartilage development disorders [5,6]. Bronchiectasiscould be a part of numerous multi-systemic diseases, such as cystic fi-brosis (CF), immunodeficiencies, alpha 1-antitrypsin deficiency, pri-mary ciliary dyskinesia (PCD), rheumatoid arthritis and inflammatorybowel diseases, especially ulcerative colitis [2].
It is beneficial to identify the cause as it aids in management deci-sion, reduce the exacerbations and alter the course of the disease bypreserving lung function [2].
In this study, we aimed to confirm the role of multi-slice computedtomography (MSCT) of the chest in the detection of pulmonarybronchiectatic lesions and to discuss the appropriate approach to itsmost possible etiology.
https://doi.org/10.1016/j.ejrnm.2018.05.004Received 11 February 2018; Accepted 15 May 2018
Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Medicine.⁎ Corresponding author at: Kasr Alainy Hospital at Kasralainy Street, Radiology Department, Egypt.E-mail address: [email protected] (Y.Y. Sabri).
The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651
This cross-sectional study included 64 patients; 36 females and 28males, age range 7–74 years (average of 47.2 years). All patients pre-sented with productive cough and dyspnea and were all referred from
the pulmonary to the radiology department in Kasr Alainy hospital forMSCT of the chest in the period from October 2016 – April 2017.
Inclusion criteria: Cases with bronchiectasis in MSCT chest wereincluded in this study.
Exclusion criteria: Cases with CT contraindications as pregnancy.Patients were subjected to:
(2.1) Thorough clinical examination with history taking, general andchest examination.
(2.2) Relevant laboratory tests were considered according to the casee.g., tuberculin test, analysis test of sputum.
(2.3) Pulmonary function test was done in 20 cases suspected of havingchronic lung diseases (chronic diffuse interstitial lung disease(CDILD) or chronic obstructive pulmonary disease (COPD).
(2.4) MSCT chest was done to all patients using 16 channels MSCT inKasr Al –Ainy.
• Assessment of CT chest: Bronchiectasis was evaluated for thefollowing:
(1) Distribution:– Diffuse or Focal.– Laterality: right lung, left lung or bilateral.– Lobar: RT upper, middle or lower.
LT upper and lingual or lower.(2) Types of bronchiectasis: signet ring, cystic, cylindrical or varicoid.(3) Bronchial wall thickening.(4) Auxiliary findings.(5) According to these CT findings together with clinical data and
laboratory results the etiologies of bronchiectasis were con-sidered.
(2.5) Histo-pathological assessment was needed in two cases with CTsuggesting bronchogenic carcinoma.
3. Results
This study involved 64 patients with bronchiectasis detected in theirMSCT of the chest.
In our study female were more commonly affected with bronch-iectasis, 56.25% (N.= 36 cases), however male cases were 43.75%(N.= 28 cases). 54.7% of our patients were in the 5th and 6th decades.
In this study, bilateral lung affection in 62.5% of cases (N.= 40)was more prevalent than unilateral affection in 37.5% of cases(N.= 24), as 26.5% (N.= 17) cases had only right sided affection, and11% (N.= 7) cases had left sided affection.
See Table 1 for the number and percentages of patient's lobar dis-tribution of pulmonary bronchiectasis.
Signet ring sign was the most common finding of bronchiectasisfound in 35.9% (N.= 12 cases), followed by the cylindrical type ofpulmonary bronchiectasis was most common morphological type ofbronchiectasis in 37.5% of cases (N.= 9), see Table 2.
Post-inflammatory etiology was most encountered in our study in42.2% (N.= 27) followed by traction bronchiectasis 34.4% (N.= 22)see Tables 3 and 4.
Table 1Number and percentages of lobar distribution of the right, left and bilateral lung bronchiectasis in a single lobe, multiple lobes and diffuse bronchiectasis.
Lobar affection Right lung only Number (N.) and Percentage/17cases
Table 2The frequency of different morphological types and other CT pictures ofbronchiectasis.
Morphological types Number (percentages)
Signet ring 12 (18.75%)Cystic 8 (12.5%)Cylindrical 14 (21.9%)Varicose 1 (1.6%)Honey combing 4 (6.25%)Bronchocele 3 (4.7%)Signet ring and cystic 4 (6.25%)Cylindrical and varicose 3 (4.7%)Signet ring, cystic and cylindrical 3 (4.7%)Signet ring and varicose 1 (1.6%)Cystic and varicose 4 (6.25%)Signet ring, cystic, cylindrical and varicose 2 (3.1%)Varicose and bronchocele 1 (1.6%)Signet ring and cylindrical 1 (1.6%)Cystic and bronchocele 2 (3.1%)Cystic, cylindrical and bronchocele 1 (1.6%)Bronchial wall thickening 31 (48.4%)
Table 3Number of cases in different causes of bronchiectasis met during the studyperiod.
Etiologies Number andpercentage
Acquired Post inflammatory 27 (42.2%)
Tractionbronchiectasis
Post granulomatous 15 (23.4%)Atypical mycobacterialinfection
Y.Y. Sabri et al. The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651
646
Table4
Thediag
nostic
approa
chto
reachdifferen
tetiologies
ofbron
chiectasis.
Loba
rdistribu
tion
/Num
ber
ofcases
Bron
chiectasis
shap
eBron
chialwall
thicke
ning
Aux
iliaryCTfind
ings
Age
grou
pClin
ical
complaint
Diagn
osis
Other
confi
rmatory
inve
stigation
Foca
l(lob
ar/seg
men
tal)
Cystic,
bron
choc
ele
Absen
tDistalairtrap
ping
You
ngIncide
ntal/recurrent
infection
Bro
nchial
atresiaan
dbr
onch
ocele
Bron
chosco
peco
nfirm
ation
Tubu
larwithcalcified
endo
bron
chialno
dule
Absen
tBilateralap
ical
scarring
,cav
itary
lesion
sMiddle
Night
feve
ran
dnigh
tsw
eat
Bro
ncho
lith
Labo
ratory
(tub
ercu
lintest)
Tubu
lar,
varico
idwith
prox
imal
masslesion
Presen
tor
absent
Pulm
onaryno
dulesan
dhilar
lymph
aden
opathy
Middle
Che
stpa
in,h
emop
tysis.
Cen
tral
bron
chog
enic
carcinom
aBron
chosco
pyan
dhistop
atho
logical
assessmen
tBilateral/U
La
pred
ominan
ce,diffus
elate
Any
shap
ewithmuc
ous
plug
ging
Presen
tCellularbron
chiolitis,a
irtrap
ping
You
ngChron
icco
ugh,
expe
ctoration,
recu
rren
tinfection.
History
ofPa
ncreatic
disease.
CFb
Labo
ratory
sweatch
loride
test
Bilateral/U
La
pred
ominan
ceCen
tral
Tubu
lar,
varico
idwith
muc
ousplug
ging
(fing
erin
glov
e),h
ighde
nseco
nten
ts
Absen
tMigratory
areasof
consolidation,
atelectasis,
grou
nd-glass
opacities,
mosaicattenu
ation,
andsm
allairw
aydisease.
Middle
Recurrent
asthma,
low
grad
efeve
ran
dprod
uctive
coug
h.ABPA
cLa
boratory
hype
rsen
sitivity
test
Bilateral/u
pper
lobe
pred
ominan
ceAsy
mmetric
Any
shap
ePresen
tor
absent
Volum
eloss,s
urroun
ding
scarring
,cavitation
,calcified
gran
ulom
aor
hilar
lymph
node
s.
Middle,
old
Night
feve
r,nigh
tsw
eat
Post
myc
obac
terial
infection
Labo
ratory
tube
rculin
test
Bilateral/m
iddlean
dling
ual
Any
morecylin
drical
Presen
tSu
rrou
ndingsm
allairw
aydisease,
scarring
Old
man
with
chronic
COPD
d
Chron
icpe
rsistent
coug
h,he
mop
tysis,
malaise,weigh
tloss,a
ndfatigu
e
Atypica
lMyc
obac
terial
Infection
Labo
ratory
inve
stigation,
sputum
/blood
culture
Bilateral/L
Le,po
sterior
segm
entof
ULa
Tubu
lar
Presen
tSu
rrou
ndingsm
allairw
aydisease
Any
Chron
ichistoryof
esop
hage
aldisease,
who
deve
lops
attacks
ofdy
spne
aan
dco
ugh
Chr
onic
aspiration
Bilateral/L
LeAny
,withho
neyco
mbing
Presen
tSu
rrou
ndingreticu
lation
s,grou
ndglass
opacitiesan
dho
neyco
mbing
Middle,
old
age
Chron
icprog
ressiveno
nprod
uctive
coug
han
ddy
spne
aTr
action
bron
chiectasis
with
Pulm
onaryfibr
osis
Bilateral/low
er,middle
lobe
san
dling
uaVaricoidwithmuc
ous
plug
ging
Presen
tAssoc
iatedde
xtrocardia
You
ngRecurrent
infection,
recu
rren
tsinu
sitis,
situsinve
rsus
Kartage
nersy
ndro
me
Bilateral/trach
eaan
dce
ntralbr
onch
iAny
withdive
rticulae,
bron
choc
ele
Absen
tSu
rrou
ndingsm
allairw
aydisease
detected
Middleag
eChron
icco
ughan
drecu
rren
tinfection
Trac
heob
ronc
homeg
aly
(Mou
nier-K
uhnsy
ndro
me)
Foca
lor
Bilateral/
Asy
mmetric
Any
,bronc
hocele
may
bepresen
tPresen
tor
absent
Surrou
ndingsm
allairw
aydisease
mostlyde
tected
.Abscess
in1case,Volum
eloss
in
Any
History
ofinfection
Post
inflam
mator
yLa
boratory
Bilateral/A
symmetric
Any
,bronc
hocele
may
bepresen
tPresen
tor
absent
Diffusehy
perinfl
ation,
mosaic
attenu
ationan
dem
physem
a.Pu
lmon
aryhy
perten
sion
.
Middle,
old
age
Chron
icsm
oker
withhistory
ofrecu
rren
tasthmatic
symptom
s.
Post
COPD
Pulm
onaryfunc
tion
tests
aUL:
uppe
rlobe
.bCF:
cystic
fibrosis.
cABP
A:A
llergic
bron
cho-pu
lmon
aryaspe
rgillosis.
dCOPD
:chron
icob
structivepu
lmon
arydisease.
eLL
:low
erlobe
.
Y.Y. Sabri et al. The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651
647
Table 4 shows the diagnostic approach to reach different etiologiesof bronchiectasis.
4. Discussion
MDCT using High resolution computed tomography (HRCT) tech-nique is considered the modality of choice for airway disease assess-ment as it shows presence, distribution, morphological type ofbronchiectasis and associated findings as well [7].
In this study bronchiectasis was more common in females in56.25%, which agrees with most of studies [8–10]. Bronchiectasis ismore common in 7th decade of life as stated by Izhakian and co-workers, 2016 [11], however in this study the most common age groupwas middle age 50–59-year-old in 30.6%, followed by age group of60–69 year-old in 24.1%, among both males and females.
Bronchiectasis could be encountered in one or both lungs, single ormultiple lobes and many diffuse lung diseases may manifest withbronchiectasis as the primary abnormality [5]. In our study, bronch-iectasis was more prevalent bilaterally and in case of focal lesions rightsided unilateral affection and lower lobe affection was more prevalent,these results were in accordance with many studies [8,11,12].
In this study, right pulmonary bronchiectatic lesions were more inthe lower lobes in 47% of cases, left pulmonary bronchiectatic lesionswere more in the upper lobe in 57.1% of cases. However, in Izhakianet al., 2016, the right pulmonary bronchiectatic lesions were found tobe more in the right middle lobe (25.9%) than in the right lower lobe(20.7%), and the left pulmonary bronchiectatic lesions were found to bemore in the lower lobe (20.4%) than that in the upper lobe (20%) [11].
The cylindrical (or tubular) bronchiectasis, is the most commonlyidentified morphologic type [13]. The three forms of bronchiectasisoften are present in the same patient, with the extent and nature ofbronchial dilatation often falling along a spectrum of imaging findings[5]. In this study, signet ring sign was the most common finding in18.75% of cases, and according to morphological type, the cylindricaltype of pulmonary bronchiectasis was most common in 21.9% of cases.
Bronchial wall thickening is the common final response of the air-ways to irritants, which causes the bronchi to become swollen and in-flamed [5]. Bronchial wall thickening present in 48.4% of our cases.
Bronchiectatic lesions of the lung usually contain air but occasion-ally contain fluid or solid material [1], fluid containing bronchiectasis(bronchoceles) were found in 4.7% of cases.
The etiology of bronchiectasis is varied, and, in most series, anunderlying cause can only be definitively identified in 50% of cases [2].In our study, we reached definite diagnosis in 57% of cases. The dis-tribution of bronchiectasis together with concomitant findings, such ascentrilobular nodules, mass lesions, cavities, and lymphadenopathy,can assist in narrowing the differential diagnosis of bronchiectasis [6].
Regarding the etiology of bronchiectasis post inflammatory was thecommonest cause of bronchiectasis in this study involving 42.2% of thepatients, followed by traction bronchiectasis representing 34.4% ofcases. Lonni and co-workers, 2015 found that the bronchiectasis mostfrequent etiologies are post inflammatory related bronchiectasis (20%),chronic obstructive pulmonary disease related bronchiectasis (15%),and traction bronchiectasis (10%) [14].
Post inflammatory bronchiectasis could be focal or diffuse [5]. Inthis study, lower lobe was the commonest site involving up to 81.4% ofpost inflammatory patients (Figs. 1 and 2). Though, in Johnson and co-workers, 2014, and Izhakian and co-workers, 2016, right middle lobewas more common [15,11].
Allergic bronchopulmonary aspergillosis was found to cause rightmiddle lobe consolidation and bronchiectasis with endobronchialhyper-density representing the fungus, and the classic sign of finger inglove (Fig. 3) [4].
Upper lobes were the most common site in traction bronchiectasis[16], as in our study involving up to 55% patients of traction bronch-iectasis patients (Fig. 4).
Fig. 1. HRCT chest axial image lung window shows right lower lobe signet ringsign and left lower lobe cystic bronchiectasis. Marked oligemia denotingbronchiolitis obliterans in case with post inflammatory bronchiectasis.
Fig. 2. CECT chest axial image lung window shows right lower lobe Post in-flammatory bronchiectasis with bronchocele.
Fig. 3. NECT chest axial image show right middle lobe consolidation withtubular hyper-dense lesion representing dilated bronchi with aspergillus in acase of ABPA.
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Sarcoidosis bronchiectasis tends to be bilateral upper lobar andsymmetrical and associated with bilateral enlargement of hilar andmediastinal lymph nodes, in up to 90% of patients and diffuse re-ticulonodular opacities in 20% of patients [17]. Fibrosis with tractionbronchiectasis and bronchiolectasis in cases of idiopathic interstitialpneumonia, is most pronounced in lower lung lobes (Fig. 5) [19].
Chronic obstructive pulmonary disease cause bilateral diffusebronchiectasis more in the lower lungs. CT demonstrates bronchial wall
thickening, a mosaic attenuation pattern of the pulmonary parenchyma,and mucous plugging (Fig. 6) [5,20].
Focal bronchiectasis related to aspiration was common in the de-pendent upper lobes and the bronchocentric areas of the lower lobestogether with the presence of esophageal lesions include large hiatalhernias predisposing to gastroesophageal reflux, diseases resulting in apatulous esophagus (scleroderma), and esophageal motility disorders[5,21].
Fig. 4. NECT chest axial, coronal images show bilateral upper lobes mostly posterior segments fibrosis and traction bronchiectasis, cicatritial emphysema anddistortion of upper airway, in a known case with tuberculosis.
Fig. 5. HRCT chest axial images show bilateral interstitial fibrosis (idiopathic interstitial pneumonia) with lower lobes traction bronchiectatic changes.
Fig. 6. HRCT chest Axial (a) and coronal (b) images show hyperinflation of both lung fields with cystic bronchiectasis in right middle lobe, fusiform bronchiectasis inright lower lobe and signet ring sign of bronchiectasis in left lower lobe. In a case of COPD with bronchiectasis.
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Slow-growing endobronchial or peri-bronchial lesions, such as car-cinoid or carcinogenic tumors (Fig. 7) and calcific intra-pulmonarylymph node (broncholith) (Fig. 8) cause mucoid impaction, post-ob-structive atelectasis, air-trapping, and distal lobar segmental, or evensingle bronchial bronchiectasis [4,5].
Cystic fibrosis classic diagnostic triad includes an abnormal sweatchloride test result, manifestations of pulmonary and pancreatic dis-ease. Bronchiectasis due to cystic fibrosis was commonly diffuse bi-lateral (Fig. 9), with upper lobar predominance [4,18].
Bronchial atresia was found to cause typical CT changes includebrochocele, occlusion of the bronchus central to the bronchocele, andemphysematous changes of the peripheral lung field (Fig. 10), [22].
In Kartagner Syndrome commonest lobes to be affected are lowerlungs, right middle lobe and lingua, and associated dextro-cardiashould be observed [23].
An adequate understanding of the underlying causes with theirspecific multi-slice computed tomography (MSCT) imaging appearanceswill allow radiologists to more confidently determine the cause of thiscommon radiologic finding, also clinical history and patient demo-graphic characteristics play an integral role in determining the appro-priate differential diagnosis [24].
5. Conclusion
the role of MDCT imaging in diagnosis and evaluation of bronch-iectasis is crucial, as it confirms the presence of bronchiectasis; and theetiology may thus be determined by means of its site, distribution,specific imaging appearance; content, shape, size; associated CT find-ings, knowledge of the associated clinical context assist to reach a de-finite diagnosis or concise the differential diagnosis.
Fig. 7. HRCT chest axial mediastinal (a) and lung (b) windows images show central mass lesion with two punctate peripheral punctate calcific foci. Distal Tubularbronchiectatic changes in right middle lobe noted in a histopathology proved case of non-small cell lung cancer.
Fig. 8. HRCT chest axial images show endobronchial nodular high density lesion with focal tubular and fusiform bronchiectatic changes in right medial basalsegment of lower lobe A case of bronchiectasis due to broncholith.
Fig. 9. HRCT chest axial image shows bilateral lower lobes signet ring signsdenoting early bronchiectasis with bronchial wall thickening. Hyperinflationand hyperlucency of both lungs lobes. In a case of cystic fibrosis with bronch-iectasis.
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Compliance with ethical standards
Conflict of interest.The authors declare they have no conflict of interest.
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Y.Y. Sabri et al. The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651