Sarcoidosis end-stage: consolidation as a result of massive fibrosis perihilar and in upper lobes. Yoon YK(1), Kim MJ(1), Yang KS(2), Ham SY(3). Ground-glass opacities have a broad etiology: Broadly speaking, the differential for ground-glass opacification can be split into 5: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. These findings are typical for Usual Interstitial Pneumonia (UIP). Perilymphatic distribution The pathogens enter the central area of the secondary lobule via the terminal bronchiole: In many cases centrilobular nodules are of ground glass density and ill defined (figure). 6. a tutorial on interpreting pulmonary edema on both chest radiograph and lung ultrasound. This finding is helpful in distinguishing PLC from other causes of interlobular septal thickening like Sarcoidosis or cardiogenic pulmonary edema. On the left another case of UIP. Centrilobular emphysema: low attenuation areas without walls. In those cases there are usually associated HRCT findings of fibrosis, such as traction bronchiectasis and honeycombing. The history was typical for hypersensitivity pneumonitis. Thomas Jefferson University Hospital, Department of Radiology, Philadelphia, Pennsylvania *Department of Radiology, Upstate Medical Center, Syracuse, New York. Notice the pneumothorax. 246 (3): 697-722. corkscrew sign (diffuse esophageal spasm), bunch of grapes sign (botryoid rhabdomyosarcoma), bunch of grapes sign (intracranial tuberculoma), bunch of grapes sign (multicystic dysplastic kidney), bunch of grapes sign (intraosseous hemangiomas). Diffuse pneumonia; Massive aspiration; Pulmonary hemorrhage; Treatment. hypersensitivity pneumonitis, respiratory bronchiolitis, centrilobular emphysema ). Apical bullae may lead to spontaneous pneumothorax. Organizing pneumonia (OP) Infectious airways diseases (endobronchial spread of tuberculosis or nontuberculous mycobacteria, bronchopneumonia), Uncommon in bronchioloalveolar carcinoma, pulmonary edema, vasculitis. Radiographics. Two instances of unilateral pulmonary edema occurring as the result of rapid re-expansion of pneumothorax are described and illustrated. The differential diagnosis is hypersensitivity pneumonitis, bronchiolitis or thromboembolic disease. It characteristically presents with the findings of central bronchiectasis, mucoid impaction and atelectasis. It is also described as 'unresolved pneumonia'. This is an uncommon finding of very severe mitral stenosis with repeated episodes or pulmonary edema and hemorrhage. Lymphangiomyomatosis is a rare disease characterized by progressive proliferation of spindle cells, resembling smooth muscle. Basic Interpretation If there are pleural nodules and also nodules along the central bronchovascular interstitium and along interlobular septa, you are dealing with a periplymphatic distribution. Sometimes these can be differentiated with an expiratory scan. High-altitude pulmonary edema (HAPE) is a life-threatening form of non-cardiogenic pulmonary edema (fluid accumulation in the lungs) that occurs in otherwise healthy people at altitudes typically above 2,500 meters (8,200 ft). Common additional findings are an enlarged heart and pleural fluid. Patients with COP typically present with a several-month history of nonproductive cough. Emboli adherent to the wall and intravascular septa are typical for chronic thromboemboli in which partial recanalization took place. Hansell DM, Bankier AA, MacMahon H et-al. As its use has increased, the number of studies positive for pulmonary embolism (PE) has decreased to less than 20%. Alveolar proteinosis is a rare diffuse lung disease of unknown etiology characterized by alveolar and interstitial accumulation of a periodic acid-Schiff (PAS) stain-positive phospholipoprotein derived from surfactant. Australasian Radiology. The diagnosis based on this CT was cardiogenic pulmonary edema. The differential diagnosis of a solitary pulmonary nodule on chest radiography or CT is broad, but more than 95% of the time the nodule is an infectious granuloma ( Fig. Not suprisingly, there is a big overlap in the causes of ground-glass opacity and consolidation and some diseases may present with both areas of ground-glass and consolidation. In centrilobular nodules the recognition of 'tree-in-bud' is of value for narrowing the differential diagnosis. Where is it located within the secondary lobule HR-pattern: Is there an upper versus lower zone or a central versus peripheral predominance. Although pulmonary edema has classically a bilateral and symmetric distribution, unilateral pulmonary edema is less common and may be confused easily with pneumonia. Under normal conditions only a few of these very thin septa can be seen. ... (usual interstitial pneumonitis) had an important role in the differential diagnosis of pulmonary fibrotic diseases, because the medication to delay or stop its lethal course or is already available. The secondary lobule is the basic anatomic unit of pulmonary structure and function. In its later stages, the granulomas are replaced by fibrosis and the formation of cysts. Honeycombing is the typical feature of usual interstitial pneumonia (UIP). However, when it is very extensive, it spreads along the lymphatics in the bronchovascular bundle to the periphery of the lung and may reach the centrilobular area. When we study patients with HRCT, we have to realize that we are looking at a selected group of patients. Mueller-mang C, Grosse C, Schmid K et-al. isolated diffuse ground-glass opacification, respiratory syncytial virus (RSV) bronchiolitis, Middle East respiratory syndrome coronavirus (MERS-CoV) infection, idiopathic hypereosinophilic syndrome (IHS), respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), desquamative interstitial pneumonia (DIP), adult respiratory distress syndrome (ARDS), adenocarcinoma in situ or minimally invasive, hockey stick sign (Creutzfeldt-Jakob disease), stepladder sign (intracapsular breast implant rupture), stepladder sign (small bowel obstruction), eccentric target sign (cerebral toxoplasmosis), trident sign (persistent primitive trigeminal artery), ginkgo leaf sign (subcutaneous emphysema), butterfly shape of the grey matter of the spinal cord, snake-eye appearance (cervical spinal cord), caput medusae sign (developmental venous anomaly), ice cream cone sign (middle ear ossicles), ice cream cone sign (vestibular schwannoma), in total anomalous pulmonary venous return, on expiratory acquisitions, which can be detected if the posterior membranous wall of the trachea is flattened or bowed inwards, eosinophilic drug reactions: peripheral airspace consolidation and GGO, neoplastic processes with a lepidic proliferation pattern. Panlobular emphysema is diffuse and is most severe in the lower lobes. This can also be seen in PE. ... Differentiation between infection and tumor may be impossible to determine by imaging features alone, in general, the clinical history renders these diagnoses relatively ... includes vasculitis, pulmonary edema and pulmonary hypertension … Centrilobular distribution: Hypersensitivity pneumonitis, Respiratory bronchiolitis, solitary nodule or mass (40% of patients). Nodular or irregular septal thickening occurs in lymphangitic spread of carcinoma or lymphoma; sarcoidosis and silicosis. Paraseptal emphysema Fleischner Society: glossary of terms for thoracic imaging. It measures about 1-2 cm and is made up of 5-15 pulmonary acini, that contain the alveoli for gas exchange. All cats had evidence of a reticular or granular interstitial pattern. There is a tendency for hydrostatic edema to show a perihilar and gravitational distribution. However, cases have also been reported between 1,500–2,500 metres or 4,900–8,200 feet in more … Hyperperfused lung adjacent to hypoperfused lung due to chronic thromboembolic disease. by Jonathan Dodd et al AJR 2006; 187:623-629. The lower zone predominance is demonstrated when you scroll through the images. The frontal chest radiograph is the key to diagnosis of acute pulmonary edema. Idiopathic pulmonary fibrosis (IPF), accounts for more than 60% of the cases of UIP. Computed tomography pulmonary angiography (CTPA) is the principal means of evaluating dyspnea in the emergency department. Non specific interstitial pneumonitis (NSIP): ground glass with traction bronchiectasis, no honeycombing. LearningRadiology.com is an award-winning educational site aimed primarily at medical students and radiology residents-in-training, containing lectures, handouts, images, Cases of the Week, archives of case quizzes, flashcards of differential diagnoses and “most commons” lists, primarily in the areas of chest, GI, cardiac, and bone radiology. NSIP has a relative good prognosis and the majority of patients respond to treatment with corticosteroids. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (3): 719-739. Differential Diagnosis. Then there are two possibilities: obstructive bronchiolitis or chronic pulmonary embolism. Pulmonary edema, with the abnormal accumulation of liquid in pulmonary alveoli or interstitial tissue, had the highest frequency cause of diffuse GGO, especially among inpatients . 27 (2): 391-408. Pulmonary edema is one of the most commonly encountered pathologic processes in chest radiology. Filling of the alveolar spaces with pus, edema, hemorrhage, inflammation or tumor cells. Denise R. Aberle, MD, Jeanine P. Wiener-Kronish, MD, W.Richard Webb, MD, Michael A. Matthay ,MD. Chronic eosinophilic pneumonia is usually associated with an increased number of eosinophils in the peripheral blood and patients respond promptly to treatment with steroids. Paraseptal emphysema is localized near fissures and pleura and is frequently associated with bullae formation (area of emphysema larger than 1 cm in diameter). The role of serum procalcitonin in the differential diagnosis of pneumonia from pulmonary edema among the patients with pulmonary infiltrates on chest radiography. nonspecific interstitial pneumonia (NSIP), organizing pneumonia (COP), adult respiratory distress syndrome and pulmonary hemorrhage. The role of the radiologist is to determine which part is abnormal: the black or the white lung. It also occurs in patients with chronic bronchitis, COPD and cystic fibrosis. This may result in a combined perilymphatic-centrilobular pattern which can simulate the random pattern. Pulmonary edema (severe) a. Cardiogenic edema (left sided congestive heart failure): dorsal and hilar distribution. Other features of LAM include adenopathy and pleural effusion. Lymphangiomyomatosis occurs only in women, usually of child-bearing age, between 17 and 50 years. Here two images af a patient with GGO as the dominant pattern. It was first thought to be specific for alveolar proteinosis, but later was also seen in other diseases. Broncho-alveolar cell carcinoma (BAC) may present as: Treatable or not treatable? Ground glass opacification is also used in chest radiography to refer to a region of hazy lung radiopacity, often fairly diffuse, in which the edges of the pulmonary vessels may be difficult to appreciate 7. Author information: (1)Division of Infectious Diseases, Department of Internal Medicine. This type of pulmonary edema is preventable by gradual expansion of the lung collapsed by pneumothorax. The random distribution is a result of the hematogenous spread of the infection. Allergic bronchopulmonary aspergillosis is a lung disease occurring in patients with asthma or cystic fibrosis, triggered by a hypersensitivity reaction to the presence of Aspergillus fumigatus in the airways. Although pulmonary edema has classically a bilateral and symmetric distribution, unilateral pulmonary edema is less common and may be con-fused easily with pneumonia. This review discusses the usefulness of bedside lung ultrasound in the diagnostic distinction between the various causes of acute dyspnoea in the emergency department, with special attention to the differential diagnosis of pulmonary oedema and exacerbation of chronic obstructive pulmonary disease (COPD). pathologic processes in chest radiology. Subpleural honeycomb cysts typically occur in several contiguous layers. Pulmonary edema should be differentiated from other diseases presenting with dyspnea, orthopnea, cough. This syndrome is unassociated with evidence of myocardial dysfunction and responds readily to diuretics and oxygen. Alveolar edema manifests as ill-defined nodular opacities tending to confluence (see image with arrows). 2003;23:1509-1519, Appendicitis - Pitfalls in US and CT diagnosis, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, Esophagus: anatomy, rings and inflammation, Multiple Sclerosis - Diagnosis and differential diagnosis, Developmental Dysplasia of the Hip - Ultrasound, Differential diagnosis of interstitial lung diseases, 'Crazy-Pavin' Pattern at Thin-Section CT of the Lungs: Radiologic-Pathologic Overview, Role of HRCT in diagnosing active pulmonary Tuberculosis, high attenuation (ground-glass, consolidation). There is uniform destruction of the underlying architecture of the secondary pulmonary lobules, leading to widespread areas of abnormally low attenuation. Ground-glass opacities have a broad etiology: 1. normal expiration 2. partial filling of air spaces 3. partial collapse of alveoli 4. interstitial thickening 5. inflammation 6. edema 7. fibrosis 8. lepidic proliferationof neoplasm 1. focal ground-glass opacification 2. diffuse ground-glass opacification 3. isolated diffuse ground-glass opacification 5 Notice the nodules along the fissures indicating a perilymphatic distribution (red arrows). When ground glass opacity presents as mosaic attenuation consider: It can be difficult to distinguish these three entities. On the left we see focal irregular septal thickening in the right upper lobe in a patient with a known malignancy. On the left a patient with both septal thickening and ground glass opacity in a patchy distribution. diffuse ill-defined centrilobular nodules (30%) due to endobronchial spread. If the vessels are the same in the 'black' lung and 'white' lung, then you are looking at a patient with infiltrative lung disease, like the one on the right with the pulmonary hemmorrhage. Pulmonary edema 1. A long list of drugs have been implicated, but this pattern is most commonly the result of cytotoxic chemotherapeutic agents such as bleomycin, busulfan, vincristine, methotrexate, adriamycin, and carmustine (BCNU). Pulmonary Tuberculosis: Up-to- Date Imaging … 4. The algorithm to distinguish perilymphatic, random and centrilobular nodules is the following: Perilymphatic nodules are most commonly seen in sarcoidosis. Differential Diagnosis Diffuse airspace opacities •Large R-sided multi-lobar pneumonia •Asymmetric pulmonary edema •Alveolar hemorrhage Improvement after 1 day, after a dialysis and significant volume removal, suggests asymmetric pulmonary edema When you think of the causes of consolidation, think of 'what is replacing the air in the alveoli'? Identical clinical, radiologic, and pathologic pulmonary changes are seen in about 1% of patients with tuberous sclerosis. Farmer's lung is the best-known HP syndrome and results from the inhalation of fungal organisms that grow in moist hay or exposure to birds as pets (1). Interstitial edema can be seen as peripheral septal lines - Kerley B lines … Look at expiratory scans for air trapping, Infection (PCP, viral, Mycoplasma, bacterial), Pulmonary edema due to heart failure or ARDS, Lung cysts (LAM, LIP, Langerhans cell histiocytosis), Irreversible destruction of alveolar walls in the centrilobular portion of the lobule, Upper lobe predominance and uneven distribution, In alpha-1-antitrypsin deficiency, but also seen in smokers with advanced emphysema, Adjacent to the pleura and interlobar fissures, Can be isolated phenomenon in young adults, or in older patients with centrilobular emphysema, In young adults often associated with spontaneous pneumothorax, lack of normal tapering with visibility of airways in the peripheral lung, associated atelectasis and sometimes air trapping, Inhaled particles: pneumoconiosis (silica or coal), Smoking related diseases (centrilobular emphysema, Lymphangitic spread of carcinoma - often unilateral. 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