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Imaging of Interstitial Lung Disease cases presented

Demetris Patsios, BA (Oxon), BM BCh,MRCP (UK) FRCR(UK) Assistant Professor of Radiology, University of Toronto, Staff Radiologist in Thoracic Imaging, UHN, Mount Sinai and Womens College Hospitals Joint Department of Medical Imaging 13th November 2010

Imaging of ILD Cases presented


Learning Objectives 1. List the hallmark radiographic features of the cases discussed 2. Provide radiological differential diagnosis and discuss their imaging characteristic features

Conflict of Interest Disclosure


None

Case 1
Ground glass Lobular areas of lower attenuation Normal lung parenchyma Normal lung volumes No architectural distortion No nodules No reticulation

Case 1
Ground glass Lobular areas of lower attenuation Normal lung parenchyma Normal lung volumes No architectural distortion No nodules No reticulation

Case 1
Main differential diagnosis on imaging
Subacute Hypersensitivity Pneumonitis Atypical Infection with associated bronchiolitis Nonspecific Interstitial Pneumonia (NSIP) Sarcoidosis

Case 2

Case 2

Case 2
Minor subpleural lung reticulation Minimal architectural distortion with fine honeycomb lung (Right Upper Lobe for example)+/traction bronchiectasis bronchiolectasis No significant ground glass remote from areas of involvement

Case 2
Upper, mid and lower zonal distribution Mild heterogeneity of lung parenchyma Pattern of reticulation extends to the pleura with no subpleural lung sparing No nodules No consolidation Difficult to comment on lung volumes on study provided scout suggest slight loss of volume

Case 2
Main differential diagnosis on imaging:
Early Idiopathic Pulmonary Fibrosis of a UIP pattern Chronic Hypersensitivity Pneumonitis Pulmonary manifestation of collagen vascular disease in a Fibrotic pattern of NSIP Pulmonary manifestation of drug reaction Sarcoidosis

Discussion
Idiopathic Pulmonary Fibrosis /Usual Interstitial Pneumonia (IPF/UIP) Nonspecific Interstitial Pneumonia (NSIP)

Hypersensitivity Pneumonitis
Acute Subacute Chronic

Drug reaction

Idiopathic Pulmonary Fibrosis IPF


Specific form of chronic fibrosing interstitial pneumonia limited to the lung and associated with the histologic appearance of Usual Interstitial Pneumonia (UIP)

Temporal and geographic heterogeneity


UIP can also be seen in
Asbestosis Chronic Hypersensitivity Pneumonitis Drug induced disease Familial IPF

Idiopathic Pulmonary Fibrosis IPF

Idiopathic Pulmonary Fibrosis IPF


Usually symmetric Basal predominant but may be diffuse Irregular Linear May progress to reticulonodular pattern Progress to volume loss In smokers volumes can be normal

Idiopathic Pulmonary Fibrosis IPF

Idiopathic Pulmonary Fibrosis IPF


Subpleural distribution Lower lung zone predominant Architectural distortion Irregular intralobular lines Traction bronchiectasis Honey comb lung cysts Air filled cysts

Idiopathic Pulmonary Fibrosis IPF


5% can be upper lung predominant Ground glass is mild Associated with fibrosis Fewer ground glass opacities remote from fibrosis Disease activity vs. fibrosis

Idiopathic Pulmonary Fibrosis IPF


Emphysema in 30% Pulmonary ossification Lymph node enlargement No centrilobular or peribronchovascular nodules No extensive consolidation No extensive ground glass opacities

Idiopathic Pulmonary Fibrosis IPF


Main differential diagnosis
Fibrotic NSIP +/- relation to connective tissue disease Asbestosis

Chronic Hypersensitivity

Nonspecific Interstitial Pneumonia


Chronic interstitial lung disease Homogenous expansion of alveolar spaces because of inflammation or fibrosis or both

More commonly associated with manifestation of connective tissue disease, hypersensitivity pneumonitis, drug induced lung disease interstitial lung disease complicating diffuse alveolar damage
Less commonly idiopathic

Nonspecific Interstitial Pneumonia

Nonspecific Interstitial Pneumonia


Hazy opacities mainly middle and lower lung zones
+/- reticular opacities Can be normal

Nonspecific Interstitial Pneumonia


Bilateral symmetric ground glass opacities Fine reticular opacities When only ground glass opacities cellular form most likely

Nonspecific Interstitial Pneumonia


Subpleural lung sparing may be distinguishing feature compared to UIP

Honeycomb lung much less common than UIP

Nonspecific Interstitial Pneumonia


Subpleural lung sparing may be distinguishing feature compared to UIP

Honeycomb lung much less common than UIP

Nonspecific Interstitial Pneumonia


Differential Diagnosis
Hypersensitivity pneumonitis

Cryptogenic organising pneumonia


IPF

Hypersensitivity Pneumonitis
Immune mediated inflammatory form of diffuse interstitial pulmonary disease caused by inhalation of antigens Can be seen in drug toxicity Traditionally three different types of presentation Acute Subacute Chronic

Hypersensitivity pneumonitis- acute

Hypersensitivity pneumonitis- acute


Diffuse air space opacities

Pattern and distribution similar to acute pulmonary oedema

Hypersensitivity Pneumonitis- acute

Hypersensitivity Pneumonitis- acute

Uncommon to perform CT in this group Diffuse ground glass opacities Consolidation

Hypersensitivity Pneumonitis- subacute


Hazy areas of increased opacity Ill defined nodules Diffuse or lower zones

Hypersensitivity Pneumonitis- subacute

Hypersensitivity Pneumonitis- subacute

Hypersensitivity Pneumonitis- subacute


Poorly defined centrilobular nodules Diffuse or patchy ground glass opacities + lobules of decreased attenuation Mid and lower lung zones

Hypersensitivity Pneumonitis- subacute

Inspiratory

Expiratory

Air trapping on Expiratory views in hyperlucent lobules

Hypersensitivity pneumonitis- chronic


Reticular pattern Honeycomb Volume loss +/- features of subacute Fibrosis may be severe in all zones

Hypersensitivity pneumonitis- chronic

Hypersensitivity pneumonitis- chronic


Fibrosis Architectural distortion Traction bronchiectasis Honeycomb lung Pattern can be peribronchovascular, patchy or random When peripheral difficult to differentiate from IPF

Hypersensitivity pneumonitis- chronic


Distribution and severity vary in zonal predominance Seldom basal lung predominance Superimposed findings of subacute disease Lymph node enlargement is common

Drug Reaction
Respiratory complications are common up to 7.7% of all adverse drug reactions in the US More than 350 medications and drugs may result in adverse pulmonary reactions Nonspecific clinical, radiologic and histologic manifestations and mimic those of acute and chronic lung diseases

Drug Reaction
They include
Diffuse Alveolar Damage Diffuse Alveolar Haemorrhage NSIP Organising pneumonia Hypersensitivity Pneumonitis Eosinophilic pneumonia UIP,LIP, DIP, Giant Cell Interstitial Pneumonia

More characteristic is the high density accumulation of Amiodarone in Lung and liver Should be considered in interstitial lung disease that does not have a characteristic constellation of signs and shows asymmetry

Drug Reaction: COP secondary to Nitrofurantoin

Drug Reaction: Amiodarone accumulation

Conclusions
Highlighted the main constellation of radiological signs associated with interstitial lung disease commonly seen

Although not pathognomonic some radiological signs may help narrow the differential diagnosis

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