imaging in interstitial lung disease , Ayder hospital ,Mekelle

1. INTERSTITIAL LUNG DISEASES
by Dr. Henock.N, Radiology resident
AYDER HOSPITAL

2. a. Reticular Interstitial Pattern
b. Ground Glass Pattern
c. Nodular Pattern
d. Cystic Pattern
e. Mosaic Pattern

3. Reticular pattern
• Linear shadows (multiple lines) appearing as mesh or net
• Can appear as
 Per bronchial cuffing
 Septal thickening
 Traction bronchiectasis
 Honey comping

5. Ethiology
 Idiopatic interstitial pneumonia
• UIP COP
• NSIP RB-ILD
• DIP LIP
 IPE
 + Adenopathy
• Sarcoidosis
• Lymphangitic carcinomatosis

6. UIP
Reticular opacities ( mainly basal )
Traction bronchiectasis
Honeycombing ; peripheral and sub pleural, many layers

7. uip

8.  NSIP
Reticular opacity; symmetric
Ground glass opacity
Scattered micro nodules
Advanced; - traction bronchiectasis
- consolidation
-microcytic

9. nsip

10.  COP
consolidation and ground glass opacity
- Per bronchial or peripheral
- Lower lobe predominance
N.B; sub pleural is usually spared

11. cop

12.  RB-ILD & DIP
 smoking related
 Ground glass opacities + centrilobular nodules
Upper lobe predominant- RB-ILD
Lower lobe predominant- DIP

13. RB-ILD

14. • LIP
 Usually associated with hiv and sjogren syndrome
 Ground glass opacity + perivascular cysts

15. LIP

16. With adenopathy
 SARCOIDOSIS
 laps
 Reticulonodular opacities
 Predominantly upper and middle lobes

17. sarcoidosis

18.  lymphangitic carcinomatosis
 laps
 Irregular interlobular septal thickening
 Pleural effusion

19. LC

20.  Nodular pattern
• Multiple rounded opacities 1-10 mm(miliary = 1-2 mm)
• In most cases small nodules can be placed into one of three
categories(PCR):
– Randomly distributed
– Centrilobular distribution
– Perilymphatic distribution

21.  Random distribution
 Centrilobular distribution:
 Perilymphatic distribution

23. • Causes of miliary
pulmonary nodules
– Miliary TB
– Fungal Infection
– Miliary metastases
– Pneumoconiosis
– Wegner’s Granulomatosis
– Pulmonary Alveolar
Microlithiasis

24.  Miliary PTB
Soft pulmonary micronodules(uniform in size &
distribution, 1-3mm) scattered through out both
lung fields with no calcification

27. • Fungal miliary pulmonary micronodular pattern
– Endemic human mycoses(in certain geographic areas)
• Histoplasmosis
• Coccidioidomycosis
• Blastomycosis
– Opportunistic mycoses(worldwide in distribution)
• Invasive aspergillosis
• Cryptococosis
• Candidiasis
• Mucormycosis

28. Hypersensitivity pneumonitis
• Immunologic response
• Can be normal
• Acute; consolidation
• Subacute; centrilobular ill defined nodules surrounded by
areas of ground glass attenuation

30. • Metastatic miliary pulmonary micronodular pattern
– Thyroid carcinoma
– Renal cell carcinoma
– Breast carcinoma
– Malignant melanoma
– Pancreatic neoplasms
– Osteosarcoma
– Trophoblastic disease

32. • Miliary pneumoconiosis
– Inhalation of inorganic dust particles that overwhelm the
normal clearance mechanism of the respiratory tract
• Silica - Silicosis
• Coal workers' pneumoconiosis(CWP)
Simple; Nodules
Complicated; Progressive Massive Fibrosis

33.  Nodules:
• Dense multiple nodules
sparing the base
• Calcification may occur

35. complicated
 Progressive Massive Fibrosis:
• Nodules enlarge and coalesce to form two big masses on
either side of the lungs
• Bilateral areas of confluent fibrosis; almost symmetrical,
almost always in the upper half of the lung – almost
pathognomonic
• Egg shell calcification of lymph nodes

39. • Wegner’s granulomatosis
– Necrotizing autoimmune disorder
– Lung, sinonasal , renal
– multiple nodules with cavitation(common)

41. Pulmonary Alveolar Microlithiasis:
• idiopathic
• bilateral sand like calcification
• middle to lower zone predilection
• Black pleura sign; at their interface with the chest wall

43. • Nearly uniform distribution of
typical fine, sandlike mottling in
the lungs
• The tangential shadow of the
pleura is displayed along the
lateral wall of the chest as a
dark lucent strip (arrows)

44.  Differential Diagnosis of multiple small(pin point)
micronodules:
Silicosis
Stannosis (inhalation of tin oxide)
Barytosis (inhalation of barytes)
Limestone & marble workers
Alveolar microlithiasis

45. Cystic pattern
– Radiolucent areas with a wall thickness of less than 4mm
– Multiple thin walled air containing lesions 1cm or
more(not seen by x-rays except for bronchiectasis)

48. • Causes may be are:
– Lymphangioleiomyomatosis(LAM)
– Langerhan’s Cell Histiocytosis(LCH)
– Emphysema
– Cystic Bronchiectasis

49.  LAM
It almost exclusively affects women of child bearing age
– Numerous cystic spaces – 90%
– Size of cysts usually 5 to 10mm
– Thin walled
– Surrounded by normal lung
– Recurrent pneumothorax – 70%
– Chylous pleural effusions – 25%
– Proliferation of smooth muscles in the walls of alveoli, bronchi,
vessels and pleural causing air trapping

51.  LCH
– Granulomatous disease
– Eosinophilic granuloma of lung
– Smoking
– Extrapulmonary; lytic rib or vertebral lesions

52. • Radiographic features:
– Small irregular cystic spaces in lung parenchyma (spares the lower
lung zones)
– 3 to 10 mm pulmonary nodules
– Pneumothorax – 30%

54. • Emphysema
– Centrilobular
– Paraseptal
– Panlobular
– Bullous

57. Cystic Bronchiectasis:
• Cystic structures continuous with the bronchial tree –
cysts along the distribution of the bronchi
• More in the lower lobes
• Peripheral cysts

60. Mosaic pattern
• Used to describe density differences between affected
and unaffected lung areas, there are patchy areas of
black and white lung
• It is a non-specific finding
• Causes may be are:
Obstructive Small Airway Disease
Occlusive Vascular Diseases
Parenchymal( infiltrating) Disease

61.  Obstructive Small Airway Disease:
• Low attenuation regions are abnormal and reflect decreased
perfusion of the poorly ventilated regions
Eg. Bronchiectasis, cystic fibrosis, constrictive bronchiolitis
 Occlusive Vascular Disease:
• Can be termed a mosaic perfusion pattern in this setting, low
attenuation regions are abnormal and reflect relative oligemia
Eg. Chronic pulmonary embolism
 Parenchymal Disease:
• High attenuation regions are abnormal and represent ground-
glass opacity

64. References
 Fundamentals of diagnostic radiology, 4th edition
 Thoracic imaging, pulmonary & cardiovascular radiology;
 Chest radiology, the essentials, 2nd edition
 Classification of diffuse lung diseases , Radiographics 2013
 HRCT diffuse cystic and mosaic pattern, AJR 2013