ADR Radiographic Pearls in ILD

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Imaging of Interstitial LungDisease 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 Imaging13th November 2010


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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


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Conflict of Interest Disclosure

None


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Case 1

Ground glass

Lobular areas of lower

attenuation

Normal lungparenchyma

Normal lung volumes

No architectural

distortion

No nodules

No reticulation


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Case 1

Ground glass Lobular areas of lower

attenuation

Normal lung

parenchyma Normal lung volumes

No architectural

distortion

No nodules

No reticulation


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Case 2


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Case 2


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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


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Case 2

Upper, mid and lower zonal

distribution Mild heterogeneity of lung

parenchyma

Pattern of reticulation

extends to the pleura withno subpleural lung sparing

No nodules

No consolidation

Difficult to comment on lungvolumes on study providedscout suggest slight loss ofvolume


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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


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Discussion

Idiopathic Pulmonary Fibrosis /Usual InterstitialPneumonia (IPF/UIP)

Nonspecific Interstitial Pneumonia (NSIP)

Hypersensitivity Pneumonitis

Acute

Subacute

Chronic

Drug reaction


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Idiopathic Pulmonary Fibrosis IPF

Specific form of chronic fibrosing interstitialpneumonia limited to the lung and associated withthe histologic appearance of Usual InterstitialPneumonia (UIP)

Temporal and geographic heterogeneity

UIP can also be seen in Asbestosis

Chronic Hypersensitivity Pneumonitis

Drug induced disease

Familial IPF


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Usually symmetric

Basal predominant but may

be diffuse

Irregular

Linear

May progress to

reticulonodular pattern

Progress to volume loss

In smokers volumes can benormal


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Subpleural distribution

Lower lung zone

predominant

Architectural distortion

Irregular intralobular

lines

Traction bronchiectasis

Honey comb lung cysts

Air filled cysts


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Emphysema in 30%

Pulmonary ossification

Lymph node enlargement

No centrilobular orperibronchovascularnodules

No extensive

consolidation No extensive ground

glass opacities


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Main differential diagnosis

Fibrotic NSIP +/- relation to connective tissue

disease

Asbestosis

Chronic Hypersensitivity


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Nonspecific Interstitial Pneumonia

Chronic interstitial lung disease

Homogenous expansion of alveolar spaces because ofinflammation or fibrosis or both

More commonly associated with manifestation of

connective tissue disease,

hypersensitivity pneumonitis,

drug induced lung disease

interstitial lung disease complicating diffuse alveolardamage

Less commonly idiopathic


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Hazy opacities

mainly middle and

lower lung zones

+/- reticular opacities

Can be normal


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Bilateral symmetric

ground glass

opacities

Fine reticular

opacities

When only ground

glass opacitiescellular form most

likely


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Subpleural lung sparing

may be distinguishing

feature compared to

UIP

Honeycomb lung much

less common than UIP


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Subpleural lung sparing

may be distinguishing

feature compared to

UIP

Honeycomb lung much

less common than UIP


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Differential Diagnosis

Hypersensitivity pneumonitis

Cryptogenic organising pneumonia

IPF


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Immune mediated inflammatory form of diffuseinterstitial pulmonary disease caused by

inhalation of antigens

Can be seen in drug toxicity

Traditionally three different types of presentation

Acute Subacute

Chronic


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Hypersensitivity pneumonitis- acute


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Hypersensitivity Pneumonitis- acute

H iti it P iti t


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Hypersensitivity Pneumonitis- acute

Uncommon to perform CT in this group

Diffuse ground glass opacities

Consolidation


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Hypersensitivity Pneumonitis- subacute

Hazy areas of

increased opacity

Ill defined nodules

Diffuse or lower zones


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Poorly defined centrilobular nodules

Diffuse or patchy ground glass opacities + lobules of

decreased attenuation

Mid and lower lung zones


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Air trapping on Expiratory views in hyperlucentlobules

Inspiratory Expiratory


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Hypersensitivity pneumonitis- chronic

Reticular pattern

Honeycomb

Volume loss

+/- features of subacute

Fibrosis may be severein all zones


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Fibrosis

Architectural distortion

Traction bronchiectasis

Honeycomb lung Pattern can be

peribronchovascular,

patchy or random

When peripheral

difficult to differentiate

from IPF


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Distribution and

severity vary in zonal

predominance

Seldom basal lungpredominance

Superimposed findings

of subacute disease

Lymph nodeenlargement is

common


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Drug Reaction

Respiratory complications are common up to7.7% of all adverse drug reactions in the US

More than 350 medications and drugs mayresult in adverse pulmonary reactions

Nonspecific clinical, radiologic and histologicmanifestations and mimic those of acute andchronic lung diseases


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Drug Reaction

They include Diffuse Alveolar Damage Diffuse Alveolar Haemorrhage

NSIP

Organising pneumonia


Eosinophilic pneumonia UIP,LIP, DIP, Giant Cell Interstitial Pneumonia

More characteristic is the high density accumulationof Amiodarone in Lung and liver

Should be considered in interstitial lung disease thatdoes not have a characteristic constellation of signsand shows asymmetry


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Drug Reaction: COP secondary to Nitrofurantoin


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ADR Radiographic Pearls in ILD

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