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 Chronic eosinophilic pneumonia is an idiopathic condition characterized by extensive filling of alveoli by an infiltrate consisting primarily of eosinophils. Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for PE. On the left a patient with random nodules as a result of miliary TB. Organizing pneumonia (OP) This year marks the 50th anniversary of its initial description by the eminent pathologists Rosen, Castleman, and Liebow (,2). Radiography. Because pulmonary edema requires prompt treatment, you'll initially be diagnosed on the basis of your symptoms and a physical exam, electrocardiogram and chest X-ray.Once your condition is more stable, your doctor will ask about your medical history, especially whether you have ever had cardiovascular or lung disease.Tests that may be done to diagnose pulmonary edema or to determine why you develope… This combination of findings is called 'crazy paving'. So uncommon diseases like Sarcoidosis, Hypersensitivity pneumonitis, Langerhans cell histiocytosis, Lymphangitic carcinomatosis, Usual Interstitial Pneumonitis (UIP) and many others become regular HRCT diagnoses and can be real Aunt Minnies. The HRCT shows focal bronchiectasis with extensive mucoid impaction, which is in the appropriate clinical setting (asthma and serum eosinophilia) typical for Allergic bronchopulmonary aspergillosis (ABPA). UIP with lung fibrosis is also a common pattern of auto-immune disease and drug-related lung injury. It is usually the site of diseases, that are located in the lymphatics of in the interlobular septa ( i.e. When you think of the causes of consolidation, think of 'what is replacing the air in the alveoli'? Re-expansion pulmonary edema can mimic other … Hypersensitivity pneumonitis: centrilobular nodules, notice sparing of the area next to pleura and fissure. Honeycomb cysts often predominate in the peripheral and subpleural lung regions regardless of their cause. These findings are typical for Usual Interstitial Pneumonia (UIP). This type of pulmonary edema is preventable by gradual expansion of the lung collapsed by pneumothorax. Unable to process the form. This case is one of the possible patterns of nonspecific interstitial pneumonia (NSIP). Normal lung appearing relatively dense adjacent to lung with air-trapping. The ground glass appearance is the result of hyperperfused lung adjacent to oligemic lung with reduced vessel caliber due to chronic thromboembolic disease. This patient presented with acute onset of dyspnea. Jeong YJ, Kim KI, Seo IJ et-al. Panlobular emphysema is diffuse and is most severe in the lower lobes. Endobronchial spread of infection: TB, MAC or any bacterial bronchopneumonia. Infectious airways diseases (endobronchial spread of tuberculosis or nontuberculous mycobacteria, bronchopneumonia), Uncommon in bronchioloalveolar carcinoma, pulmonary edema, vasculitis. Basic Interpretation Langerhans cell histiocytosis (LCH): multiple thick walled cysts; smoking history. In most cases small nodules can be placed into one of three categories: perilymphatic, centrilobular or random distribution. Alveolar edema manifests as ill-defined nodular opacities tending to confluence (see image with arrows). Australasian Radiology. Pulmonary edema is the abnormal accumulation of fluid in the extravascular compartments of the lung and may be classified as increased hydrostatic pressure edema seen in heart failure, permeability edema with diffuse alveolar damage as seen in acute respiratory distress syndrome, permeability edema … As in UIP (usual interstitial pneumonia) it mainly involves the dependent regions of the lower lobes, but NSIP lacks the extensive fibrosis with honeycombing. There are also additional findings, that support this diagnosis like mediastinal lymph nodes and a nodular lesion in the left lung, that probably represents a metastasis. Unilateral Pulmonary Edema—Differential Diagnosis. Lymphangiomyomatosis (LAM): regular cysts in woman of child-bearing age. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (3): 719-739. This is called the dark bronchussign HP usually presents in two forms either as ground glass in a mosaic distribution as in this case or as centrilobular nodules of ground glass density (acinar nodules). In addition there is traction bronchiectasis indicating the presence of fibrosis. Sometimes the term reticulonodular is used. The most peripheral nodules are centered 5-10mm from fissures or the pleural surface. Pulmonary Tuberculosis: Up-to- Date Imaging … This syndrome is unassociated with evidence of myocardial dysfunction and responds readily to diuretics and oxygen. Even fibrosis as in UIP, NSIP and long standing sarcoidosis can replace the air in the alveoli and cause consolidation. Pulmonary lymphangitic carcinomatosis (PLC) Honeycombing is defined by the presence of small cystic spaces with irregularly thickened walls composed of fibrous tissue. Unilateral pulmonary edema is unusual and some of its causes differ from those generally associated with the more common bilateral involvement. Nodular or irregular septal thickening occurs in lymphangitic spread of carcinoma or lymphoma; sarcoidosis and silicosis. Most patients die within 10 years of the onset of symptoms. The frontal chest radiograph is the key to diagnosis of acute pulmonary edema. There is no honeycombing or traction bronchiectasis, so we can rule out fibrosis. Perilymphatic area is the peripheral part of the secundary lobule. Nodules can usually be seen to involve the pleural surfaces and fissures, but lack the subpleural predominance often seen in patients with a perilymphatic distribution. Lymphangiomyomatosis occurs only in women, usually of child-bearing age, between 17 and 50 years. In severe panlobular emphysema, the characteristic appearance of extensive lung destruction and the associated paucity of vascular markings are easily distinguishable from normal lung parenchyma. The differentials include the following: LCH in the early phase is a nodular disease (figure). Unlike perilymphatic and random nodules, centrilobular nodules spare the pleural surfaces. The CO-RADS classification uses features of COVID-19 on chest CT to indicate the likelihood of COVID-19 pulmonary involvement based on CT imaging (ref Prokop et al). Cardiogenic pulmonary edema: incidental finding in HRCT, smooth septal thickening with basal predominance (Kerley B lines), ground-glass opacity with a gravitational and perihilar distribution, thickening of the peribronchovascular interstitium (peribronchial cuffing). Dependent edema caused by venous insufficiency is more likely to improve with elevation and worsen with dependency.5,14 Edema associated with decreased plasma oncotic pressure (e.g., malabsorption, liver failure, nephrotic syndrome) does not change with dependency. In its later stages, the granulomas are replaced by fibrosis and the formation of cysts. Hyperperfused lung adjacent to hypoperfused lung due to chronic thromboembolic disease. 1. Ray P, Arthaud M, Birolleau S, et al. The initial working diagnosis must be critically reviewed if … Knowledge of the lung anatomy is essential for understanding HRCT. 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). Radiographics. There are patchy areas of black and white lung. Many cases are idiopathic, but OP may also be seen in patients with pulmonary infection, drug reactions, collagen vascular disease, Wegener's granulomatosis and after toxic-fume inhalation. Corresponding Author. 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 Bronchiectasis Identical clinical, radiologic, and pathologic pulmonary changes are seen in about 1% of patients with tuberous sclerosis. Isolated diffuse ground-glass opacity in thoracic CT: causes and clinical presentations. When they are confluent, HRCT shows diffuse ground glass. The term mosaic attenuation is used to describe density differences between affected and non-affected lung areas. Typically also have enlarged left atrium and ventricle, venous congestion. 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. Many of the negative PE studies provide an alternative expla … There was no history of smoking and this was a 40 year old female. Sarcoidosis: nodules with perilymphatic distribution, along fissures, adenopathy. Pulmonary edema should be differentiated from other diseases presenting with dyspnea, orthopnea, cough. Yoon YK(1), Kim MJ(1), Yang KS(2), Ham SY(3). Sometimes these can be differentiated with an expiratory scan. Emphysema typically presents as areas of low attenuation without visible walls as a result of parenchymal destruction. Hypersensitivity pneumonitis usually presents with centrilobular nodules of ground glass density (acinar nodules). 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. Centrilobular area is the central part of the secundary lobule. As its use has increased, the number of studies positive for pulmonary embolism (PE) has decreased to less than 20%. We will discuss the following subjects: Secondary lobule We report a case of right upper lobe pulmonary edema caused by the acute onset of severe mitral regurgitation. Pulmonary edema occurs with the presence of increased blood capillary permeability of capillary pressure, lymphatic obstruction … Differential diagnosis: prior granulomatous disease, calcified … Although pulmonary edema has classically a bilateral and symmetric distribution, unilateral pulmonary edema is less common and may be confused easily with pneumonia. Austin JH, Müller NL, Friedman PJ et-al. Notice lymphadenopathy. The role of the radiologist is to determine which part is abnormal: the black or the white lung. Postoperative CT imaging of the thorax exhibited extensive, centrally accentuated consolidations with surrounding ground-glass opacity in all lung lobes, suggestive of pulmonary edema. There is a tendency for hydrostatic edema to show a perihilar and gravitational distribution. 6. It characteristically presents with the findings of central bronchiectasis, mucoid impaction and atelectasis. Two instances of unilateral pulmonary edema occurring as the result of rapid re-expansion of pneumothorax are described and illustrated. Unilateral Pulmonary Edema—Differential Diagnosis. If pleural nodules are visible, the pattern is either random (miliary) or perilymphatic. Diffuse Alveolar Hemorrhage Tan-Lucien H. Mohammed, MD, FCCP Key Facts Terminology Classifications based on immune status, immune complexes, histology, or presence of glomerulonephritis (pulmonary-renal syndrome) Imaging Findings CT patterns nonspecific; specific clinical diagnosis cannot be made … There is also a lower lobe predominance and widespread traction bronchiectasis. a spoken lecture given by Jud W. Gurney for www.chestx-ray, Santiago E. Rossi, MD et al Chest Radiology. There are two lymphatic systems: a central network, that runs along the bronchovascular bundle towards the centre of the lobule and a peripheral network, that is located within the interlobular septa and along the pleural linings. On the other hand, mild and even moderately severe panlobular emphysema can be very subtle and difficult to detect on HRCT(1). Familiarity with the causes of unilateral pulmonary edema … This combination of findings is typical for Langerhans cell histiocytosis. Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by abnormal intraalveolar accumulation of surfactant-like material (,1). If no cause can be identified it is called cryptogenic organizing pneumonia (COP). In those cases there are usually associated HRCT findings of fibrosis, such as traction bronchiectasis and honeycombing. This suggested a chronic disease. Method: This review discusses imaging techniques, diagnostic algorithms, imaging findings and endovascular treatment of acute thrombotic PE, and illustrates important differential … The secondary lobule is supplied by a small bronchiole or terminal bronchiole in the center, which is parallelled by the centrilobular artery. Radiographics. These include: Most diseases with a low attenuation pattern can be readily distinguished on the basis of HRCT findings. Author information: (1)Division of Infectious Diseases, Department of Internal Medicine. Bronchiectasis is defined as localized bronchial dilatation. Pulmonary edema is fluid accumulation in the tissue and air spaces of the lungs. 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). On the left another patient with ground glass pattern in a mosaic distribution. Pulmonary edema has variable manifestations. Radiology 2005; 237:395-400. It shows evidence of both interstitial and alveolar edema. Although the mechanism is poorly understood, these drugs may induce pulmonary edema in pregnant women, even though this effect has not been observed with the treatment of asthma in the nonpregnant state. fibrosis). This pulmonary effect has been … Farhad Azimi M.D. Pulmonary edema is one of the most commonly encountered pathologic processes in chest radiology. pulmonary edema. Identical findings can be seen in patients with lymphoma and in children with HIV infection, who develop Lymphocytic interstitial pneumonitis (LIP), a rare benign infiltrative lymphocytic disease. Hilar lymphadenopathy is visible in 50% and usually there is a history of malignancy. Computed tomography manifestations of type I pulmonary edema mainly include local or multiple GGOs, patchy high-attenuation patterns, and large patchy high-attenuation patterns in both lungs, which typically exhibit the high-attenuation butterfly sign with both hila as the center, accompanied by signs of interstitial pulmonary edema … Sarcoidosis end-stage: consolidation as a result of massive fibrosis perihilar and in upper lobes. In lung carcinoma and lymphangitic carcinomatosis adenopathy is usually unilateral. Hansell DM, Bankier AA, MacMahon H et-al. Radiographics. Cardiogenic pulmonary edema generally results in a combination of septal thickening and ground-glass opacity. Paraseptal emphysema These nodules eventually cavitate and become cysts. Farhad Azimi M.D. 2. Pulmonary edema occurs with the presence of increased blood capillary permeability of capillary pressure, lymphatic obstruction … An upper lobe predominance in the size and number of cysts is common. Familiarity with the causes of ... Contralateral Pulmonary Edema Differential Diagnosis. Then there are two possibilities: obstructive bronchiolitis or chronic pulmonary embolism. Rupture of these cysts can result in pneumothorax. Are there additional findings HR-pattern: Look for the presence of pleural nodules. One pulmonary edema grading based on chest radiograph appearances and pulmonary capillary wedge pressure (PCWP) is as follows:. Radiographic and CT Features of Viral Pneumonia. Hypersensitivity pneumonitis (HP) is an allergic lung disease caused by the inhalation of antigens contained in a variety of organic dusts. iii. Predominantly lobar pulmonary edema is rarer still. 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. Fleischner Society: glossary of terms for thoracic imaging. Hypersensitivity pneumonitis usually presents with centrilobular nodules of ground glass density (acinar nodules). 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. FIGURE 70A FIGURE 70B FINDINGS Figure 70A: Posteroanterior (PA) plain film of the chest and coned-down view of the same image. focal or diffuse consolidation (30%) as in this case. 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. In addition, typical rapid progression of radiologic findings within 1-2 days, followed by the rapid resolution of the opacities within several days, could exclude the diagnosis of organizing pneumonia or other underlying lung diseases from the differential diagnosis. On the left a patient with ground glass pattern in a mosaic distribution. The majority of patients are young or middle-aged adults presenting with nonspecific symptoms of cough and dyspnea. Non specific interstitial pneumonitis (NSIP): ground glass with traction bronchiectasis, no honeycombing. It shows evidence of both interstitial and alveolar edema. It was first thought to be specific for alveolar proteinosis, but later was also seen in other diseases. However, cases have also been reported between 1,500–2,500 metres or 4,900–8,200 feet in more … Check for errors and try again. On the left another case of UIP. In the reticular pattern there are too many lines, either as a result of thickening of the interlobular septa or as a result of fibrosis as in honeycombing. On the left we see consolidation and ground-glass opacity in a patient with persistent chest abnormalities and weight loss without signs of infection. Because pulmonary edema requires prompt treatment, you'll initially be diagnosed on the basis of your symptoms and a physical exam, electrocardiogram and chest X-ray.Once your condition is more stable, your doctor will ask about your medical history, especially whether you have ever had cardiovascular or lung disease.Tests that may be done to diagnose pulmonary edema or to determine why you develope… Unilateral pulmonary edema is a distinctly unusual clinical entity, often misdiagnosed initially as one of the more common causes of focal lung disease. This finding can allow honeycombing to be distinguished from paraseptal emphysema in which subpleural cysts usually occur in a single layer. TB: Tree-in-bud appearance in a patient with active TB. Hydrostatic versus increased Permeability Pulmonary Edema: Diagnosis based on Radiographic Criteria in Critically ill Patients. 27 (2): 391-408. The diagnosis based on this CT was cardiogenic pulmonary edema. Ground-glass opacity is nonspecific, but a highly significant finding since 60-80% of patients with ground-glass opacity on HRCT have an active and potentially treatable lung disease. LCH is an uncommon disease characterised by multiple irregular cysts in patients with nicotine abuse. On the left two cases with chronic consolidation. The final diagnosis was cryptogenic organizing pneumonia (COP). Cystic lung diseases as listed in the table on the left. ... 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 … In end stage sarcoidosis we will see fibrosis, which is also predominantly located in the upper lobes and perihilar. Previous Article Differential Diagnosis of Postpartum Pulmonary Edema. In 1958, Dr Rosen was Chief of Pulmonary and Mediastinal Pathology at the Armed Forces Institute of Pathology (AFIP), and the majority of patients in hi… Radiology. 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 3. The history was typical for hypersensitivity pneumonitis. On the left a case with multiple round and bizarre shaped cysts. The images show two cases with GGO, one without fibrosis and potentially treatable and the other with traction bronchiectasis indicating fibrosis. 4. It appears to represent a form of noncardiac pulmonary edema, possibly caused by drug-induced fluid retention superimposed on that normally occurring in the gravid state. Hilar and mediastinal lymphadenopathy It was described in earlier years as Bronchiolitis-obliterans-organizing pneumonia (BOOP). Increased lung attenuation is called ground-glass-opacity (GGO) if there is a hazy increase in lung opacity without obscuration of underlying vessels and is called consolidation if the increase in lung opacity obscures the vessels. . UIP or 'end-stage lung' is a pathology diagnosis and usually shown at lungbiopsy, when honeycombing is visible. In both ground glass and consolidation the increase in lung density is the result of replacement of air in the alveoli by fluid, cells or fibrosis. Nodular ground-glass opacity at thin-section CT: histologic correlation and evaluation of change at follow-up. Eosinophilic lung diseases: a clinical, radiologic, and pathologic overview. Honeycombing is the typical feature of usual interstitial pneumonia (UIP). Centrilobular distribution 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 . ... (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. diffuse ill-defined centrilobular nodules (30%) due to endobronchial spread. Listed in the areas of abnormally low attenuation in cryptogenic organizing pneumonia ( ). Pneumonia, when this is consistent with the findings of fibrosis lung due to 1! Critically ill patients are randomly distributed relative to structures of the clinical course and the interstitium! Interstitial disease and drug-related lung injury report a case with multiple cysts that are distributed... 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Usually associated HRCT findings will be eosinophilia interstitial pneumonias, edema, vasculitis next to and. Darker as the dominant pattern can also have enlarged left atrium and ventricle, venous congestion contrast to LCH is! Then there are patchy non-segmental consolidations in a patient with active TB also common Table 1 ) Ham...