CASES

1. CASES DR ASHISH R2 DEPT OF RADIODIAGNOSIS SSGH 11-12-08

2. CASE 1 • 42 / F  • Presented with dyspnea for 3 months • Peripheral eosinophil count is normal • No other complaints

3. Chest radiograph shows bilateral patchy ground glass opacities and large reticulations.

4. HR CT scans show diffuse ground glass opacities with mild bronchovascular bundle distorsion and interlobular septal thickenings. Consolidations are predominant in basal lung fields

5. Radiologic findings • Chest radiograph shows bilateral patchy ground glass opacities and large reticulations. • HR CT scans show diffuse ground glass opacities with mild bronchovascular bundle distorsion and interlobular septal thickenings. Consolidations are predominant in basal lung fields. Pathologic findings show multiple areas of chronic inflammation with fibrosis and fibroblastic proliferation, and aggregation of alveolar macrophages in the alveolar spaces.  

6. Differential Diagnosis of Ground Glass Opacities

7. INCREASED LUNG OPACITY • THE AIRBRONCHOGRAM CAN BE SEEN IN BOTH GGO & CONSOLIDATION. GROUND GLASS OPACITY CONSOLIDATION VESSELS ARE OBSCURED. VESSELS ARE SEEN THROUGH THE OPACITY.

8. GGO Vessels are Seen through The opacity.

9. consolidation Vessels are not seen through the opacity.

10. GGO can reflect the presence of either fibrosis or inflammation. • In some patient with ground glass opacity visible on HRCT, superimposition of a reticular pattern results in an appearance termed crazy – paving.

11. GGO may be seen in • Hypersensitivity pneumonitis • Acute interstitial pneumonia (ARDS) • Pulmonary edema • Pulmonary hemorrhage • Pneumonia ( pneumocystic carinii, viral, mycoplasma ) • Acute eosinophillic pneumonia • Usual interstitial pnumoina and idiopathic pulmonary fibrosis • Desquamative interstitial pneumonia • Respiratory bronchiolitis interstitial lung disease • Bronchilolitis obliterance organizing pneumonia • Chronic eosinophilic pneumonia • Chrug-strauss syndrome • Lipoid pneumonia • Alveolar proteinosis

12. Ground glass opacity Reticulation superimposed No reticulation Honeycombing findings Of fibrosis Interlobular septal thickening Active disease likely Fibrosis likely (95%) Honeycombing differential diagnosis Crazy paving differential diagnosis

13. No reticulation Active disease likely (80%) DDs of GGO extensive nodular Peripheral or patchy HP Pulmonary edema Hemorrhage ARDS Interstitial pneumonia ( NSIP, DIP) PAP HP BOOP Pulmonary edema Hemorrhage vasculitis Interstitial pneumonia (NSIP, DIP) HP PAP BOOP Eosinophilic pneumonia

14. In our case differential diagnosis are BOOP HP Interstitial pneumonia (NSIP, DIP) PAP Eosinophilic pneumonia

15. Hypersensivity pneumonitis • Also k/a Extrinsic allergic alveolitis, is an allergic lung disease caused by the inhalation of antigens contained in a veriety of organic dusts. For e.g. Farmer’s lung, bird breeder’s lung etc. • 3 stages : • acute, subacute and chronic

16. In ACUTE stage, the patient is symptomatic; & the CXR may be normal, or may show alv.eolar opacities. HRCT will not add any new information In SUBACUTE stage, HRCT reveals: * Bilateral patchy GGO, along with * Centrilobular nodules in the areas with GGO. * Focal areas of reduced lung attenuation. (note that we have both GGO & reduced attenuation, this gives the classic appearance of the head-cheese). * Air trapping on expiratory HRCT.

17. Lung window of thin-section (1.0-mm collimation) CT scan obtained at level of aortic arch shows poorly-defined micronodules in both lungs with centrilobular distribution. Also note background area of ground-glass opacity.

18. Pacemaker was placed for atrial fibrillation in left chest wall. Inspiratory high-resolution CT scans show areas of varying attenuation in both lungs, including ground-glass attenuation, normal lung, and areas of low attenuation due to mosaic perfusion (head-cheese sign). Ill-defined centrilobular nodules are also noted.

19. In CHRONIC stage, there will be fibrosis with relative sparing of the lung bases ( cf. IPF with predominant fibrosis involving the lung bases.) • The radiographic appearance of recurrent, transient GGO or ill-defined consolidation superimposed on a pattern of small nodules is typical and highly s/o HP.

20. Lung window of HRCT shows diffuse ground glass opacity, peribronchial, subfissural and peripheral consolidation, irregular and linear opacities with mild parenchymal distortion.

21. Changes of fibrosis with interlobular septal thickening with superimposed GGO

22. Desquamative interstitial pneumonia • DIP represent small airway and parenchymal reaction to cigarette smoke. • Common between 30 – 50 yrs of age group. • HRCT findings • Bilateral patchy ground glass opacity • Subpleural and basal predominance • Reticular opacities • Superimposition of first two findings * • Honeycombing ( uncommon ) • Associated centrilobular emphysema

23. b/l GGO with subpleural and basal Predominance. Reticular opacities Centrilobular emphysema

24. Nonspecific intersitial pneumonia • NSIP is characterized by inflammation and fibrosis involving predominantly the alveolar walls but lacking any specific features, so it is therefore a diagnosis of exclusion. • Age group: 9 – 78 yrs average age is 50 yrs HRCT findings: • Patcy ground glass opacity • Airspace consolidation • Irregular reticular opacities • Honeycoming (uncommon) • Peripheral and lower lung predominance*

25. 39 yr old woman with NSIP Intralobular and interlobular linear opacities and irregular interlobular septal thickening resulting in a fine b/l reticular pattern. Patchy GGO with traction bronchiatasis.

26. Alveolar proteinosis • PAP is a disease characterized by filling of the alveolar space with a periodic acid- schiff-positive proteinaceous material, rich in lipid. F:M – 4:1 Age group 30 – 50 yrs HRCT findings: • Bilateral GGO • Smooth septal thickening in abnormal areas • Superimposition of first two findings (crazy paving)* • Consolidation • Patchy or geographic distribution

27. HRCT scans show extensive air-space consolidation and ground glass attenuation. In addition, reticular pattern is apparent, presumably representing thickening of the interlobular septa, showing a typical crazy paving appearance.

28. Chronic eosinophilic pneumonia HRCT findings • Pacthy unilateral or bilateral airspace consolidation • Peripheral, middle and upper lung predominace* • Ground glass opacity with or without superimposed septal thickening ( crazy paving ) • Linear or band like subpleural opacities.

29. HRCT scans show patchy areas of consolidation in both lungs. Associated bullae in apex and small air cavities, most likely associated centrilobular emphysema, are also seen.

30. Churg- strauss syndrome • Diagnostic criteria • Patient with vasculitis who have • Asthma • Eosinophilia of geater than 10% of the WBC count • Neuropathy • Trasient pulmonary opacities • Sinus abnormalities and • Extravascular eosinophils on biopsy

31. HRCT findings • Consolidation or ground glass opacity which may have peripheral distribution or be patchy and geographic • Pulmonary nodules 0.5 to 3.5 cm in dia. Which may contain air bronchograms or cavitate • Centrilobular nodules • Bronchial wall thickening or bronchiectasis • Interlobular septal thickening due to edema

32. Thin-section CT scans show multifocal patchy consolidations and poorly defined nodules in subpleural region.    She had paranasal sinusitis. Histopathologic findings from skin, nerve, and soft palate biopsies were consistent with Churg-Strauss syndrome (necrotizing vasculitis with or without eosinophil infiltration). 

33. Bronchiolitis obliterans organzing pneumonias ( BOOP ) • Also k/a cryptogenic organizing pneumonia • BOOP is a disease characterized pathologically by the presence of granulation tissue polyps within the lumina of bronchioles and alveolar ducts and patchy areas of organizing pneumonia. • Most cases are idiopathic, but BOOP – like reaction may also be seen in patients who have pulmonary infection, drug reaction, collagen vascular disease, wegener’s granulomatosis and after toxic fume inhalation

34. Clinical features: several months h/o dry cough, LGF, malaise and shortness of breath. On PFT’s it shows restrictive pattern Clinically and functionally, the findings may be similar to IPF, although duration of symptoms in pt with BOOP is shorter, systemic symptoms are more common and finger clubbing is rarely seen. Patient usually respond well to steroids and have a good prognosis.

35. Radiographic findings: • Patchy, nonsegmental, U/L or B/L areas of airspace consolidation. • Small nodular opacities either alone or more commonly in association with areas of consolidation.

36. HRCT findings Patchy consolidation ( in 80%) or GGO ( in 60%), often with a subpleural and/or peribronchial distribution. Bronchial wall thickening or dilatation in abnormal lung regions Small, ill-defined nodules –often centrinodular (peribronchial or peribronchiolar) Large nodules or masses Lower lung zones predominance Crazy paving may be present.

37. In our case

38. CASE 2 • 60 yrs old male patient c/o neck pain since 6 months.

40. Lateral view of the neck shows one less vertebral bodies than spinous processes. There is complete destruction of C3 vertebral body. This represents an extreme case of vertebra plana.

41. The differntial diagnosis of the vertebra plana includes: • Metastasis • Multiple myeloma • Eosinophilic granuloma • Lymphoma • Trauma • Tuberculosis

42. There are no special features on this single radiograph that would help us to definitively pick out one special entity from among this differential.

45. AP and lateral radiographs of the left forearm and AP view of the right tibia and fibula, showing multiple lucent lesions and a pathologic fracture in the proximal fibula. • Knowledge of these additional images trims the differential diagnosis down considerably to essentially myeloma and metastatic disease. • The lesions here are also fairly discrete, with sharp margins. This appearance is common with myelomatous lesions, but is much less common with metastatic lesions. • Urine examination also shows Bence Jones protienuria.

46. Multiple myeloma is a primary malignancy of the plasma cells of the marrow. • Myeloma may present with many different signs and symptoms, which are usually due to the excessive proliferation of abnormal plasma cells. • In the skeleton, these accumulations of plasma cells may lead to resorption of trabeculae. This may lead to osteopenia, bone pain, kyphosis, height loss, and eventually pathologic fractures.

47. Total serum protein is usually increased, with an increase in the globulin fraction & leads to wide M band on plasma electrophoresis. • Urinary protein electrophoresis is also a helpful test, and may demonstrate abnormalities even when the serum electrophoretic pattern is normal. • Bence Jones proteinuria is present in 40 - 60 % of myeloma patients. Excretion of this protein may lead to damage of the renal tubules, resulting in Fanconi's syndrome and osteomalacia in some patients.

48. The axial skeleton is the usual site of involvement in myeloma, although the appendicular skeleton can certainly be involved. • Lesions are usually multiple (hence the name myltiple myeloma), although solitary lesions (plasmacytomas) are occasionally seen. • The typical pattern of osseous involvement with myeloma is that of widespread osteolytic lesions which appear fairly uniform in size.

49. Classic radiological features are: • Multiple well defined punched out lesions throughout the skeleton, often most characteristic in the skull. • Generalized osteopenia • Pathological fractures : many of the fractures are vertebral compression. Fracture of the long tubular bones heal readily with normal amount of callus.

50. The appearance of myeloma on radionuclide imaging is unpredictable. False negative lesions are common, and a large percentage of lesions positive on radionuclide exam are actually due to fractures or foci of amyloid deposition. • For this reason, radiography is felt to be a much more specific and valuable technique in the followup of myeloma patients.