Gamal Rabie Agmy MD FCCP

Professor of Chest Diseases Assiut University

Types of Collapse

6-Compression Atelectasis

Flat waist Sign

This sign refers to flattening of the contours of the aortic knob and adjacent

main pulmonary artery

It is seen in severe collapse of the left lower lobe and is caused by leftward

displacement and rotation of the heart

Types of Collapse

6-Compression Atelectasis

Flat waist Sign

This sign refers to flattening of the contours of the aortic knob and adjacent

main pulmonary artery

It is seen in severe collapse of the left lower lobe and is caused by leftward

displacement and rotation of the heart

Flat waist Sign

This sign refers to flattening of the contours of the aortic knob and adjacent

main pulmonary artery

It is seen in severe collapse of the left lower lobe and is caused by leftward

displacement and rotation of the heart

Juxtaphrenic peak sign

The juxtaphrenic peak sign refers to the peaked or

tented appearance of a hemidiaphragm which can

occur in the setting of lobar collapse It is caused by

retraction of the lower end of diaphragm at an inferior

accessory fissure (most common) major fissure

or inferior pulmonary ligament It is commonly seen

in upper lobe collapse but may also be seen in middle

lobe collapse

Fallen Lung Sign

This sign refers to the appearance

of the collapsed lung occurring

with a fractured bronchus

The bronchial fracture results in

the lung to fall away from the

hilum either inferiorly and laterally

in an upright patient or posteriorly

as seen on CT in a supine patient

DD

Pneumothorax causes a lung to

collapse inward toward the hilum

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Comet Tail Sign

bullSeen on CT of the chest

bullConsists of curvilinear opacity extending

from subpleural mass toward hilum

bullProduced by the distortion vessels and

bronchi that lead to adjacent rounded

atelectasis

(posterioranterior) position Note

that the x-ray tube is 72 inches away

the supine AP (anteriorposterior)

position the x-ray tube is 40 inches

from the patient

Dee method for approximating the position o f the carina can

be used This involves defining the aortic arch and then drawing a line Inferomedially through the middle of the arch

at a 45 degree angle to t he midline

The Ideal position for endotracheal tubes is in the

mid trachea 5cm from the carina when the head is

neither flexed nor extended This allows for

movement of the tip with head movements The

minimal safe distance from the carina is 2cm

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Luftsichel Sign

bullGerman for sickle of air (luft air sichel

crescent)

bullParamediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

bullOccurs more commonly on the left than in

the right

Comet Tail Sign

bullSeen on CT of the chest

bullConsists of curvilinear opacity extending

from subpleural mass toward hilum

bullProduced by the distortion vessels and

bronchi that lead to adjacent rounded

atelectasis

(posterioranterior) position Note

that the x-ray tube is 72 inches away

the supine AP (anteriorposterior)

position the x-ray tube is 40 inches

from the patient

Dee method for approximating the position o f the carina can

be used This involves defining the aortic arch and then drawing a line Inferomedially through the middle of the arch

at a 45 degree angle to t he midline

The Ideal position for endotracheal tubes is in the

mid trachea 5cm from the carina when the head is

neither flexed nor extended This allows for

movement of the tip with head movements The

minimal safe distance from the carina is 2cm

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Comet Tail Sign

bullSeen on CT of the chest

bullConsists of curvilinear opacity extending

from subpleural mass toward hilum

bullProduced by the distortion vessels and

bronchi that lead to adjacent rounded

atelectasis

(posterioranterior) position Note

that the x-ray tube is 72 inches away

the supine AP (anteriorposterior)

position the x-ray tube is 40 inches

from the patient

Dee method for approximating the position o f the carina can

be used This involves defining the aortic arch and then drawing a line Inferomedially through the middle of the arch

at a 45 degree angle to t he midline

The Ideal position for endotracheal tubes is in the

mid trachea 5cm from the carina when the head is

neither flexed nor extended This allows for

movement of the tip with head movements The

minimal safe distance from the carina is 2cm

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

(posterioranterior) position Note

that the x-ray tube is 72 inches away

the supine AP (anteriorposterior)

position the x-ray tube is 40 inches

from the patient

Dee method for approximating the position o f the carina can

be used This involves defining the aortic arch and then drawing a line Inferomedially through the middle of the arch

at a 45 degree angle to t he midline

The Ideal position for endotracheal tubes is in the

mid trachea 5cm from the carina when the head is

neither flexed nor extended This allows for

movement of the tip with head movements The

minimal safe distance from the carina is 2cm

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Dee method for approximating the position o f the carina can

be used This involves defining the aortic arch and then drawing a line Inferomedially through the middle of the arch

at a 45 degree angle to t he midline

The Ideal position for endotracheal tubes is in the

mid trachea 5cm from the carina when the head is

neither flexed nor extended This allows for

movement of the tip with head movements The

minimal safe distance from the carina is 2cm

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

The Ideal position for endotracheal tubes is in the

mid trachea 5cm from the carina when the head is

neither flexed nor extended This allows for

movement of the tip with head movements The

minimal safe distance from the carina is 2cm

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Notice the increased lucency of the cardiophrenic sulci in this patient

with inferior anteromedial pneumothoraces A CT scan confirms the

diagnosis

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

a hyperlucent upper

quadrant with

visualization of the

superior surface of the

diaphragm and

visualization of the

inferiorvena cava

double-diaphragm

sign

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Antero lateral air may

increase the

radiolucency at the

costo phrenicsulcus

This is called the deep

sulcus sign

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Apicolateral

pneumothorax

(arrows) with right upper lobe collapse

(arrowheads)

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

shifting of the heart

border

the superior vena cava

and the inferior vena

cava

The shifting of these

structures can lead to

decreased venous return

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

bullMediastinal shifT is

usually

seen in a tension

pneumothorax

bullThe most reliable sign of

tension pneumothorax is

depression of a

hemidiaphragm

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Radiographic Signs of Pneumomediastinum

Subcutaneous emphysema

Thymic sail sign

Pneumoprecardium

Ring around the artery sign

Tubular artery sign

Double bronchial wall sign

Continuous diaphragm sign

Extrapleural sign

Air in the pulmonary ligament

Ginkgo leaf sign bull The ginkgo leaf sign is a chest plain radiography

appearance which is seen at extensive subcutaneous

emphysema of the chest wall Air outlines the fibers of

the pectoralis major muscle and creates a branching

pattern that resembles the branching pattern in the

veins of a ginkgo leaf

Nodular Patternitie

Secondary pulmonary lobular

anatomy

The terminal bronchiole in the center

divides into respiratory bronchioles with

acini that contain alveoli

Lymphatics and veins run within the

interlobular septa

Centrilobular area in blue (left)

and perilymphatic area in yellow

(right)

Nodular Pattern

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Secondary pulmonary lobular

anatomy

The terminal bronchiole in the center

divides into respiratory bronchioles with

acini that contain alveoli

Lymphatics and veins run within the

interlobular septa

Centrilobular area in blue (left)

and perilymphatic area in yellow

(right)

Nodular Pattern

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

The terminal bronchiole in the center

divides into respiratory bronchioles with

acini that contain alveoli

Lymphatics and veins run within the

interlobular septa

Centrilobular area in blue (left)

and perilymphatic area in yellow

(right)

Nodular Pattern

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Nodular Pattern

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Perilymphatic distribution

Centrilobular distribution

Random distribution

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

ARE NODULES IN CONTACT WITH PLEURA

NO

CENTRILOBULAR

YES

PERILYMPHATIC RANDOM

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Size Distribution Appearance

Nodules and Nodular Opacities

Size

Small Nodules lt10 mm Miliary - lt3 mm

Large Nodules gt10 mm Masses - gt3 cms

Appearance

Interstitial opacity

Well-defined homogenous

Soft-tissue density

Obscures the edges of vessels or adjacent structure

Air space

Ill-defined inhomogeneous

Less dense than adjacent vessel ndash GGO

small nodule is difficult to identify

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Interstitial

nodules Air space opacity

Miliary tuberculosis

sarcoidosis

in a lung transplant patient

with bronchopneumonia

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

RANDOM no consistent relationship to any structures

PERILYMPHATIC corresponds to distribution of lymphatics

CENTRILOBULAR related to centrilobular structures Distribution

75

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Disseminated histoplasmosis and nodular ILD

CT scan shows multiple bilateral round circumscribed

pulmonary nodules

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Notice the nodules along the fissures indicating a

perilymphatic distribution (red arrows)

The majority of nodules located along the bronchovascular

bundle (yellow arrow)

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Sarcoidosis

The majority of nodules located

along the bronchovascular bundle

(yellow arrow)

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

PERILYMPHATIC NODULES

Perilymphatic and Random distribution of

nodules seen in sarcoidosis

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Centrilobular distribution

Hypersensitivity pneumonitis

Respiratory bronchiolitis in

smokers

infectious airways diseases

(endobronchial spread of

tuberculosis or

nontuberculous

mycobacteria

bronchopneumonia)

Uncommon in

bronchioloalveolar

carcinoma pulmonary

edema vasculitis

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Random distribution

Small random nodules

are seen in

Hematogenous

metastases

Miliary tuberculosis

Miliary fungal infections

Sarcoidosis may mimick

this pattern when very

extensive

Langerhans cell

histiocytosis (early

nodular stage)

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Langerhans cell histiocytosis early nodular stage before the typical cysts appear

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Differential diagnosis of a nodular

pattern of interstitial lung disease

SHRIMP Sarcoidosis

Histiocytosis (Langerhan cell

histiocytosis)

Hypersensitivity pneumonitis

Rheumatoid nodules

Infection (mycobacterial fungal viral)

Metastases Miliary TB

Microlithiasis alveolar

Pneumoconioses (silicosis coal

workers berylliosis)

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Cystic Lung Lesions

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

DECREASED LUNG

ATTENUATION

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Lung Cysts

Pulmonary fibrosis (Honeycombing)

Lymphangiomyomatosis

Langerhanscell histiocytosis

Lymphocytic Interstitial Pneumonia (LIP)

Differential Diagnosis

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Rough Reticular Fine Reticular

Traction

Bronchiectasis

and

Interface

sign

Honey

combing

UIP UIP or NSIP

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Usual Interstitial Pneumonia UIP

HRCT Findings

Reticular opacities thickened intra- and

interlobular septa

Irregular interfaces

Honey combing and parenchymal distorsion

Ground glass opacities (never prominent)

Basal and subpleural predominance

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Basal and subpleural distribution

UIP

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Inconsistent with UIP pattern (any one of seven features

Possible UIP pattern (all three features)

UIP pattern (all four features)

bullUpper or mid lung

predominance subpleural basal

predominance

bullsubpleural basal

predominance

bullperibronchovascular

predominance reticular abnormality bullreticular abnormality

bullextensive ground glass

abnormality (extent gt reticular

abnormality)

bullhoneycombing with or

without traction

bronchiectasis

bullprofuse micronodules

(bilateral predominantly upper

lobes

Absence of features

listed as inconsistent

with UIP pattern

Absence of features

listed as inconsistent

with UIP pattern

bulldiscrete cysts (multiple

bilateral away from areas of

honeycombing)

bulldiffuse mosaic attenuationair

trapping (bilateral in three or

more lobes)

bullconsolidation in broncho-

pulmonary segment(s)lobe(s)

Radiological features of idiopathic pulmonary fibrosis 2011

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Lymphangioleiomyomatosis (LAM)

HRCT Morphology

Thin-walled cysts (2mm - 5cm)

Uniform in size rarely confluent

Homogeneous distribution

Chylous pleural effusion

Lymphadenopathy

in young women

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Lymphangioleiomyomatosis (LAM)

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Tuberous Sclerosis (young man)

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Langerhans Cell Histiocytosis

HRCT Findings

Small peribronchiolar nodules (1-5mm)

Thin-walled cysts (lt 1cm)

Bizarre and confluent

Ground glass opacities

Late signs irreversible parenchymal fibrosis Honey comb lung septal thickening

bronchiectasis

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

1 year later

Peribronchiolar Nodules Cavitating nodules and cysts

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Langerhans Cell Histiocytosis

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Langerhans Cell Histiozytosis

Key Features

Upper lobe predominance

Combination of cysts and noduli

Characteristic stages

Increased Lung volume

Sparing of costophrenic angle

S

M

O

K

I

N

G

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Langerhans Cell Histiocytosis

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Langerhans Cell Histiocytosis

Differential Diagnosis

Only small nodules Sarkoidosis Silikosis

Only cysts idiopathic Fibrosis

LAM

Destruktive emphysema

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Benign lymphoproliferative

disorder Diffuse interstitial infiltration of

mononuclear cells

Not limited to the air ways as

in follicular Bronchiolitis

LIP

= Lymphocytic Interstitial Pneumonia

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Sjoumlgren LIP

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

LIP

= Lymphocytic Interstitial Pneumonia

Rarely idiopathic

In association with Sjoumlgrenrsquos syndrome

Immune deficiency syndromes AIDS

Primary biliary cirrhosis

Multicentric Castlemeanrsquos disease

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Sjoegren disease

Dry eye and dry mouth

Fibrosis bronchitis and bronchiolitis

LIP

Overlap

Sarcoid DMPM MXCT

SLE RA (pleural effusion)

Up to 40 x increased risk for lymphoma (mediastinal

adenopathy) and

2 x times increased risk for neoplasma

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Young woman Dry mouth Smoker

LAM LIP Histiocytosis

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Wegenerlsquos disease

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Rheumatoid Arthritis

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Honeycombing

HRCT showing

subpleural

broncheolectasis

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Honeycombing and traction bronchiectasis in UIP

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Typical UIP with honeycombing and traction

bronchiectasis in a patient with idiopathic

pulmonary fibrosis (IPF)

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Distribution within the lung

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular Pattern

Gamal Rabie Agmy MD FCCP

Professor of chest Diseases

Assiut university

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Linear Pattern A linear pattern is seen when there is

thickening of the interlobular septa

producing Kerley lines

Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics

The most common cause of interlobular

septal thickening producing Kerley A

and B lines is pulmonary edema as a

result of pulmonary venous

hypertension and distension of the

lymphatics Kerley B lines

Kerley A lines

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

DD of Kerly Lines

Pulmonary edema is the most common cause

Mitral stenosis

Lymphangitic carcinomatosis

Malignant lymphoma

Congenital lymphangiectasia

Idiopathic pulmonary fibrosis

Pneumoconiosis

Sarcoidosis

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

HRCT of the lung

Reticular pattern ndash HRCT

numerous clearly visible interlobular septa outlining lobules of characteristic size and shape

interlobular septal thickening

very fine network of lines within visible lobules

intralobular interstitial thickening

several layers of air-filled cysts 3-10 mm in diameter with thick walls (1-3 mm)

honeycombing

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

Interlobular septal thickening ndash dd

smooth thickening

pulm edema pulm hemorrhage lymphangitic carc lymphoma

nodular thickening

lymphangitic carc sarcoidosis amyloidosis

irregular thickening

fibrosis

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

Interlobular septal thickening ndash pulmonary edema

smooth septal thickening isolated or in combination with ground-glass opacity

peribronchovascular and subpleural interstitial th

perihilar and gravitational distribution bilateral findings of CHF

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

Interlobular septal th ndash lymphangitic carcinomatosis

smooth or nodular septal thickening smooth or nodular thickening of peribronchovascular

interstitium and fissures thickening of the intralobular axial interstitium

focal or asymmetric distribution

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticulation or not reticulation helliphellip

ldquocrazy pavingrdquo

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

Honeycombing ndash significance

air-containing cystic spaces having thick fibrous walls lined by bronchiolar epithelium

fibrosis is present

UIP is likely the histologic pattern

IPF is very likely in the absence of a known disease

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

Honeycombing ndash differential diagnosis

basal distribution

middleupper distribution

chronic HP sarcoidosis

IPF collagen vasc dis asbestosis drugs

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

interlobular septal thickening

irregular lung distorsion

nodular smooth

bull fibrosis (sarcoidosis asbestosis)

bull pulm edema bull linf carc bull hemorrhage

bull sarcoidosis bull linf carc

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Reticular pattern

adapted from Webb RW ndash HRCT of the lung III ed 2001

honeycombing

bull IPF (60) bull collagen vascular dis bull drug reaction bull asbestosis (uncommon)

subpleural posterior LL predominance

bull sarcoidosis bull chronic HP bull radiation

other distribution (UL parahilar)

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Head cheese sign

It refers to mixed

densities which includes

consolidation

ground glass

opacities

normal lung

Mosaic perfusion

bull Signifies mixed

infiltrative and

obstructive disease

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Head cheese sign

Common cause are

1 Hypersensitive pneumonitis

2 Sarcoidosis

3 DIP

127

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Headcheese sign

Headcheese sign in

hypersensitivity

pneumonitis

HRCT scan shows lung with

a geographic appearance

which represents a

combination of patchy or

lobular ground-glass opacity

(small arrows) and mosaic

perfusion (large arrows)

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Mosaic Patternitie

By

Gamal Rabie Agmy MD FCCP Professor of Chest Diseases Assiut University

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Mosiac pattern

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Where is the pathology

in the areas with increased density meaning there is ground glass

in the areas with decreased density meaning there is air trapping

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Pathology in black areas

Airtrapping Airway

Disease

Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic connective tissue diseases drug reaction

after transplantation after infection

Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall

Sarcoidosis granulomatous inflammation of bronchiolar wall

Asthma Bronchiectasis Airway diseases

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Bronchiolitis

obliterans

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Pathology in white Areas

Alveolitis Pneumonitis

Ground glass desquamative intertitial pneumoinia (DIP)

nonspecific interstitial pneumonia (NSIP)

organizing pneumonia

In expiration both areas (white and black) decrease in

volume and increase in density

DECREASE IN CONTRAST

DIFFERENCES

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

Mosaic Perfusion

Chronic pulmonary embolism

LOOK FOR

Pulmonary hypertension

idiopathic cardiac disease pulmonary

disease

CTEPH =

Chronic thrombembolic

pulmonary hypertension

CTEPH =

Chronic thrombembolic

pulmonary hypertension