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PHYSICIANS’ MEET09.04.2009
Prof. S.SUNDAR’s unit
AN INTERESTING C.T.
Dr.N. Arun Kumar
Prof. S.SUNDAR’s unit
• Dhanushkodi, an 84 year old male Pt. got admitted in urology department as a case of BPH.
• h/o breathlessness on exertion +• vitals normal• ECG- WNL• ECHO- Normal Study• CXR- reticulo nodular pattern involving lower
zones of both the lungs•
HRCT FEATURES
LUNG PARENCHYMA- • bilateral diffuse interlobular septal thickening with
ground-glass opacities. • Honeycomb changes in both the lung fields.
IMPRESSION
INTERSTITIAL LUNG DISEASE- ? Idiopathic Pulmonary Fibrosis
INTERSTITIAL LUNG DISEASE Exertional dyspnoea Persistent, non productive cough Hemoptysis, wheezing, chest pain Involvement of parenchyma of the lung alveoli alveolar epithelium capillary endothelium perivascular tissues lymphatic tissues
CHEST ROENTGENOGRAPHIC FINDINGS
Bibasilar reticular pattern Nodular/mixed pattern of alveolar fillings &
increased reticular markings Nodular opacities with predilection of upper lung
zones sarcoidosis PLCH Chronic Hypersensitivity Pneumonitis silicosis berylliosis RA Ankylosing Spondylitis
Contd…
Basal reticular opacities –often visible on CXR even several years before the development of symptomsCXR correlates poorly with clinical/HP stage of the disease CXR finding of honeycombing- pathologic findings of cystic spaces & progressive fibrosis (poor prognosis) CXR is nonspecific
COMPUTED TOMOGRAPHY
HRCT is superior to CXR Better assessment of the extent & distribution of
the disease useful in patients with normal CXR Co-existing disease- best recognized by HRCT –
mediastinal adenopathy, carcinoma, emphysema HRCT- to preclude the need of lung biopsy in IPF,
sarcoidosis, hypersensitivity pneumonitis, asbestosis, lymphangitic carcinoma, PLCH
Determination of the most appropriate area from which biopsy samples should be taken
RESPIRATORY SYMPTOMS & SIGNS Dyspnoea In some patients with sarcoidosis extensive parenchymal silicosis lung ds.on CXR without PLCH significant dyspnoea Hs.Pneumonitis
Wheezing
clinically significant chest pain uncommon Hemoptysis
fatigue & weight loss
SYSTEMIC EXAMINATION OF RS
• Tachypnoea• Bi-basilar end inspiratory dry crackles• Crackles may present in the absence of CXR
findings• Scattered late inspiratory high-pitched rhonchi
(inspiratory squeaks) in bronchiolitis• In mid & late stages of disease- Pulm.HTN & Cor
Pulmonale• Cyanosis & clubbing- in advanced disease
ATYPICAL FINDINGS IN HRCT
• Extensive ground-glass abnormalities
• Nodular opacities
• Upper zone/Middle zone predominance
• Prominent hilar/mediastinal lymphadenopathy
DIFFERENTIAL DIAGNOSES• Connective Tissue Diseases (scleroderma, RA)• Asbestosis (parenchymal bands of fibrosis & pleural plaques)• Subacute/chronic hypersensitivity pneumonitis (lack the bibasilar
predominence seen in IPF)• Sarcoidosis• Desquamative Interstitial Pnemonitis extensive ground-
• Respiratory bronchiolitis glass opacity
• Hypersensitivity Pneumonitis without basal or
• Idiopathic BOOP peripheral
• Non-Specific Interstitial Pneumonitis (NSIP) predominence
Contd…
• Lymphangitic Carcinomatosis • Cardiogenic Pulmonary Edema reticular pattern• Alveolar Proteinosis• Miliary TB • PLCH nodular pattern• Respiratory Bronchiolitis• Cryptogenic Organizing Pneumonia• Lymphangiomyomatosis • Centrilobular Emphysema
THANK U