Authors: Kinga Karlinger, Erika Márton
9.1. The Lung
9.1.4. Basic radiograph abnormalities
9.1.5.4. Lung parenchymal diseases
9.1.5.4. Lung parenchymal diseases
Chronic obstructive lung diseases
Symptoms include: recurrent cough, shortness of breath during physical activity, and recurrent bronchitis.
Chronic bronchitis
Bronchus walls thicken due to inflammation, bronchoalveolar spaces congest with mucus, and there is superinfection, alveolar wall damage, and development of emphysema.
Emphysema
Pathology: abnormal permanent airway enlargement of distal air spaces (from the terminal bronchioli towards the periphery), enlarged air content, and elongated, damaged walls resulting in capillary and precapillary destruction and increased lung volume.
Pathophysiology: air is trapped during expiration, causing the residual air to accumulate and the volume of the affected lung zones increase.
Forms of emphysema
Diffuse: chronic bronchitis without obstruction (essential) chronic bronchitis with obstruction
Partial: Bullous emphysema (progressive lung dystrophy) Ventillation emphysema
Radiograph signs of diffuse emphysema Barrel chest
Diaphragmatic depression, flattened or concave domes of the diaphragm Shallow respiration
Increased lung volume (hyperinflation)
Tapering of pulmonary vessels (air/blood quotient shifts + capillary destruction) Increased lucency of the lung
Dilatation of the central hilar pulmonary arteries developing in cases with pulmonary hypertension centroperipheral discrepancy
Small, vertically-oriented cardiac consolidation (due to diaphragmatic depression) Emphysema types according to the localisation (often referring to the origin) Centrilobular
Panlobular Paraseptal Bullous
Bullous emphysema (progressive lung dystrophy) has defined emphysematous bullae and, usually, diffuse emphysematic changes. Bullae have subtle walls and unstructured
air-containing abnormalities that can be observed nearby in particular areas, often on the margins or near the fissures.
89 10. Emphysema. Chest radiograph (PA): diaphragmatic depression with flat arches.
62 year old women suffering from COPD.
11: Centrilobular emphysema, CT image.
76 year old man, previous therapy because of metastatic rectum carcinoma. Bilateral extensive emphysematous bulla development, fibrotic shadows.
12. Bullous emphysema. CT axial image and coronal reformat.
59 year old man. RUL: 2-5 cm large subpleural bullae.
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13: Emphysema, bilateral chest radiograph
90 year old woman, hx of breast cancer, secondary pulmonary disease, TB therapy.
Bronchiectasis
Causes: congenital (e.g. bronchus wall faintness)
secondary impairments (inflammations, bronchostenosis)
Bronchiectasis causes and maintains a perifocal recurring pneumonia and lung fibrosis.
Primary symptom: listen for defined crackles not ending for cough Forms: cystic, cylindrical, and varicose
Localisation: often lower lobe dominance
Radiograph signs of bronchiecstasis: Summation pattern constisting of small, ring-shaped consolidations
HRCT indications: A signet-ring sign indicating a small caliber arterial branch next to a broad bronchus
14. Bronchiectasis. CT (axial image and coronal reformat) 70 year old man, RML long cylindrical bronchial dilatations.
91 9.1.5.5. Inflammatory diseases: pneumonias (lobar, broncho-, interstitial pneumonia)
Localisation: lobe, segment Pneumonia
Radiograph signs: Blurry consolidation (patchy opacities) in various forms and extensions.
Note that the radiograph is ―delayed‖, meaning consolidation appearance and disappearance is later, as anticipated based on the clinical signs. In general, the radiograph is not specific to the causative organism, except in the case of Staphylococcus.
- Bronchopulmonar (spreading along the bronchioli): no air bronchogram - Lobar (spreading from alveoli to alveoli): air bronchogram can be seen - Atypical (interstitium): linear opacities
Differential diagnosis: Similar consolidation may originate from lung infarction, tumor, TB, or lung edema. Clinical features and dynamic observations help in the diagnosis.
Types of pneumonia:
Primary: develops in the basically healthy lung; causative organisms: bacteria, Mycoplasma, or virus
Secondary: develops in the previously diseased lung fibrosis, bronchiectasis, azygos lobe, lung sequestration, bronchial stenosis /occlusion (aspiration, foreign body, bronchial tumor), cardiovascular diseases (eg. pulmonary congestion)
Perifocal: develops around a lung infarction or tumor
Secondary pneumonias are characterized by long-lasting disease course, and a likelyhood of recurrence (―superior cause‖). Aspiration pneumonia is patchy and multifocal, with right lower lobe dominance. In bronchial stenosis-associated forms, pneumonia may be
complicated by atelectasis, as indicated by sharper margins with increasing extension during its course.
Staphylococcus pneumonia: has a pathognomonic appearance of multiple, round nodules that are liable to assimilate. Localisation can be anywhere, but is typically solitary, rarely multiple.
Consolidation intensity depends only on the thickness in the beam direction. Consolidation structure is inhomogeneous-homogeneous-inhomogeneous, according to the phase of the disease course.
The edema fluid is closer to the lower border (gravitation); therefore the lobe border stands out (eg. the horizontal fissure in upper lobe pneumonia). The edema does not suddenly change its size nor does it change the volume of the concerned lobe. It does not result in hilar lymph node enlargement, but can be associated with slight pleural effusion.
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15. Atypical interstitial lobar pneumonia a.) CT b.) radiograph 45 year old man. He had a chill, serious cough, yellow-green tracheal excretion.
Left-sided lymphadenopathy next to the aortic arch on the left. Irregular infiltrations
(opacities) in the lung parenchyma in subpleural and LUL dominance. (by the contribution of Zsuzsanna Monostori, MD, PhD)
16. Right lobar pneumonia. a.) PA b.) lateral radiograph.
Mycoses
Increasing incidence since the adaptation of antibiotics and steroids.
Examples include actinomycosis, candidiasis, and aspergillosis.
Radiograph sign: pneumonia-like, small, blurry, multifocal or extent, homogeneous consolidation.
TB (tuberculosis)
(Only the radiological signs of lung TB forms are discussed here, not the disease itself) The primary TB complex usually develops unilaterally in the periphery of the middle lung zone. This primary nodule is a solitary, small blurry infiltration that is associated with a hilar lymphadenitis or lymph node enlargement demonstrated by the widening of the same side hilum. A peribronchial lymphangitis-associated reticular pattern can be observed inbetween the primary nodule and the lymphadenomegaly. The primary complex is susceptible to calcification. As a result, there may be extensive affection or enlargement of the hilar lymph node. Lobar or segmental bronchial stenosis may be caused by these lymphadenopathies, and associated with ventil atelectasis or emphysema.
93 Hematogenously spreading (lung) TB causes symmetrical, miliary dissemination indicated by small 1-2 mm nodules. These small nodules can only be distinguised by CT, because the summation effect superposes their consolidations on the radiograph. The pellets cumulate in the upper lobes may have a tendency to conflate, resulting in pleural effusion. Hilar
lymphadenopathy is not characteristic here. Hematogenous dissemination can be confined to certain lobes and these can calcify having a traction effect with focal scarring (sintering) causing local emphysema. Certain nodules, particularly Simon nodules in the lung apex, can progress and remain active. The Assmann-type early infiltration is located infraclavicularly.
The rapid course form of TB is Landouzy sepsis (sepsis tuberculosa acutissima) and is observed as various sizes of more or less slurred patches instead of nodules.
Lung phthisis can appear in very polymorphic and varied in images. The patterns are very unsteady, such that the radiographic picture can change from day-to-day. Images can be:
assymmetric with side-by-side localisation
cavernous (ring-shaped) with wall thickness depending on disease stage. May include air-fluid level and draining bronchus with thickened wall
cirrhotic/fibrotic parenchymal scarring, striated and blurry pattern, including traction emphysema, bronchiectasis, calcification
exsudative (blurry, confluating, blurred margin) or productive (sharp margin, fine or rough, blurry) nodular pathologies
17a, b: Apical TB. HRCT, coronal reconstruction
Right apex, segment 1: reticular pattern and mosaic-like ground glass opacity (similarly mind changes in b. 6th segment, too). Extensive TB-specific lesions in apical dominance.
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18a 18b
18. Tuberculosis a.) CT, b.) PA radiograph 45 year old man, pulmonary TB proven by microbiological culture.
LLL on CT: irregular, multicavitary nodular lesion: caverna.
(by the contribution of Zsuzsanna Monostori, MD, PhD)
19. Tuberculosis, bidirectional chest radiographs and HRCT. (coronal reconstruction)
75 year old man: hx of hypertension, smoking. Symptoms: dyspnea, productive cough. Moist rales of auscultatory findings above the LLL, tension irritability in the level of lower dorsal spine.
a.) Chest radiograph, bilateral: Mild increased vascular markings. Extensive patchy lobar infiltration in the RUL Previous TB specific lesions in the left apex. The diaphragm contour is blurry on the right side (appr. 4 finger-wide pleural effusion). Cardiomegaly. Medium large dilated sclerotic aorta.
b.) HRCT: Reticular pattern of 10x10x5 cm area in the right apex (1st segment), (septal thickenings), mosaic-like ground glass opacity in the righ apex. Subpleural total atelectasis (mainly 1st segment): irregular mainly nodular soft tissue streak associated with the pleura (max. appr. 1 cm thickness). Some tiny subpleural emphysematous bullae in the right apex.
95 9.1.6. Tumors