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