High Resolution Computed Tomography of The Lungs - UpToDate

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www.uptodate.com2017UpToDate
Highresolutioncomputedtomographyofthelungs
Author: PaulStark,MD
SectionEditors: TalmadgeEKing,Jr,MD,NestorLMuller,MD,PhD
DeputyEditors: GeraldineFinlay,MD,SusannaILee,MD,PhD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jan2017.|Thistopiclastupdated:Jan29,2016.
INTRODUCTIONTheinitialimagingtoolforthelungparenchymaremainsthechestradiograph.Itisunsurpassedintheamountofinformationityieldsinrelationtoits
cost,radiationdose,availability,andeaseofperformance.However,thechestradiographhasitslimitations.Itisnormalin10to15percentofsymptomaticpatientswith
proveninfiltrativelungdisease,inupto30percentofthosewithbronchiectasis,andincloseto60percentofpatientswithemphysema[1].Inseveralstudies,thechest
radiographhasbeenshowntohaveanoverallsensitivityof80percentandaspecificityof82percentfordetectionofdiffuselungdisease[2].Chestradiographycould
provideaconfidentdiagnosisinonly23percentofcases,andthoseconfidentdiagnosesprovedcorrectonlyin77percentofcases.
Forthesereasons,highresolutioncomputedtomography(HRCT,alsocalledthinsectionCTscanning),isfrequentlyusedtohelpclarifyspecificproblems.Theclinical
applicationsofHRCTwillbereviewedhere.TheprinciplesofCTimagingarediscussedseparately.(See"Principlesofcomputedtomographyofthechest".)
CLINICALAPPLICATIONOFHRCTHRCT,whichhasasensitivityof95percentandaspecificityapproaching100percent[25],canoftenprovidemoreinformationthan
eitherchestradiographyorconventionalCTscanning.Aconfidentdiagnosisispossibleinroughlyonehalfofcases,andtheseareprovencorrectanestimated93percentof
thetime.
HRCTmaybeparticularlyusefulinthefollowingsettings:
Itcandetectlungdiseaseinsymptomaticpatientswithanormalchestradiograph.
Itcanprovideanaccurateassessmentofthepattern,distribution,andtoalesserdegree,assesstheactivityandpotentialreversibilityofdiffuselungdisease.
Itdemonstratesahighcorrelationbetweenradiographicandhistopathologicappearances.
Inpatientswithnondiagnosticfindingsonchestradiography,itcanprovideamorespecificdiagnosisorexcludecertaindiseases.
Itcanbeusedtodeterminethetypeandsiteoflungbiopsy.(See"Roleoflungbiopsyinthediagnosisofinterstitiallungdisease".)
Itcanbeusedtodetectorevaluatespecificproblemsordiagnoses,suchasmetastaticlesions,solitarypulmonarynodules,emphysema,bullouslungdisease,
bronchiectasis,anddiffuseparenchymaldisease.
ConventionalhelicalCTscanningisthepreferredmethodforthedetectionandevaluationofmediastinaldisease,ratherthanHRCT(see"Approachtotheadultpatientwitha
mediastinalmass").Multislice,multidetectorrowCTscanningemploysroutinelythinsectionsof1to1.25mmandhighspatialfrequencyalgorithmwhichprovides"high
resolution"inthevastmajorityofthoracicCTscans.
ResolutionThetechnicalfeaturesofHRCTincludeathincollimationof1to1.25mmandtheuseofahighspatialfrequency(bone)algorithm.Theinplanespatial
resolutionofmodernCTscannerscanreach0.25mm.Thus,interlobarfissures,whichare0.15mminthickness,canfrequentlybeimaged(image1).Thepatternof
scanningvarieswiththesuspecteddiagnosis.Scanningshouldoccurat1cmintervalsfordiffuselungdiseasebutshouldbelimitedtotheinvolvedareaforfocallung
processesandsolitarypulmonarynodules.Inposterobasallungdisease,pronescanningcaneliminategravitationalchangesordependentatelectasisthatcanmimiclung
disease(image2).Pronescansareusefulinpatientswithsubtleabnormalitiesorwithnormalchestradiographs.Withcurrentmultislice,multidetectorrowhelicalCT
scanners,acompletevolumetric,helicaldatasetwithoutgapsiscommonlyobtainedwith1to1.25mmreconstructedsectionthickness.
NormalanatomyThebasiclungunitthatisregularlyvisibleonHRCTisthesecondarypulmonarylobule,whichissurroundedbyinterlobularsepta.Thediameterofthe
secondarypulmonarylobulevariesfrom1to2.5cm.Itisformedbyacongregationofthreetofiveaciniandhasapolyhedralshape.Itcontainscorestructuresformedby
pulmonaryarteriole,bronchioleandperibronchiolarlymphatics,adjacentlungparenchyma,andseptalstructureswhichcancontainlymphaticstructuresaswell.Anacinus
encompassesthelungunitdistaltoaterminalbronchioleandcontainsanaverageof400alveoli.Ithasadiameterof5to10mmandcanoccasionallybeseenonthin
sections.Centrilobulararterialbranchesareimportantforlocalizationofpathologicalprocessesandarelocated5to10mmfromthepleura.
HRCTPATTERNSThediagnosticapproachforhighresolutioncomputedtomography(HRCT)reliesuponthepredominantpatternofabnormalities,onthezonal
distributionofdisease,onassociatedfindingssuchaspleuralplaques,calcifications,thickening,effusions,lymphnodeenlargement,andtheclinicalhistory.Criteriaof
importanceincludethechronicityofthediseaseprocessandthepatient'simmunestatus.
ThebasicHRCTpatternsareareflectionofalterednormalanatomy,includingterminalandrespiratorybronchioles,alveolarducts,alveolarsacs,pulmonaryarterioles,
lymphatics,andthelooseinterstitialconnectivetissuenetwork.Thepatternsincludereticularandnodularstructures,increasedopacity(groundglassandairspacefillingor
consolidation),anddecreasedopacity,includingcysticlesions,mosaicattenuation,andgastrapping.Accompanyinglesionsincludelinearopacities,parenchymalbandsand
architecturaldistortion.
ReticularpatternTheinterstitialpulmonarynetworkisresponsibleforthereticularpattern.Itiscomposedoftheaxial(ie,bronchovascular)interstitium,theinterlobular
(ie,subpleuralandsubfissural)interstitium,andthealveolarseptal(ie,intralobular)interstitium.Thepulmonarylymphaticsfollowtheinterstitialnetwork.
Areticularpatterncanbeclassifiedaslarge(coarse),intermediate,orfine.Thelarge(coarse)reticularpattern(1cm)isduetothickeningofinterlobularseptaintermediate
reticularchangescanbeseenwithhoneycombing,whichformstackedsubpleural,smallcysticspacesfinereticularchangesareseenwithalveolarseptal,intralobular
thickening.Irregularintersectinglinescanproducea"steelwool"pattern.
PerilobularpatternTheperilobularregionincludestheborderingstructuresofthesecondarypulmonarylobuleslikepleura,interlobularsepta,pulmonaryveins,
paraseptalinterstitium,paraseptalalveoli,andsubpleuralinterstitium.Thickeningofthesestructurescanproduceacoarsereticularpatternwithpolygonalandarcadelike
opacities.Thepatternhasbeendescribedinuptohalfofpatientswithorganizingpneumonia[6].
NodularpatternNodularpatternsincludeairspacelesionswithfuzzyborders,andinterstitialnoduleswithsharp,unsharp,orstellatemargination.
Sharpinterstitialnodulescanbeseenwith[7]:
Langerhanscellhistiocytosis
Silicosis
Metastaticdisease
Miliarytuberculosis
Disseminatedfungaldisease
Unsharpinterstitialnodulesarefoundin[7]:
Sarcoidosis
Subacutephaseofhypersensitivitypneumonia
Stellateinterstitialnoduleshavebeendescribedin[8]:
Langerhanscellhistiocytosis(socalledstarfishnodules)
Nodulescanbefurtherclassifiedaccordingtotheirdistributionas:
Perilymphatic,
Random,hematogenous,orperivascular
Centrilobular
Airspace
PerilymphaticnodulesPerilymphaticnodulesaresubpleuralinlocation,andarealsofoundalonginterlobularsepta,interlobarfissures,andalongbronchovascular
bundles.Thesenodulestendtobenonuniformandpatchyindistribution,andhaveatendencytocluster.Theyaremostfrequentlyfoundinsarcoidosis,lymphangitic
carcinomatosis,andsilicosis.Whentheclusteringoccursinasubpleurallocation,pseudoplaquescanform.
Random,hematogenous,orperivascularnodulesRandomorperivascularnoduleshaveasimilarsubpleuraldistribution,butshowauniformanddiffuse
distribution.Theydonotcluster.Theyaretheresultofhematogenousdisseminationandarecharacteristicallyfoundinmiliarytuberculosis,miliaryfungaldisease,septic
embolization,andmetastaticspreadoftumor(image3AB).Theymayhaveabasalpredominancewithcentrilobularandsubpleurallocation,aswellasproximitytotheir
feedingvessels.
CentrilobularnodulesCentrilobularnodulessparethesubpleuralregionandthelungunderlyingtheinterlobarfissurestheyarefound5to10mmremovedfromthe
pleuralsurfaces.Theyhaveadiffuseorpatchydistribution,andtendtosurroundsmallvessels.Theyarefoundinhypersensitivitypneumonia,sarcoidosis,Langerhanscell
histiocytosis,andrespiratory,follicular,andcellularbronchiolitis(image4).Centrilobularnodulesaredescribedinrarecasesofdiffuseidiopathicneuroendocrinehyperplasia
(DIPNECH).
Anaccompanyingtreeinbudpatternisindicativeofinfectiousbronchiolitisoraspiration.Rarecausesofcentrilobularnoduleswithtreeinbudappearancearediffuse
panbronchiolitis,follicularbronchiolitis,vasculartumorspread(tumorembolization),andsocalledcelluloseortalcgranulomatosisinintravenousdrugabusers.
Centrilobulargroundglassnodulescanbeseeninrespiratorybronchiolitisofsmokers,follicularbronchiolitis,andhypersensitivitypneumonia(usuallyinnonsmokers).
AirspacenodulesAirspacenodulesarecentrilobularandcanalsoformthe"treeinbud"pattern,buttheyareslightlylargerthantypicalcentrilobularnodules.They
areseeninbronchogenicspreadoftuberculosis,aspiration,infectiousbronchiolitis,anddiffusepanbronchiolitis.Thepathologiccorrelateisanaccumulationofpus,mucus,
caseousmaterial,orinflammatoryinfiltrationofbronchiolarwalls.
GeneralapproachAnalgorithmicapproachtosmallnodulesonHRCTcanbeattemptedbyasking,"Dothenodulestouchtheparietalpleuraortheinterlobar
fissures?"
Ifyes,thenthenodulesarelikelytobeperilymphaticorhematogenous.Clusteringofthenodulessuggestssarcoidosis,silicosisorlymphangiticcarcinomatosis,thelatter
frequentlywiththickeningofinterlobularsepta.Nonclustered,diffusenodulesthatabutthepleuralortheinterlobarfissuresarelikelyrandom,hematogenousnodules,eg,
miliarytuberculosis,fungaldissemination,hematogenousmetastaticdisease,orsepticembolization.
Ifno,thenthepresenceorabsenceofatreeinbudpatternhastobedetermined:centrilobularnoduleswithouttreeinbudpatternarefoundinrespiratorybronchiolitis,
hypersensitivitypneumoniaandLangerhanscellhistiocytosis.Centrilobularnoduleswithtreeinbudpatternareprimarilyfoundwithinfectiousbronchiolitisand
aspirations.
IncreasedattenuationIncreasedattenuationoflungparenchymaonHRCTisgenerallyduetoinfectiousorinflammatoryprocesses.
GroundglassopacificationGroundglassopacificationreferstofocalordiffuseveillikeopacificationofthelung,whichdoesnotobscurethevascularstructuresor
therestoftheanatomicdetailsanddoesnotyieldairbronchograms(image5andimage6andimage7).Itindicatessubthresholdparenchymalabnormalitiesbelowthe
spatialresolutionofHRCT.Groundglassopacificationoccursinearlyinterstitiallungdisease(image8),withincomplete,earlyalveolarfilling,withincreasedpulmonary
capillarybloodvolume,andwithpartialcollapseofalveoli,particularlyonexpiratoryscansperformedclosetofunctionalresidualcapacityofthelungs[912].Claimsthatit
solelyrepresentsearly"alveolitis"haveproveninaccurate.Inapproximatelyonethirdofpatientswithinterstitiallungdisease,groundglassopacitycorrelateswithestablished
fibrosis.Insuchcases,accompanyingtractionbronchiectasescanusuallybedetected[13].
Inrareinstances,increasedlungattenuationmaybedifficulttodetectifitisdiffuse,homogeneous,andsubtle.Averyconspicuousdisplayofbronchi(ie,the"blackbronchus"
sign)isahelpfulfindingthatsuggestsdiffuse,subtleincreasedlungattenuation.
Subtleradiographicabnormalitiesmaybeaccompaniedbyamarkeddecreaseinthediffusioncapacityforcarbonmonoxide(DLCO)ofupto50percent,facilitatingtheir
recognition[12].Examplesofdiseasesthatmaypresentwithsubtleincreasedlungattenuationincludeearlyhypersensitivitypneumonia,Pneumocystisjirovecii(formerly
calledPneumocystiscarinii)pneumonia,cellularnonspecificinterstitialpneumonia,desquamativeinterstitialpneumonia,andsubacutediffusealveolardamage.Incontrast,
mostdiffuselungdiseasesthatpresentwithgroundglassopacificationarepatchy,withmultifocalvariabilityinattenuationthatisreadilydetectedonanexpiratoryscan.
Acutediseasesthatmanifestwithdiffusegroundglassopacitiesincludepulmonaryedema,pulmonaryhemorrhage(image9),Pneumocystisjiroveciipneumonia,
mycoplasmaandviralpneumonia,acuteinterstitialpneumonia(AIP),acuteeosinophiliclungdisease,andearlyhypersensitivitypneumonia[11].AmongHIVpositivepatients,
groundglassattenuationispresentin90percentofpatientswithPneumocysticjiroveciipneumoniaandabsentin95percentofpatientswhodonothavePneumocystic
jiroveciipneumonia.AmongimmunocompromisedpatientswithoutAIDS,groundglassopacitiesmayindicatePneumocysticjiroveciipneumonia,drugreactions,pulmonary
hemorrhage,orlymphoma.
Chronicpulmonarydisordersthatinducediffusegroundglassopacificationeitherastheonlyfindingorinconjunctionwithfibrosis,interlobularandintralobularseptal
thickening,ornodulesincludehypersensitivitypneumonia,desquamativeinterstitialpneumonia(DIP),respiratorybronchiolitisassociatedinterstitiallungdisease(RBILD),
nonspecificinterstitialpneumonia(NSIP),pulmonaryalveolarproteinosis,bronchioloalveolarcarcinomaalsocalledadenocarcinomainsitu,organizingpneumonia,and
sarcoidosis[11].
"CrazyPaving"referstogroundglassopacitieswithinterspersedthickenedinterlobularandintralobularsepta.Initiallydescribedinpulmonaryalveolarproteinosis,itcanalso
befoundinatypicalpneumonia,pulmonaryhemorrhage,diffusealveolardamage,andpseudoalveolarsarcoidosis[14,15].(See"Treatmentandprognosisofpulmonary
alveolarproteinosisinadults"and"Causes,clinicalmanifestations,anddiagnosisofpulmonaryalveolarproteinosisinadults".)
Groundglassopacitiesmaybefocal.Suchopacitiestypicallyrepresentfocalatelectasis,focalfibrosis,focalinflammation,atypicalalveolarhyperplasia,orbronchioloalveolar
carcinoma(ie,adenocarcinomainsitu)[12].Followupscansafterthreemonthsmayshowclearingifthefocalgroundglassopacityisinflammatoryinorigin.However,ifthe
focalgroundglassopacitypersistsandexceeds10mmindiameter,bronchioloalveolarcarcinoma(adenocarcinomainsitu)shouldbesuspected[12].Smaller,circumscribed,
persistentgroundglassopacitiesusuallyrepresentatypicalalveolarhyperplasia.Theygrowinonly10percentofcasesandonly1percentcanyieldasolidcomponentand
converttoaminimallyinvasiveadenocarcinoma.Thisconversiontakesatleast3.5years[16].
ConsolidationorairspacefillingConsolidationorairspacefillingcausesopacificationbut,incontrasttogroundglassattenuation,itresultsinobscurationofvascular
structuresaccompaniedbyairbronchograms(image10AB).Thesechangesareduetoreplacementofalveolargasbypus,edema,blood,surfactant,orcells.Inacute
cases,pneumonia,pulmonaryedema,diffusealveolardamage[17],andpulmonaryhemorrhageshouldbeconsidered.Inchroniccases,cryptogenicorganizingpneumonia,
eosinophilicpneumonia,andbronchioloalveolarcarcinoma(mucinousadenocarcinoma)arelikelypossibilities.
Inrarecases,aninterstitialprocesssuchassarcoidosiscanwidenthealveolarseptaandcompressthealveolibutsparethebronchi,thusmimickingairspacefillingdisease
(ie,pseudoalveolarsarcoidosis).
DecreasedattenuationDecreasedattenuationcanresultfromemphysema,cysticlungdisease,asthma,bronchiolitisobliteranswithhypoxicvasoconstriction,bronchial
obstructionwithgastrappingduetoacheckvalveobstruction,orpulmonaryhypoperfusionfromseverepulmonaryhypertension,particularlyifitisduetochronic
thromboembolicdisease(CTEPH).Ageneralizeddecreaseinattenuationisunusual,butmaybeseenwithincreasingageduetoanincreaseinthesizeofalveolifrom250
micrometersto500micrometersindiameter.Itmayalsobeseeninindividualswithpulmonaryarterialhypertensionorasystemicsclerosisrelatedpulmonaryvasculopathy,
likelyreflectingreducedcomplianceofthepulmonaryarterialtree[12].
MosaicattenuationRedistributionofbloodflowtowardsnormalpartsofthelungmayleadtoincreasedattenuationofuninvolvedparenchyma.Thispatternofvariable
regionalattenuationoflungparenchymaduetoregionaldifferencesinperfusionisknownasmosaicperfusionormosaicattenuationandleadstosharplydefined
heterogeneityoflungattenuation.Itcanresultfromregionalvariationsinperfusionduetovasculardisease,airwayabnormalitieswithhypoxicvasoconstriction[18],orareas
ofinfiltrativelungdiseasewithgroundglassattenuationinterspersedbetweenislandsofnormallung[19].Itcanbeseeninupto20percentofabnormalHRCTstudies
performedfordiffuseinfiltrativelungdisease.
Differentiationofincreasedattenuationduetofocalincreaseinbloodflowfromtruegroundglassattenuationcanbemadebyevaluatingthevesselsize:vesselsizeand
numberwillbeequalinareasofincreasedanddecreasedattenuationwhencausedbyinfiltrativelungdisease.Vesselsizeandnumberwillbedecreasedinregionsof
hypoattenuation,whendealingwithairwaysorvasculardisease.Expiratoryscanswillamplifytheareasofhypoxicvasoconstrictionandgastrappinginairwaysdiseasebut
willnotaffectregionsofhypoperfusionresultingfromvascularobstruction.Inaddition,bronchiolitisobliteransisfrequentlyassociatedwithbronchialwallthickening,
bronchiectasis,bronchiolectasis,andlobularlucencies,whereaschronicthromboembolicdiseaseandidiopathicpulmonaryarterialhypertensionareaccompaniedbydilation
ofthecentralpulmonaryarteriesandlarger,betterdefinedareasofhypoattenuation.Mosaicattenuationwillaccuratelydepict95percentofdiffuseinfiltrativediseasesand85
percentofsmallairwaysobstructionbutonly40percentofpatientswithchronicobstructionofpulmonaryarterialbranches.
Lobulargasorairtrappinghasbeendescribedin40to60percentofasymptomatic,nonsmokingindividuals.Itcanberegardedasanormalvariant,particularlyonexpiratory
scans[12].Lungaffectedbygasorairtrappingusuallyshowsadecreaseinattenuationbelowminus856HU[20].
CysticlungdiseaseCystsaredefinedasfocalregionsoflowattenuationwithperceptible,welldelineatedwalls.Emphysematousspacesandbullaeusuallyhavean
imperceptiblewallandoccasionallycentralvessels.BronchiectaticcystsdisplaythesignetringorCabochonringsignduetoanaccompanyingarteryintheirwall.Cystscan
beseeninendstagelungdiseasewithhoneycombinginIPF,collagenvasculardiseaseswithfibrosingalveolitis,Langerhanscellhistiocytosis,lymphangioleiomyomatosis
(LAM),lymphocyticinterstitialpneumonia(LIP)withfollicularbronchiolitis,and,rarely,indesquamativeinterstitialpneumonia(DIP).
ThecystsinIPFcharacteristicallyaresubpleuralinlocationandmultilayeredormultitiered.InLangerhanscellhistiocytosis,theyaretypicallyassociatedwithnodules,have
irregular,bizarreshapes,arediffuselyorrandomlydistributedthroughoutthelungparenchyma,predominantintheupperandmiddlelungregions,andtendtosparethelung
bases.InLAM,thecystsareroundandarediffuselydistributedthroughouttheentirelung.Inimmunocompromisedpatients,Pneumocystisjiroveciipneumoniacanbe
associatedwithcyststhatareupperlungpredominantinupto30percentofcases.ThisisparticularlycommonafteraerosolizedtherapyorprophylaxiswithPentamidine
whichcannotreachtheapices,renderingthemmoresusceptibletoPneumocystisjiroveciipneumoniathantherestofthelungs.
LungcystsareacharacteristicfindinginBirtHoggDubsyndrome[2123].Thesebasal,multiseptatecystsareassociatedwithskintagsandrenaltumors.(See"Primary
spontaneouspneumothoraxinadults",sectionon'Other'and"Hereditarykidneycancersyndromes",sectionon'BirtHoggDubsyndrome'.)
Pneumatocelesareassociatedwithbluntorpenetratingtrauma,barotraumainventilatedpatientswithARDS,withStaphylococcalpneumonia,orafterkeroseneinhalation.
Pneumatoceleshaveatendencytoenlargewithmechanicalventilation,butcanregresswithresolutionoftheunderlyingdisease.
Scattered,thinwalledcystscanbeseeninhealthy,nonsmokingelderlypeopleintheabsenceofclassicemphysema[12,24].
HRCTDISEASEDISTRIBUTIONThezonaldistributionofdifferentlungdiseasescanbeofhelpinarrivingataspecificdiagnosis.
Theupper(cranial)partsofthelungaretypicallyinvolvedingranulomatousdiseases(eg,sarcoidosisandhypersensitivitypneumonia),Langerhanscellhistiocytosis,and
pneumoconioses,suchassilicosisandcoalworkers'pneumoconiosis,butnotasbestosis.
Thelower(basal)partsofthelungtendtobeaffectedinfibrosinglungdiseases,suchasidiopathicpulmonaryfibrosis,collagenvasculardiseases,nonspecificinterstitial
pneumonia(NSIP),asbestosis,fibrosingdrugreactions,andbenignagerelatedpulmonaryfibrosis.
Preferentialinvolvementofthecentral,axiallungparenchymaoccursinsarcoidosis,lungparenchymallymphoma,Kaposi'ssarcoma,andwithcentrifugalextensionof
lymphangitictumorfromhilarlymphnodesintothelungperiphery.Hydrostaticpulmonaryedemacandisplayaperihilar,socalledbutterflyorbatwingconfiguration.Acute
pulmonaryhemorrhagecanalsohaveacentral,perihilardistributionwithtypicalsubpleuralsparing.Postengraftmentpulmonaryconsolidationinpatientswith
hematopoieticstemcelltransplantationhasacentraldistribution.Radiationpneumoniahasacentralperihilardistributionaftermediastinaltumorradiationtherapy[25].
Theperipheryofthelungismorefrequentlyaffectedinidiopathicpulmonaryfibrosis,collagenvasculardiseases,asbestosis,drugreactions,eosinophiliclungdisease,
organizingpneumonia,desquamativeinterstitialpneumonia,rarecasesofpseudoalveolarsarcoid,graftversushostdisease,andunusualcasesofmucinous
adenocarcinoma(bronchioloalveolarcellcarcinoma).
Theanterior(ventral)orposterior(dorsal)partsofthelungscanbeinvolvedinpulmonaryedema.Inmostdiseases,theanteriorlungclearsearlierthanthedependent,
basallungduetothe"buckethandlemotion"oftheanteriorribsduringventilationwithlargerexcursionsoftheanteriorlung.Indiffusealveolardamage,thedependent
dorsallungisinitiallyconsolidatedandnoncompliant,andthemiddleregionofthelungshowsprimarilygroundglasschangesthatcanrevertwithmechanicalventilation.
Theanteriororventralaspectsofthelungareleastinvolvedacutelyandtendtobehyperventilatedduringmechanicalventilation.Thisventral,diseasefreelunghas
beencalled"babylung"andissusceptibletobarotrauma,volutraumaofmechanicalventilationandoxygentoxicitywithsubsequentdelayedfibrosisoftheanterioror
ventralaspectsofthelungintherecoveryphaseofdiffusealveolardamage[26].
Apredispositionforinvolvementoftheposterosuperiorregionsofthelungisfoundinreactivationmycobacterialorfungalinfections,aswellassilicosis.Apredilectionfor
involvementoftheposteroinferiorpartsofthelungisobservedinaspirationpneumonia,hydrostaticpulmonaryedema,andasbestosis.
Diffuseinvolvementofthelungcanbeseeninlymphangioleiomyomatosisandinadvancedstagesofalloftheabovementionedinfiltrativelungdiseases.
PULMONARYDISEASESManydiseasescanbewellcharacterizedbyhighresolutioncomputedtomography(HRCT),asdiscussedinthissection.
EmphysemaEmphysemaformationfollowsamarkedreductioninterminalandrespiratorybronchioleswithsubsequentdestructionofalveolibyneutrophilsand
macrophages.FourtypesofemphysemacanbedifferentiatedbyHRCTwithahighdegreeofsensitivityandspecificity[27,28]:
Centrilobularemphysemaoccurspreferentiallyintheupperlobesandproducesholesinthecenterofthesecondarypulmonarylobules(image11),frequentlywitha
visiblevesselinthecenterofthelucency.Thesecondarypulmonarylobulesarenotdestroyed.
Panlobularemphysemamorecommonlyinvolvesthelungbases,resultinginageneralizedpaucityofvascularstructuresitalsoaffectstheentiresecondarypulmonary
lobule(image12).Panlobularemphysemacancoexistwithcentrilobularemphysema.
Paraseptal(distalacinar)emphysemaproducessmall,subpleural,andsubfissuralcollectionsofgaslocatedintheperipheryofthesecondarypulmonarylobule(image
13).Itisconsideredapanlobularformofsubpleuralorsubseptaldestructionandrepresentsaprecursorofbullae(image14).
Paracicatricialorpericicatricial(irregular)emphysemaisfoundinthevicinityofscarsandisfrequentlyaccompaniedbylungparenchymaldistortion.
Combinedpulmonaryfibrosisandemphysemaconsistsofapicalpredominantemphysemaaccompaniedbybasalpulmonaryfibrosiswithconcurrentpulmonaryarterial
hypertensionandamoredismallongtermprognosis.Thiscombinationoffindingshasbeenidentifiedin8percentofpatientswithemphysema[29].
Theattenuationcoefficientofemphysematouslungusuallydecreasestoavaluebelowminus950HU[20,29].
BullousdiseaseHRCTisusefulintheevaluationandtreatmentofpatientswithbullousdisease(image15).Thenumber,location,andextentofbullae,thestateofthe
remaininglung,andtheeffectofthedominantbullaonotherthoracicstructurescanbeassessed.Largebullaedonotcompressadjacentstructuressincetheydisplaythe
propertyofincreasedcompliance.Rather,thenormallungretractsawayfromthelargebullaeaccordingthenormal,preservedelasticrecoilofthelungparenchyma.Solitary
giantbullaethatproducemarkedrelaxationatelectasisintheneighboringparenchymaandarenotassociatedwithgeneralizedemphysemarespondbesttosurgicaltherapy.
Bullousdiseaseisamanifestationofparaseptalemphysemainmostcases[30].
AirwaysdiseasesHRCTisusefulinassessingthecaliberoftheairways,aswellasindetectingdiseasesofbothlargeandsmallairways(eg,bronchiectasisand
bronchiolitis)[31].
AirwaycaliberThecaliberofabronchusisassessedbycomparingittothediameteroftheadjacentpulmonaryarterybranch.Thenormalarterialtobronchialratiois
closetooneinthemidlung,decreasesto0.8to0.9intheupperlobes,andincreasestoabout1.2inthelowerlobes.Athighaltitude,theseratiosarelowerduetoareduced
diameterofthepulmonaryarterybranchescausedbyhypoxicvasoconstriction.Inelderlyindividuals,theseratiosaresimilarlylowerduetomilddilatationofthebronchi[12].
Smallairwaysaredefinedasbronchiolesdevoidofcartilageandwithaluminaldiameterof2mmorless.
BronchiectasisHRCThasreplacedbronchographyasthemethodofchoicefordiagnosingbronchiectasis(image16AG)ithasasensitivityof97percentwhenusing
bronchographyasthegoldstandard[32].HRCTisalsousefulintheevaluationofhemoptysis,whichisfrequentlyduetosubclinicalbronchiectasisandendobronchialtumors
HRCTcandetectthebleedingsourceinnearly50percentofcases[33,34].(See"Clinicalmanifestationsanddiagnosisofbronchiectasisinadults".)
Minimumintensityprojectionisanothereffectivewayofpostprocessingaxialthinsectionandevaluatingbronchiectases.Theetiologyofbronchiectasescanbededucedfrom
thecraniocaudaloraxialtoperipherydistributionofinvolvedairways:
Bronchiectaseswithupperormidlungpredominancearefoundinpatientswithcysticfibrosis,sarcoidosis,tuberculosis,allergicbronchopulmonaryaspergillosis.
Bronchiectaseswithanteriororventralpredominanceareseenwithatypicalmycobacterialinfection,asasequelaofacuterespiratorydistresssyndrome.
Bronchiectaseswithlowerlungpredominanceareexpectedinchronicaspiration,pulmonaryfibrosis,primaryciliarydyskinesia,immunodeficiency,andalpha1antitrypsin
deficiency.
BronchiectaseswithcentralpredominancearefoundintracheobronchomegalyMounierKuhn,WilliamsCampbellSyndrome,andallergicbronchopulmonary
aspergillosis.
FocalbronchiectasesarevisiblewithendobronchialorperibronchialtumorsandinSwyerJamessyndrome.
Diffusebronchiectasescanbeseenaccompanyingdiffusebronchiolitisobliterans[35].
Bronchiectaticairwaysareeasilyseenastubularstructuresthatdonottaperandcanbeseenwithin1cmofthepleura[36].Thedilatedbronchiareusually1.5timeswiderin
diameterthantheaccompanyingpulmonaryarterybranch.ThiscrosssectionalconfigurationresemblesasignetringandisthereforecalledthesignetringorCabochonring
signitcanhelptodifferentiateabronchiectaticcystfromotherkindsofcysts.Largercystscanmimicbullae,buttheirlocationinthecentralratherthanthesubpleuralregion
andtheirsegmentalclusteringaresuggestiveofbronchiectaticcysts(image17andimage18andimage19andimage20).
Airwaysremodelingalsoleadstothickeningofthebronchialwallswithluminalirregularitiesduetocorrugationofcartilageandhypertrophyofmucusglands.Bronchial
diverticulosisarisesfromfocaldepression,fusion,anddilatationofbronchialglandductswithherniationthroughmusclefibers.Itcanbeseenin12percentofheavysmokers.
BronchiolitisHRCTcontributestothediagnosisofsmallairwaysdisease(bronchiolitis)[18](see"Bronchiolitisinadults").Severaltypesofbronchiolitiscanbe
identified[37]:
Respiratorybronchiolitisaffectsmostsmokersbutisseenonlyin20percentofsmokersonHRCT.Itresultsfrominertialimpactionofparticlesatthebifurcationofsmall
airways.Itaffectspreferentiallytheupperlobesandyieldscentrilobulargroundglassnodules.Itisfrequentlyassociatedwithrespiratorybronchiolitisinterstitiallung
disease.(See"Respiratorybronchiolitisassociatedinterstitiallungdisease".)
Bronchiolitisobliterans,alsocalledconstrictivebronchiolitis,ischaracterizedbyapatternofmosaicattenuationwithalternatingoligemiaandpseudogroundglass.
Normalpartsofthelungarehyperperfusedandhaveincreasedattenuation,whileabnormallungregionsarehypoperfusedduetohypoxicvasoconstriction.Paired
inspiratoryandexpiratoryCTscanscandefineregionsoflunginvolvedwithbronchiolitisbydemonstratingunequalventilationwithgastrapping,leadingtoformationofa
mosaicpattern.Somepatientswithconstrictivebronchiolitishavemildassociatedbronchialdilationandbronchiectasis.Patientswithdiffuseidiopathicpulmonary
neuroendocrinehyperplasia(DIPNECH)maydisplayfindingssimilartoconstrictivebronchiolitis,associatedwithcentrilobularnodules.Patientswithsevererefractory
asthmamayalsoshowgastrappingonexpiratoryCTscanssimilartobronchiolitisobliterans[38,39].
Cellularbronchiolitiswithnodulesandbranchinglines,or"treeinbud"pattern.Thepathologicbasisfor"treeinbud"patternisanactivebronchiolitiswithinflammatory
cellsinthewallsofdistalairwaystogetherwithinflammatoryexudatesandmucusimpactingthelumenofbronchioles.The"treeinbud"patterncorrespondstodilated
andimpactedbronchiolesimagedparallelorperpendiculartotheimagingplaneofCT.Inrareinstances,"treeinbud"patterncanbeseenduetovascularabnormalities
liketumorembolizationorintravasculartalcandmethylcelluloseparticlesdepositedinpulmonaryarteriolesofintravenousdrugabusers.

Cellularbronchiolitisisafeatureofinfections,includingbronchogenic/endobronchialspreadoftuberculosis,respiratorysyncytialvirus,adenovirus,mycoplasma,and
bronchioloinvasiveaspergillosisinimmunecompromisedhosts.Aspiration,diffusepanbronchiolitisinAsianpatients,asthma,postinflammatorybronchiectasis,and
cysticfibrosiscanalsodisplaythispattern.Asimilarpatterncanbefoundinpatientswithhypersensitivitypneumonialeadingtointensebronchiolarandperibronchiolar
inflammation.
Follicularbronchiolitisisdefinedaslymphoidhyperplasiaofthebronchusassociatedlymphoidtissue(BALT).Itischaracterizedbythepresenceofhyperplasticgerminal
centersalongthebronchioles.Itmayrepresentavariantoflymphocyticinterstitialpneumonia(LIP).Thistypeofbronchiolitisisseenintandemwithimmunodeficiencies,
collagenvasculardisease,andhypersensitivityreaction.TheCTmanifestationsincludecentrilobularnodules,largerperibronchialnodules,andassociatedgroundglass
opacities[40].InconjunctionwithLIP,follicularbronchiolitiscanleadtotheformationofrandomcysts.
LymphangiticcarcinomatosisPulmonarylymphangiticcarcinomatosisispartofthespectrumofmetastaticdisease.Mostcasesresultfromdisseminationof
adenocarcinomas.Microhematogenousspreadtotheperipheryofthelung,withsubsequentretrograde,centripetallymphaticextensiontowardthehilarregion,isthe
responsiblemechanisminapproximately75percentofpatients.Theremainingcasesareduetocentrifugalextensionfromahilartumororfromanipsilaterallungorbreast
carcinoma.Inthelattersettings,thelymphangiticspreadisunilateralincomparison,microhematogenousseedingisfrequentlybilateral.
HRCTcandetectlymphangitictumorinupto50percentofpatientswhoaresymptomaticbuthavenormalappearinglungsonchestradiography.Theimagingfeaturesof
lymphangitictumoraredeterminedbythepatternofbronchovascularandlymphaticspread(image21AB)[41].Thecharacteristicfindingsarethickeningoftheinterlobular
septa,withbeadingcausedbyperilymphaticnodules,polygonorpolygonalarcadeformation,andthickeningofthecentralbronchovascularstructures(socalledcentraldots).
Inspiteoftheextensiveinvolvement,thelungparenchymaisnotdistorted.Theabsentdistortiondistinguisheslymphangiticspreadfromsarcoidosis,whichcanotherwise
producesimilarfindingsbutusuallywithlessconspicuousthickeningofinterlobularsepta.
SarcoidosisSarcoidosisaffectsboththelungparenchymaandlymphatictissuewithnoncaseatinggranulomata.Theclassicpresentationconsistsofenlargementofhilar
andmediastinallymphnodeswithorwithoutlungparenchymalinvolvement.Insomepatients,however,parenchymaldiseaseoccursintheabsenceofobviouslymphnode
enlargement.Markedparenchymaldistortioncanoccurinthelatestages.HRCTcanalsodetectpulmonaryinvolvementinasubsetofsymptomaticpatientswhohavea
normalchestradiograph,therebyexpeditingorfacilitatingbiopsyanddiagnosis.
CharacteristicfeaturesofsarcoidosisonHRCTincludebilateral,symmetrichilarandmediastinallymphnodeenlargement,thickeningofbronchovascularbundles,bronchial
wallthickening,bronchialnarrowing,thickeningandbeadingofinterlobularsepta,peribronchiolarandperilymphaticsmallunsharpnodules,groundglassopacificationlarger,
parenchymalmasseswhichconsistofmerged,confluentsmallnoduleswithindividualseparatenodulesattheperipheryofthisconglomeratemass:thisconstellationof
findingshasbeendubbedthegalaxysign[42]consolidation(pseudoalveolarpattern),parenchymalbands,distortionoflungarchitecture,cysts,andtractionbronchiectasis
(image22AC)[43,44]areotherfrequentlydescribedfindingsinpatientswithsarcoidosis.Preferentialpatchysubpleural,upperlobe,andperibronchovascularinvolvementis
present.(See"Clinicalmanifestationsanddiagnosisofpulmonarysarcoidosis".)
IdiopathicinterstitialpneumoniasTheidiopathicinterstitialpneumonias(IIPs)areasubsetofdiffuseinterstitiallungdiseasesofunknowncause,characterizedby
expansionoftheinterstitialcompartment(ie,thatportionofthelungparenchymasandwichedbetweentheepithelialandendothelialbasementmembranes)byaninfiltrateof
inflammatorycells.Theinflammatoryinfiltrateissometimesaccompaniedbyfibrosis,eitherintheformofabnormalcollagendepositionorproliferationoffibroblastscapable
ofcollagensynthesis.
Seventypesofidiopathicinterstitialpneumoniashavebeendescribed.Theyincludeusualinterstitialpneumonia/idiopathicpulmonaryfibrosis(UIP/IPF),nonspecificinterstitial
pneumonia(NSIP),desquamativeinterstitialpneumonia(DIP),respiratorybronchiolitisinterstitiallungdisease(RBILD),acuteinterstitialpneumonia(AIP),cryptogenic
organizingpneumonia,andLIP.(See"Idiopathicinterstitialpneumonias:Clinicalmanifestationsandpathology".)
RadiologicevaluationoftheIIPsmayobviatetheneedfortissuediagnosis(particularlyinsomecasesofUIP/IPF).Moreoften,itnarrowsthedifferentialdiagnosis.
IdiopathicpulmonaryfibrosisIPF(pathologicallydefinedbythepresenceofusualinterstitialpneumoniaorUIPpattern)isassociatedwithcharacteristic
radiographicchanges[4549].TheUIPpatternonHRCTischaracterizedbythepresenceofbibasalandperipheral,subpleuralreticularopacities,oftenassociatedwith
tractionbronchiectasiswhichisamarkerforfibrosis.Membranesofcollapsedalveoliasaresultofscarringcontributetothelinearandreticularopacities.Honeycombing
iscommonandiscriticalformakingadefinitivediagnosisofIPF[50].HoneycombingonHRCTisusuallydefinedassubpleural,clustered,multilayeredormultitiered
cysticairspaceswithwelldefinedwalls.Thecysticspacesaretypically3to10mmindiameter,butoccasionallymaybeaslargeas2.5cmandmayrepresentcollapsed
secondarypulmonarylobulesaroundrespiratorybronchioles(image23AB)[51].Honeycombingmayrepresentsimplificationofthelungarchitecturewithcollapsed
secondarypulmonarylobulesandbronchiolectasis.Temporalandspatialheterogeneitywithconcurrentinjuryandrepair,arepathologiccharacteristicsofIPF.

Thepresenceofcoexistingpleuralabnormalities,micronodules,gastrapping,nonhoneycombcysts,extensivegroundglassopacities,consolidation,ora
peribronchovascularpredominantdistributionshouldleadtoconsiderationofanalternativediagnosis[51].Endstagehypersensitivitypneumonia[52],nonspecific
interstitialpneumonia,rheumatoidarthritisinterstitiallungdisease(RAILD),Sjgrensyndrome[53],drugreactionsand,rarely,sarcoidosiscanalsocauseradiological
findingssimilartoIPF[54].ChroniccryptogenicorganizingpneumoniacanoccasionallybemistakenforIPFhowever,itsradiologicfeatures(peripheralabnormalregions
ofconsolidationwithairbronchogramsorgroundglassopacities)andshortertimecoursearedifferentiatingfeatures[55].
ThemostrecentconsensusconferenceclassifiestheHRCTfindingsinto(1)aUIPpatternwith,peripheral,subpleural,basalpredominantreticularopacities,traction
bronchiectasesandhoneycombing,(2)apossibleUIPpatternwheretheabovementionedfindingsarepresentexceptforhoneycombing,and(3)apatterninconsistent
withUIPwherethebasal,peripheralpredominanceofopacitiesisabsentandgroundglassorperibronchovascularopacitiesarepresent.

Inabout10percentofpatientswithIPF,acceleratedUIPoccurswithsuddendeterioration,diffusealveolardamage,peripheralconsolidation,and/orgroundglass
opacificationsuperimposedonthechronicUIPpatternwithpoorprognosis.ThesefindingscanbesimilartodenovoAIP,whichisdescribedbelow.
CombinedpulmonaryfibrosisandemphysemaThecombinationofemphysemaintheupperlobesandfibrosisinthelowerlobesisincreasinglyrecognizedasa
distinctclinicalphenotypeinsmokers,particularlyinmenintheirsixthandseventhdecade,andiscompatiblewithtwosimultaneousconditions[56].Honeycombing,
reticularopacities,andtractionbronchiectasesarethemostcommonfindingsinthelowerlungs,whiletheupperlungsexhibitparaseptalandcentrilobularemphysema
[57].ThepatternoffibrosisreflectseitherIPForNSIP.Theemphysematousfocimayhavethickerwallsthantypicallyexpectedinbullae[24].Thetotallungvolumeis
preservedwithoutthetypicalhyperinflationofsevereemphysema.Patientstypicallyexhibitmarkedreductioninthediffusingcapacityforcarbonmonoxide(DLCO).
Pulmonaryarterialhypertensionandlungcanceraremorecommoninthiscohortofpatients[56].
NonspecificinterstitialpneumoniaNSIPcanoccurineitheracellularorafibroticform.HRCTfeaturesincludegroundglassattenuationinadiffuseorpatchy
distribution,preferentiallyalongbronchovascularbundles,withreticularopacitiesandtractionbronchiectasis[58,59].Honeycombingisonlyrarelynoted.NSIPalso
displayspathologicallytemporalandspatialhomogeneity,whichdistinguishesthisentityfromUIP[60].Relativesparingofthelungimmediatelyadjacenttothepleurain
thedorsalregionsofthelowerlobesischaracteristic[61].TheradiographicappearanceofNSIPisdiscussedingreaterdetailseparately[62].(See"Nonspecific
interstitialpneumonia",sectionon'Chestimagingstudies'.)
RespiratorybronchiolitisinterstitialpneumoniaRBILDisasmokingrelateddiseasecharacterizedbysmallperibronchiolarnodulesandgroundglass
opacificationrelatedtotheaccumulationofduskypigmentedmacrophagesinthebronchiolesandadjacentalveoli.Itrepresentsthemostcommonformofbronchiolitis
andhasanupperlobepredominance.PairedinspiratoryandexpiratoryCTscanscandefineregionsoflunginvolvedwithbronchiolitisbydemonstratingunequal
ventilationwithgastrapping.(See"Idiopathicinterstitialpneumonias:Clinicalmanifestationsandpathology".)
DesquamativeinterstitialpneumoniaDIPisdiagnosedalmostexclusivelyinsmokers.ItislikelythatDIPandRBILDarehighlyrelatedifnotidenticallesions,
differingonlyintheseverity,location,andextentoftheabnormality(ie,RBILD=mild/earlyDIP)[63].RBILDhasupperlobepredilectionandislesslikelyatthebases,
whereasdesquamativeinterstitialpneumoniahasabasalpredominance.HRCTshowshomogeneousgroundglassopacitieswithouttheperipheralreticularopacities
andhoneycombingthataretypicalofUIP.Rather,DIPischaracterizedbymoreconfluentgroundglassandconsolidativeopacificationofthebasallungperiphery.
AcuteinterstitialpneumoniaAIP(previouslycalledHammanRichsyndrome)isclinicallyuniqueamongtheIIPsbecauseofitsrapidprogression.Itisalsodescribed
asidiopathicacuterespiratorydistresssyndrome(ARDS).HRCTshowsbilateralsymmetricareasofgroundglassopacificationandconsolidationwithtraction
bronchiectasis[64].Thesefindingsareduetodiffusealveolardamage(DAD)withincreasedpermeabilityedemaandhyalinemembranes.(See"Acuteinterstitial
pneumonia(HammanRichsyndrome)".)
LymphocyticinterstitialpneumoniaLIPischaracterizedbyhomogenousinfiltrationoftheinterstitiumwithamonoclonalorpolyclonalpopulationofTlymphocytes
andrepresentsdiffuselymphoidhyperplasiaofbronchialassociatedlymphatictissue.ItcanbeseeninpatientswithSjgren'ssyndromebuthasbecomeanAIDS
definingdisease,particularlyinchildren.Itcanprogresstolymphomaofthelungparenchyma.OnHRCT,groundglassopacities,reticularopacities,andperivascular
cystspredominate.Thesecystsaremostlikelyassociatedwithfollicularbronchiolitisandaretheresultofgastrappingandfocaldestructionofalveolarwalls.(See
"Lymphoidinterstitialpneumoniainadults".)
OrganizingpneumoniaOrganizingpneumonia,characterizedpathologicallybyplugsoforganizingfibroblastictissuethatoriginatesinthealveolarductsandextends
intothebronchiolesittypicallyshowsperibronchialandperipheral,subpleuralareasofconsolidation,groundglassopacities,bandlikeopacities,interlobularseptal
thickeningonHRCT,occasionallywithtractionbronchiectasesandinterspersedfibrotic,reticularchangeswithaperilobularpatternthatformspoorlydefinedarcadelike
orpolygonalstructuresinsubpleurallocation(image24andimage25andimage26)[65].Anothersuggestivefindingisthepresenceofringsorcrescentsof
consolidationsurroundinggroundglassopacities,whichhavebeencalledthereversehalosignandtheatollsign[6,66].(See"Cryptogenicorganizingpneumonia".)
AsbestosisAsbestosisleadstopredominantlybasalanddorsallungparenchymalfibrosis(image27).Othercharacteristicfindingsinclude:peribronchiolarfibrosisthat
formscentrilobularnodules,intralobularandinterlobularseptalfibrosisthatformssubpleuralshortlines,coarseparenchymalbands,andsubpleuralcurvilinearbandsthat
parallelthepleuraandrepresentfibroticbridgingfromonecentrilobularregiontothenext[67].Coarsehoneycombingcanbeseeninadvancedstages.Coexistentpleural
plaquesarefrequentlyidentified,particularlyinpatientswithcurvilinearsubpleurallines.SomeradiologistsfavorproneHRCTinpatientswithasbestosistobetterdisplaythe
fixed,nongravitationalchangesatthelungbases.(See"Asbestosrelatedpleuropulmonarydisease".)
Inlargerstudies,upto30percentofasbestosexposedindividualsdemonstrateanabnormalHRCTinspiteofanormalchestradiograph.Asbestosisisassociatedwithmore
parenchymalbandsorlongscarsthanIPF[67].
LangerhanscellhistiocytosisLangerhanscellhistiocytosis(eosinophilicgranuloma,histiocytosisX)accountsforapproximately3percentofallchronicinfiltrativelung
diseases.Itpresentsinthreeforms:
Pulmonaryinvolvementonlyin60percentofpatients.Thisisolatedpulmonaryformisseenprimarilyinadultsmokers,whoaccountfor90percentofsuchcases.
Pulmonaryandskeletalstructuresareaffectedin20percent.
Othersystemic,visceralmanifestationsareseenin20percent.
Onconventionalradiographs,Langerhanscellhistiocytosisshowsupperlobepredominance,particularlyintheinitialstages.Thefirstvisiblechangeincludessmallnodular
opacities2to5mmindiameterwithscatteredroundedopacitiesordiffuse,miliarynodules.Anintermediatereticularpatternbecomesvisibleonchestradiographin
advanceddisease.
HRCThaschangedourunderstandingofthetrueimagingfindingsinthisdisorder[68].SharplydefinedorstellatecentrilobularnodulesaretheinitialfindingonHRCT.In
earlystages,thenodulescomposedofLangerhanscellsandeosinophilsarecenteredonrespiratorybronchiolesandtheadjacentinterstitium.Multiplethinwalledcystsof
varyingsizeandbizarreshape,aretypicallypresentdiffuselythroughouttheupperandmiddlelungzoneswithrelativesparingofthebases(image28AB).Someofthese
cystscanresembleemphysematousbullaethedifferentiatingfeaturesaretheslightlythickerwallandtheirdiffuselocation,permeatingtheentirecrosssectionofthelung
parenchymaratherthantheperipheral,subpleuralregionofthelung.Thecystshavebizarre,irregularshapes,whichcanappearincombinationwithnodulesinthe
intermediatestagesofthedisease.Theiretiologyisnotclear,buttheyseemtoresultfromcavitationofnodulesorrepresentdilatedairways,imagedincrosssection.They
resultfrominflammationthatdestroysbronchiolarwallsanddilatesairways.Inadditionpericicatricialemphysemacancontributetocystformation[69].
PatientswithLangerhanscellhistiocytosispreservetheirlungvolumesthroughoutthecourseofthedisease.Thisisincontrasttomostotheradvancedinterstitiallung
diseases,inwhichshrinkinglungvolumesaretherule.(See"PulmonaryLangerhanscellhistiocytosis".)
LymphangioleiomyomatosisPulmonarylymphangioleiomyomatosis(LAM)affectswomenofreproductiveage.Itresultsfromahamartomatousproliferationand
agglomerationofsmoothmusclecellsinthelung.(See"Sporadiclymphangioleiomyomatosis:Epidemiologyandpathogenesis".)
Thechestradiographshowscoarsereticularopacities,withorwithoutpleuraleffusionandpneumothorax,aswellaslargelungvolumes.HRCTdemonstratesmultiplecysts
distributeddiffuselythroughoutthelung(image29ABandimage30)[70].ThecystsinLAMareroundedandcanbesimilartothoseseeninLangerhanscellhistiocytosis,
thoughbizarrecystshapesareunlikelyinLAM.Thedistributionofcystsisdifferentinthesedisorders.ThecystsinvolveallcompartmentsofthelunginLAM,butshowan
upperlobepredominanceinLangerhanscellhistiocytosis.
PulmonaryalveolarproteinosisPulmonaryalveolarproteinosis(PAP),alsocalledpulmonaryalveolarlipoproteinosis,resultsfromdisturbedclearanceofsurfactantfrom
alveoli.ThepredominantCTfeatureofPAPisgroundglassopacificationwithsmoothlythickenedinterlobularseptallines.Thispatterniscalled"crazypaving"[15].Lobularor
geographicsparingareaccompanyingfeatures.Thedifferentialdiagnosticconsiderationsincludepulmonaryedema,pneumonia,alveolarhemorrhage,andARDSwith
diffusealveolardamage[71].(See"Causes,clinicalmanifestations,anddiagnosisofpulmonaryalveolarproteinosisinadults".)
PneumocystispneumoniaPneumocystisjiroveciipneumoniaisoneofthemostcommonpulmonaryinfectionsinpatientswithAIDS.Thechestradiographisdeceptively
normalinabout10percentofsymptomaticpatients,butsubtleabnormalitiescanbeseenonHRCT.Theprimarychangeisdiffuseorpatchygroundglassopacification,
occasionallyforminga"crazypaving"pattern(image31AB)[15,72].Consolidativechanges,nodules,andthickeningofinterlobularseptaarerarelyseen.Patientstreated
withaerosolizedpentamidinemayhavepreferentialPneumocystisinvolvementoftheupperlobesandoftendisplaycysticchanges,duetolackofpentamidinepenetrationin
thepulmonaryapices(image32).(See"ClinicalpresentationanddiagnosisofPneumocystispulmonaryinfectioninHIVinfectedpatients".)
HypersensitivitypneumoniaHypersensitivitypneumonia(ie,extrinsicallergicalveolitis)representsatype3allergicreactionorimmunecomplexdisease.Itdisplaysa
mixtureofdiffuseorpatchygroundglassopacificationwithlobularsparing,lobulargastrapping(thesocalledheadcheesepattern)similartoamosaicpatternorresembles
nonspecificinterstitialpneumoniaorcentrilobularpoorlydefinedairspacenodulesin50percentofcasessimilartorespiratorybronchiolitis.Linearandreticularchanges
superveneinlaterstages,withrelativebasalsparing(image33ACandimage34)[73,74].Untreatedpatientscaneventuallydevelopfrankhoneycombingandcoarsefibrosis
withscarring,tractionbronchiectases,andlossofvolumeprimarilyintheupperlobes.PatientswithfibrotichypersensitivitypneumoniacandevelopaUIPpattern[52].(See
"Classificationandclinicalmanifestationsofhypersensitivitypneumonitis(extrinsicallergicalveolitis)".)
HRCTOFINTERLOBULARSEPTALTHICKENINGNormally,onlyscatteredinterlobularseptaarevisibleonhighresolutioncomputedtomography(HRCT),particularlyin
theupperlobes,sincetheirthicknessisatthelimitofspatialresolutionandonlyrarelyexceeds0.1mm.Thickeningofinterlobularseptamayresultfromaccumulationof
interstitialliquid,cells,orcollagenandcanbesimulatedbyalveolar,paraseptal,perilobularpathologicalchanges.Interlobularseptalthickeningcanbesmooth,nodular,or
irregularincontour[75].
Smoothinterlobularseptalthickeningisseeninhydrostaticinterstitialpulmonaryedema,allergicpulmonaryedema,centrallymphaticobstructionduetobronchogenic
carcinoma,fibrosingmediastinitis,orpulmonaryvenoocclusivedisease,andlymphangiticcarcinomatosis.Rarely,itcanbeseeninpulmonaryalveolarproteinosisandwhen
combinedwithgroundglassopacities,ityieldsthe"crazypaving"pattern[15].
Nodularinterlobularseptalthickeningcanbeobservedinpatientswithlymphangiticcarcinomatosis,sarcoidosis,silicosis,lymphoma,andKaposi'ssarcoma.Occasionally,
nodularthickeninghasbeendescribedinmiliarytuberculosisandhistoplasmosis,whererandom,perivascularnodulespredominate.
IrregularinterlobularthickeningisseeninpatientswithUIP/IPF,collagenvasculardiseases,andasbestosis.
Calcificinterlobularseptalthickeningcanbeararefeatureofalveolarmicrolithiasis[76].Thisdiseaseactuallyonlysimulatesinterlobularseptalthickeningduetothehigh
concentrationofcalcospheritesincloseappositiontotheperilobularregionofsecondarypulmonarylobulesratherthanactualcalcificationoftheinterstitium.
HRCTINFOCALLUNGDISEASEHRCTcanbehelpfulinfocallungdiseases,suchasgranulomatosiswithpolyangiitis(formerlycalledWegener'sgranulomatosis),
conglomeratemassesinsarcoidosisandpneumoconiosiswiththesocalledgalaxysign,focalorganizingpneumoniawiththereversedhalosignandatollsign[77],
amiodaroneinducedpneumoniainducedbyiodinedeposition,roundedatelectasis,andcavitatingmalignancies(image35AE)[42].Itcanfacilitatemorphologic
characterizationoflesions,sincebronchiectasis,airbronchograms,cavitation,clusterednodules,andspiculationofedgescanbedetectedwithahighdegreeofcertainty.
Therelationshipofanoduletofissures,aswellaspreciselocalizationtoasegmentorlobe,canbeachieved.Ifabronchusfeedsintoafocalabnormality,theyieldof
bronchoscopicbiopsywillbehigher:HRCTcanguidetheprocedureandpredictitssuccessrate(image36andimage37).
EFFECTSOFNORMALAGINGProgressivedecreaseinattenuationofthelungsisseeninhealthynonsmokingadultsduetoaprogressiveincreaseinalveolardiameter
from250micronsto500microns.Adecreaseofminus50HUhasbeenregisteredbetweentheagesof20and70yearsofage[12].Aphysiologicincreaseincollagenwith
agemayleadtosubtlefibrosiswithbasalsubpleuralreticularopacities,identifiedin60percentofindividualsbeyond75yearsofage.Thissenile,agerelatedpulmonary
fibrosishasbeencalledbydifferentdesignations,includingpresbytericlung,geriatricinterstitiallungdisease,andmatureinterstitiallungdisease(MATILD).Itisrelatedtoa
milddegreeofinterstitialfibrosiswithtractionbronchiectasesandbronchiolectasis.Scatteredthinwalledcystsinindividualsolderthan75yearsofagewitharandom
distributionhavebeendescribedaswell[24].Gasorairtrappingonexpiratoryscansbecomesmorecommonandcanbeseeninmorethan60percentofexamined
individuals.Mildsenilebronchialdilatationwithaconcurrentdecreaseinthearterialtobronchialratioshouldnotleadtothediagnosisofbronchiectases[12].(See'Airway
caliber'above.)
EFFECTSOFSMOKINGSmokingplaysanimportantroleinthedevelopmentofseveralinterstitialandsmallairwaysdiseasesincludingrespiratorybronchiolitis,
desquamativeinterstitialpneumonia,pulmonaryLangerhanscellhistiocytosis,andprobablyinidiopathicinterstitialfibrosis,sinceabout70percentofpatientswithinterstitial
pulmonaryfibrosis(IPF)arecurrentorformersmokers.Rheumatoidarthritisassociatedinterstitiallungdisease(RAILD)occursthreetimesmorefrequentlyinsmokersthan
innonsmokerswithrheumatoidarthritis.Acentrilobularpatternisassociatedwithrespiratorybronchiolitis,whichischaracterizedbyaccumulationofpigmentedmacrophages
inthealveoliandalveolarducts.Thesecentrilobularnodulesareprecursorsofsmokersemphysemaandcanprogresstocentrilobularemphysema(ie,thenodulesare
replacedbycentrilobularlucencies).AcuteeosinophilicpneumoniainbingesmokersandacutepulmonaryhemorrhagewithantiGBMantibodiescanbeprecipitatedby
smoking.
Asymptomaticsmokerswithnormallungfunctioncandisplayparenchymalnoduleswithlowattenuation,groundglassopacities,subpleuralmicronodules,subpleuralreticular
opacities,occasionalhoneycombingandtractionbronchiectases,andnonemphysematouscysts.Thesefindingsoccurinuptoeightpercentofthepopulationofsmokers
[29,56].Thesubpleuralreticularopacitiesaresimilartothoseseeninelderlyindividuals,butatanearlierageinsmokers.Interstitialchangesmaymaskthefunctionaleffectof
concurrentemphysemawithlessoverallhyperexpansionofthelungs.Theseinterstitialfindingsinsmokersmayrepresentamildformofnonspecificinterstitialpneumonia,
fibrosissubtype,andmayindicateprematureagingofthelungs[12,56,78].Ofnote,smokingcanbeprotectiveofhypersensitivitypneumoniaandsarcoidosiswithanodds
ratioforthesediseasesof0.62.Thisprotectionmaybetheresultofmildimmunosuppressiontriggeredbysmoking.
SUMMARYANDRECOMMENDATIONS
Highresolutioncomputedtomography(HRCT,alsocalledthinsectionCTscanning)providesmoredetailthaneitherchestradiographyorconventionalCTscanning,with
anoverallsensitivityof95percentandaspecificityapproaching100percent.Comparedtochestradiography,HRCTcanmoreaccuratelyassessthepatternand
distributionofdiffuselungdisease,whichmaybebeneficialwhentryingtonarrowthedifferentialdiagnosisordefineatargetforlungbiopsy.(See'Clinicalapplicationof
HRCT'above.)
HRCTpatternsincludelinearandreticularopacities,nodularopacities,largeconfluentopacities(eg,groundglassopacities,consolidation),anddecreased
parenchymalopacity(eg,emphysema,cysticlesions,mosaicattenuation,gastrapping).Thesepatternsmaybeaccompaniedbyparenchymalbandsand
architecturaldistortion.(See'HRCTpatterns'above.)
Distributionsofdiseaseincludeapicalversusbasal,centralversusperipheral,anteriorversusposterior,anddiffuse.(See'HRCTdiseasedistribution'above.)
MajordiseasesthatcanbeoptimallycharacterizedbyHRCTincludeemphysema,bullousdisease,airwaysdiseases(eg,bronchiectasis,bronchiolitis),lymphangitic
carcinomatosis,sarcoidosis,theidiopathicinterstitialpneumonias,asbestosis,Langerhanscellhistiocytosis,lymphangioleiomyomatosis,Pneumocystispneumonia(PCP,
nowcalledPneumocystisjiroveciipneumonia),andhypersensitivitypneumonia.(See'Pulmonarydiseases'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic6988Version20.0
GRAPHICS
InterlobarfissuresonHRCT
Thecurvilinearinterlobarfissureshaveathicknessof0.15mm.Therightminor
fissurehasaboomerangconfiguration(arrow)insidetheboomerang,the
middlelobeisvisible,surroundedbytherightupperlobe.Therightmajorfissure
appearsasanobliquestraightline,delineatingthesuperiorsegmentoftheright
lowerlobeposteriorly.
HRCT:highresolutioncomputedtomography.
CourtesyofPaulStark,MD.
Graphic82418Version3.0
NormalHRCToflungwithpositionalchanges
HRCToflungwithnormalgravitationalchangesthatleadtoanincrease
inattenuationintheposterobasalandlaterobasalsegmentofthelowerlobes
(arrows).Arepeatpronescanwouldclearlydemonstratethetransient,
positionalnatureofthisopacity.
Perivascularnodules
Multiplesmallperivascularnodules,duetometastaticsmallcellcarcinoma,are
scattereddiffuselythroughoutallcompartmentsofthelung.
Talcgranulomatosis
Talcgranulomatosisinanintravenousdruguserwithmultiple,partially
confluent,bilateralmicronodules.
Coalworker'spneumoconiosis
Multiplecentrilobularnodulesarevisiblediffusely.
Pulmonaryedemaaftercocainefreebasing
Bilateralpatchyareasofgroundglassopacityareseen.
CTscanofpulmonaryedemaduetoneardrowning
Groundglassopacitiesareseeninbothupperlobes.Intherightlung,ground
glassopacitiesabuttheminorfissureandsparethemiddlelobe.
Computedtomographyofhydrostaticpulmonaryedema
Axial(A)andcoronal(B)computedtomographicimagesofhydrostatic
pulmonaryedemainapatientwithacuterenalfailure.Imagesshowperihilar
groundglassopacities(arrows),lobularairspacenodules,andpleuraleffusions
bilaterally(arrowheads).
Computedtomographyofinterstitiallunginvolvement
fromrheumatidarthritis
Axial(AandC)andcoronal(B)computedtomographicimagesofrheumatoid
arthritisassociatedinterstitiallungdisease.Imagesshowgroundglassand
consolidativeopacitiesinvolvingthelowertwothirdsofthelungsthatsparethe
upperlobe.Thispatternoflunginvolvementcorrespondstocellularnonspecific
interstitialpneumonia.
Computedtomographyofmicroscopicpolyangiitis
Axialcomputedtomographicimageofapatientwithpulmonaryhemorrhagefrommicroscopic
polyangiitis.Groundglassopacitiesandconsolidationareseenthroughoutbothlungs.
Pneumoniawithairbronchogram
Severepneumoniawithhomogenousconsolidationoftherightupperlobeand
markedairbronchogramformation,characteristicofairspacedisease.
Pneumoniawithairbronchogram
LymphocyticinterstitialpneumoniainapatientwithHIVinfection.Themain
changesaregroundglassopacificationintherightmiddlelobeandconsolidation
suggestiveofairspacediseaseintherightlowerlobewithaclearlyvisibleair
bronchogram.
HIV:humanimmunodeficiencyvirus.
Centrilobularemphysemapulmonaryhypertension
AxialCTimagesconfirmthepresenceofcentrilobular(centriacinar)emphysema(A)andpulmonary
hypertension(B).Thelungparenchymashowslucentspacesofparenchymaldestructioninterspersed
amongnormallungtissuebestappreciatedintherightupperlobe(A).Themainpulmonaryartery
(arrow)measures3.8cm(normal<2.9cm).Thepulmonaryarteryandaortashouldbeaboutthesame
sizeandinthiscasethemainpulmonaryarteryislargerthanthecompanionascendingaorta.
CT:computedtomography.
Panlobularemphysema
HRCTshowsapaucityofvascularstructuresinbothlowerlobes,mostevidentin
theanteriorbasalsegmentoftherightlowerlobe.
Paraseptalemphysema
Severalsubpleuralemphysematousspacesarepresentintheperipheryofthe
leftupperlobe(arrows)inapatientwithaccompanyingseverecentrilobular
emphysema.
Paraseptalemphysemawithbullae
Paraseptalemphysemaintheperipheryofbothupperlobesandintheleftlower
lobeonabackgroundofcentrilobularemphysema.Severallargesubpleural
bullaearevisibleinbothlungsandaretheresultofparaseptalemphysema.
Severebullousdiseaseinalpha1antitrypsindeficiency
Largebilateralsubpleuralbullaeleadtoretractionoftheunderlyingnormallung
parenchyma.Thebullaehaveanincreasedcomplianceandallownormallungto
retractaccordingtoitsintrinsicelasticrecoil.Thebullaearenotundertension
theireffectissimilartothatofapneumothorax("intrapulmonary
pneumothorax").
Cylindricalbronchiectasis
HRCTshowsscarringwithbibasallossofvolumeintheposterobasaland
laterobasalsegmentsofbothlowerlobes.Thesegmentalbronchiaremildly
distendedanddistorted(arrows).Theyarewiderindiameterthantheir
accompanyingsegmentalpulmonaryarterybranchesandareclosetogether.
Thesechangesareprobablyduetoaprevious,incompletelyresolved
pneumonia.
Cylindricalbronchiectasisofrightlowerlobe
HRCTshowsmilddilatationoftheposterobasalandlaterobasalsegmental
bronchiintherightlowerlobe(arrow).Multipleilldefined,peripheralrightlower
lobenodulesarevisibleandrepresentmucousplugsindilatedsubsegmental
bronchi(arrowhead).
Cylindricalbronchiectasisintherightmiddlelobe
Multiplecircularlucencies(arrow)areseeninthecontractedmiddlelobe,most
likelyaspartofasocalledrightmiddlelobesyndrome.
CTscanofthelungsinapatientwithcysticfibrosis,
demonstratingbronchiectasis
Computerizedtomography(CT)ofthechestinapatientwithcysticfibrosis
demonstratesmildcylindricalbronchiectasis,withthickenedbronchialwalls
involvingtheupperlobesandthesuperiorsegmentsofthelowerlobes.Notethe
subsegmentalatelectasisintheposteriorsegmentoftherightupperlobe.
Severebronchiectasis
Severebronchiectasisinadestroyedrightlungasasequelaofnecrotizing
pneumonia.Completecicatrizationatelectasisoftherightlungwitha
cardiomediastinalshifttotheright.Therightlungispermeatedbysmallcystic
structuresconsistentwithcysticbronchiectasis.
Postradiationtractionbronchiectasis
TractionbronchiectasisinapatientwithHodgkin'sdiseaseandpreviousmantle
irradiation.Themainfindingisparamediastinalradiationfibrosis,withlossof
volumeandmildcylindricalbronchiectasis.
Centralbronchiectasisinallergicbronchopulmonary
aspergillosis
Centralbronchiectasisinapatientwithallergicbronchopulmonaryaspergillosis.
Multipledilatedthirdandfourthgenerationbronchiareseen.Smallerperipheral
bronchifilledwithmucusaccountforthebranchinglinearopacitiesinthedistal
lungparenchyma.
Cysticbronchiectasis
Posttuberculousbronchiectasischaracterizedbymarkeddestructionoftheright
upperlobewithcylindricalandcysticbronchiectasisandcicatrizationatelectasis.
Thesefindingsexplaintheipsilateralrotationalshiftofthemediastinum.
Cylindricalandvaricosebronchiectasisispresentintheleftupperlobe.
Computedtomographyofpanbronchiolitis
DiffusepanbronchiolitisinaJapaneseAmericanpatient.Extensivebilateralcentrilobularnoduleswitha
treeinbudpatternandbronchialwallthickeningareseen,featuresthataretypicalofinfectious
bronchiolitisandbronchitis.
Computedtomographyofinfectiousbronchiolitis
(AandB)Axialimagesfromapatientwithinfectiousbronchiolitis.Imagesshow
diffusecentrilobularnodules,treeinbudpattern,andmildbilaterallowerlobe
cylindricalbronchiectases.Amosaicpatternofattenuationisseeninbothlungs,
moreconspicuousontherightthanontheleft.(C)Axialimagefromapatient
withinfluenzarelatedbronchiolitis.Bilaterallowerlobepredominantcentrilobular
nodulesareseenwithatreeinbudpattern,mucoidimpactionofsegmental
lowerlobebronchi,andbronchialwallthickening.
Computedtomographyofrespiratorybronchiolitis
AxialCTscansshowmultiplesmallsolidandgroundglasscentrilobularnoduleswith
upperlobepredominance.Mildbibasal,subpleural,reticularopacitiesindicateage
relatedandsmokingrelatedpulmonaryfibrosis.
Computedtomographyappearanceoflymphangitic
carcinomatosis
Lymphangiticcarcinomatosisfrommetastaticcarcinomaofthecervix
characterizedbydiffusebilateralthickeningofbronchovascularbundles.
Peribronchialthickeningresultsinvisualizationofmoreperipheralbronchi.The
majorfissuresareslightlythickened.Severalthickenedinterlobularseptaare
seenintheposterioraspectoftherightlung.Smallsubpleuralnodulesintheleft
lowerloberepresentperilymphaticnodules.
CTappearanceofasymmetriclymphangitic
carcinomatosis
Asymmetriclymphangiticspreadofbronchogeniccarcinoma,primarilyinvolving
therightlung.Thickenedbronchovascularbundlesandafinereticularpattern
areseenandprobablyrepresentthickenedinterlobularandintralobularseptae.
Polygonformationisseenintheanteriorandmedialaspectoftherightlung.
Severalthickenedinterlobularseptaarepresent,abuttingthemedialpleuraof
therightlung.
Sarcoidosis
Large,illdefinedleftperihilarconsolidation,unilaterallefthilarenlargement,and
bilateralperipheralpoorlydefinednodulesarepresent.Thesefindingsare
suggestiveofthepseudoalveolarformofsarcoidosis.Theconfluentnodulesin
thecentralregionoftheleftlungyieldthesocalledgalaxysign.
Scarringinsarcoidosis
Sarcoidosiswithmarkedscarringandparenchymaldistortionintheupperlobes,
bullaformation,andcavities.Thesechangesareirreversible.
Miliarynodulesinsarcoidosis
Sarcoidosiswithmultiplenodules,1to2mmindiameter,inaperibronchiolar
location.Beadingofthemajorfissuresischaracteristicoflymphatic
involvement.Bilateralhilarlymphnodeenlargementispresent.
HoneycombcystsinIPF/UIP
IPF/UIPwithbilateral,smallsubpleuralhoneycombcystswhichareseparatedby
normalparenchyma.Theanteriorsegmentalbronchusoftheleftupperlobeis
slightlydilated,consistentwithmildtractionbronchiectasis.
IPF:idiopathicpulmonaryfibrosisUIP:usualinterstitialpneumonia.
MarkedhoneycombinginIPF
Usualinterstitialpneumoniapatternwithmarkedhoneycombingandtraction
bronchiectasisinbothlowerlobesalongwithanabsenceofgroundglass
changes.Theperipheralregionsofthelowerlobesandmiddlelobearetypically
involved,sparingthecentralpartsofthelowerlobes.
IPF:idiopathicpulmonaryfibrosis.
Cryptogenicorganizingpneumonia
HighresolutionCTscanincryptogenicorganizingpneumonia.Asymmetric
groundglassopacitiesareseen,withapredominantlyperipheraldistribution
(arrows).
Computedtomographyofcryptogenicorganizingpneumonia
Axialimageshowingbilateralupperlobeparenchymalconsolidationwithclearlyvisibleairbronchograms.
Computedtomographyofcryptogenicorganizingpneumoniainapatient
withchroniclymphocyticleukemia
Axialimageofapatientwithchroniclymphocyticleukemiashowingsignsofcryptogenicorganizing
pneumonia.Bibasalsubpleuralconsolidationsareseen.Inaddition,leftlowerlobeperilobularpatternis
seenformingarcadesintheposterobasalsegment.
Asbestosis
CTscaninasbestosisshowsbibasalopacitieswhicharedifficulttodifferentiate
fromgravitationalchangeswithoutapronescan.Severalsmallcystic,
honeycomblikechangesattheleftlungbaseaswellasapleuralplaqueinthe
rightanteriorhemithoraxarefindingswhichmakethediagnosisofasbestosis
likely.
CysticchangesinLangerhanscellhistiocytosis
Langerhanscellhistiocytosis(eosinophilicgranuloma)inanadolescentboy
characterizedbymultiplecystsintheupperandlowerlobes.Thecystsare
interspersedthroughouttheparenchymaandhaveaslightlythickwall.A
posteriorrightupperlobenoduleispartofthediseaseprocess.
CysticchangesinLangerhanscellhistiocytosis
Langerhanscellpulmonaryhistiocytosis(eosinophilicgranuloma)inan
adolescentboycharacterizedbymultiplecystsintheupperandlowerlobes.The
cystsareinterspersedthroughouttheparenchymaandhaveaslightlythickwall.
Aposteriorrightupperlobenoduleandconfluentbibasalpatchylowerlobe
opacitiesarealsopartofthediseaseprocess.
Lymphangioleiomyomatosis
Lymphangioleiomyomatosisina42yearoldwoman.Multiplesmallcysts
permeatetheentirelungparenchyma.
Advancedlymphangioleiomyomatosis
Advancedlymphangioleiomyomatosischaracterizedbyseveredestructionofthe
lungparenchymawithreplacementbycysts.
Computedtomographyoflymphocyticinterstitial
pneumonia
Axial(AandB)andcoronal(C)computedtomographicimagesofapatientwith
chroniclymphocyticinterstitialpneumoniafromsystemiclupuserythematosus
(SLE).Imagesrevealupperlobepredominantgroundglassopacitiesandair
spacenodules.Lowerlobepredominantcysticdiseaseismostlikelyrelatedto
follicularbronchiolitisfromunderlyingSLE.
Pneumocystisjiroveciipneumonia
PneumocystisjiroveciipneumoniainapatientwithAIDS.Groundglassopacities
inapatchydistributionarebestseenintheanteriorsegmentoftheleftupper
lobe.Anaccompanyingleftlowerlobebacterialpneumoniaispresent.
AIDS:autoimmunedeficiencysyndrome.
Pneumocystisjiroveciipneumonia
Pneumocystisjiroveciipneumoniainapatientonhighdosesofcorticosteroids.
Confluentconsolidationisinterspersedwithgroundglassopacitiesand
thickeningoftheinterlobularsepta.
Pneumocystisjirovecipneumonia
Computedtomographicscanfromapatienttreatedwithaerosolized
pentamidine.Upperlobegroundglassopacitiesareinterspersedwithmultiple
smallcysticspacesthatdiffuselypermeatethelungparenchyma.
Acutephaseofhypersenstivitypneumonia(extrinsic
allergicalveolitis)
CTscanshowsgroundglassopacificationofthelungsduringtheacutephaseof
hypersensitivitypneumonia(extrinsicallergicalveolitis).Severalsecondary
pulmonarylobulesaresparedandappearasdarkerareasinbothlowerlobes.
Lowerattenuationsecondarypulmonarylobulesinbothlowerlobesare
indicativeofgastrapping.Theresultingpatternhasbeendubbed"headcheese
sign."
Subacutehypersensitivitypneumonia(extrinsicallergic
alveolitis)
Subacutehypersensitivitypneumonia(extrinsicallergicalveolitis)withmultiple
socalledacinarnodulespermeatingtheentirelung.
Chronichypersensitivitypneumonia(extrinsicallergic
alveolitis)
Chronicphaseofhypersensitivitypneumonia(extrinsicallergicalveolitis)dueto
birds.Focalhoneycombingispresentintherightupperlobeandmildbilateral
cylindricalbronchiectasisisvisible.
Computedtomographyofbronchiolitisobliterans
Axialimageshowsamosaicpatternconsistentwithbronchiolitisobliterans.Lowattenuationlungregions
mayrepresenthypoxicvasoconstrictionandgastrapping.Groundglassopacitiesareindicativeofnormal,
hyperperfusedlungparenchyma.
Pulmonaryhemorrhageingranulomatosiswith
polyangiitis(Wegener's)
Illdefinednodulewithanairbronchogramduetohemorrhageandnecrosisin
granulomatosiswithpolyangiitis(Wegener's).
Amiodaronepulmonarytoxicity
Computedtomographicscanobtainedwithoutintravenouscontrastmaterial
revealsahighattenuationrightupperlobeconsolidation(upperpanel).Images
fromtheupperabdomen(lowerpanel)demonstrateincreasedattenuationofthe
liverparenchyma.Theattenuationofthislesionistheresultofiodinedeposition
fromchronicamiodaronetherapy.
Roundedatelectasis
Roundedatelectasisintherightlowerlobe.Thelesionhasacurvilinear
connectiontotherighthilum,asocalledcomettail.Adjacentpleuralthickening
ispresent,whichischaracteristicofroundedatelectasis.
Cavitatingbronchogeniccarcinoma
Theirregularinternalwallcontourandthewallthicknessofthecavitatinglesion
aresuggestiveofmalignancy.
Smallsubpleuralcavitatinglesion
Smallperipheralcavitatinglesioninasubpleurallocation,detectedonlywith
highresolutionCTscan.
Noduleinbronchioloalveolarcellcarcinoma(focal
mucinousadenocarcinoma)
Illdefinednoduleinthesuperiorsegmentofthelingulawithasocalledrabbit
tailextendingtowardstheanterioraspectofthechestwallandanair
bronchogram.Thebronchusextendsintothelesion,assuringahighyieldfor
bronchoscopy.
Computedtomographyofgroundglassnodules
Axialcomputedtomographicimageofatypicalalveolarhyperplasiawithmultiple
smallgroundglassnodulesintheanteriorandposteriorsegmentsoftherightupper
lobe(arrows).
ContributorDisclosures
PaulStark,MD Nothingtodisclose TalmadgeEKing,Jr,MD Nothingtodisclose NestorLMuller,MD,PhD Nothingtodisclose GeraldineFinlay,MD Nothingto
disclose SusannaILee,MD,PhD Nothingtodisclose
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throughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDate
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High Resolution Computed Tomography of The Lungs - UpToDate

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