Signs and patterns of Lung Disease

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Signs and patterns of Lung Disease:

Dr. Varun Babu Md resident Aims, kochi Signs and patterns of Lung Disease

Air bronchogram sign:

Air bronchogram sign Dr. Varun Branching, linear, tubular lucency representing a bronchus or bronchiole passing through airless lung parenchyma Does not differentiate non obstructive atelectasis from other abnormal parenchymal opacities like pneumonia Indicates underlying opacity is parenchymal rather than pleural or mediastinal

Air crescent sign:

Air crescent sign Dr. Varun Mass growing within a pre existing cavity or an area of pneumonia that undergoes necrosis or cavitates Forms a peripheral crescent of air between the intracavitary mass and the cavity wall Mycetomas

Bulging fissure sign:

Bulging fissure sign Dr. Varun Klebsiella pneumonia involving upper right lobe. Confined to one lobe, with consolidation spreading rapidly, causing lobar expansion and bulging of the adjacent fissure inferiorly

Continuous diaphragm sign:

Continuous diaphragm sign Dr. Varun Continuous lucency outlining the base of the heart, represents pneumomediastinum Air in the mediastinum tracks extra pleurally between heart and diaphragm

CT angiogram sign:

CT angiogram sign Dr. Varun Identification of vessels within an airless portion of lung on contrast enhanced CT Vessels are prominently seen against a background of low attenuation material Bronchoalveolar carcinoma, lymphoma, infective pneumonias.

Deep sulcus sign:

Deep sulcus sign Dr. Varun Deep, sometimes finger like collection of intra pleural air ( pneumothorax ) in the costophrenic sulcus as seen on supine CXR Air rises to the non dependent anteromedial basilar pleural surface, may not cause displacement of visceral pleural line laterally or at the apex

Fallen lung sign:

Fallen lung sign Dr. Varun Appearance of the collapsed lung occurring with a fractured bronchus Lung falls away from the hilum Inferiorly, laterally in the upright film Posteriorly in supine film

Flat waist sign:

Flat waist sign Dr. Varun Flattening of the contours of the aortic knob and adjacent main pulmonary artery Seen in severe collapse of left lower lobe; caused by leftward displacement and rotation of heart

Finger-in-glove sign:

Finger-in-glove sign Dr. Varun In ABPA, bronchi become impacted with mucus, cellular debris, eosinophils and fungal hyphae Impacted bronchi appear radiographically as opacities with distinctive shapes – variously described as gloved finger, inverted toothpaste etc

Golden S sign:

Golden S sign Dr. Varun When a lobe collapses around a large central mass, the peripheral lung collapses & central portion of the lung is prevented from collapsing by the presence of the mass The relevant fissure is concave towards the lung peripherally but convex centrally & shape of the fissure resembles an S or reverse S Signifies presence of a central obstructing mass ? Bronchogenic carcinoma

Halo sign:

Halo sign Dr. Varun Ground glass attenuation on CT that surrounds, or forms a halo around, a denser nodule or area of consolidation. Hemorrhagic pulmonary nodules produces this sign When seen in acute leukemia, suggests early invasive pulmonary aspergillosis

Hampton hump sign:

Hampton hump sign Dr. Varun Pulmonary infarction secondary to pulmonary embolism produces an abnormal area of opacification on the chest radiograph, which is always in contact with the pleural surface May assume a variety of shapes

Juxtaphrenic peak sign:

Juxtaphrenic peak sign Dr. Varun Small triangular shadow obscures the dome of the diaphragm, secondary to upper lobe atelectasis . Shadow is caused by traction on the lower end of the major fissure, inferior accessory fissure or the inferior pulmonary ligament

Luftsichel sign (Luft –air; Sichel - sickle):

Luftsichel sign ( Luft –air; Sichel - sickle) Dr. Varun In left upper lobe collapse, the superior segment of the left lower lobe, which is positioned between the aortic arch & the collapsed left upper lobe, is hyperinflated . This aerated segment is hyperlucent , sickle shaped where it outlines the aortic arch. This periaortic lucency is called Luftsichel sign More commonly seen on the left.

Melting ice cube sign:

Melting ice cube sign Dr. Varun Appearance of a resolving pulmonary infarct on a chest radiograph or CT, which looks like an ice cube that is melting peripherally to internally. Distinguished from the pattern of resolving pneumonia, where opacification disappears in a patchy fashion

Ring around the artery sign:

Ring around the artery sign Dr. Varun Well defined lucency encircling the right pulmonary artery Suggestive of pneumomediastinum

Silhouette sign:

Silhouette sign Dr. Varun Obliteration of the borders of the heart, other mediastinal structures or diaphragm by an adjacent opacity of similar density. An intra thoracic lesion not anatomically contiguous with a border of one of these structures will not obliterate the border.

Split pleura sign:

Split pleura sign Dr. Varun Normally the thin visceral and parietal pleura cannot be distinguished as two separate structures on CT scanning. With an exudative pleural effusion, such as empyema , the fluid separates the thickened and enhancing pleural layers.

Westermark sign:

Westermark sign Dr. Varun Oligemia of the lung beyond an occluded vessel in a patient with pulmonary embolism.

Spine sign:

Spine sign Dr. Varun Lower lobe pneumonia may be poorly visualized on a PA radiograph Lateral view reveals an interruption in the progressive increase in the lucency of the vertebral bodies from superior to inferior

Honeycomb pattern:

Honeycomb pattern Dr. Varun Cystic spaces with thick, clearly definable fibrous walls lined by bronchiolar epithelium. Due to destruction of alveoli and loss of acinar architecture; associated with pulmonary fibrosis Cysts typically layered along the pleural surface (non layered subpleural lucencies – para septal emphysema)

Honeycomb pattern:

Honeycomb pattern Dr. Varun Cystic spaces avg 1cm in diameter, clearly definable walls 1-3mm thick, air filled, appear lucent when compared to lung parenchyma. a/w other findings like architectural distortion, intralobular interstitial thickening, traction bronchiectasis , irregular linear opacities

Honeycomb pattern:

Honeycomb pattern Dr. Varun D/Ds Idiopathic pulmonary fibrosis Collagen vascular disease Asbestosis Chronic hypersensitivity pneumonitis Drug related fibrosis

Septal thickening :

Septal thickening Dr. Varun Interlobular septum marginates part of a secondary pulmonary lobule and contains pulmonary veins and lymphatics Measures 0.1mm in thickness. Abnormal thickening – fibrosis, edema or infiltration by cells or other material In peripheral lung, thickened septa 1-2cm long, perpendicular to pleural surface corresponds to Kerley B lines. Thickening can be smooth or nodular

Septal thickening :

Septal thickening Dr. Varun Smooth thickening Pulmonary edema or hemorrhage Lymphangitic spread of carcinoma, lymphoma, leukemia Interstitial infiltration with amyloid Some pneumonias

Septal thickening :

Septal thickening Dr. Varun Nodular thickening Lymphangitic spread of carcinoma, lymphoma Sarcoidosis Silicosis, coal workers pneumoconiosis Lymphocytic interstitial pneumonia Amyloidosis

Cystic pattern :

Cystic pattern Dr. Varun Thin walled, well defined, well circumscribed, air or fluid containing lesion, 1cm or more in diameter, with an epithelial or fibrous wall. Results from a heterogeneous group of diseases that have in common the presence of focal or multifocal or diffuse parenchymal lucencies & lung destruction. D/Ds Langerhan cell histiocytosis Lymphangioleiomyomatosis Sarcoidosis Lymphocytic interstitial pneumonitis Collagen vascular diseases Pneumocystis pneumonia Centrilobular emphysema & cystic bronchiectasis mimic cystic disease

Cystic pattern :

Cystic pattern Dr. Varun Langerhan cell histiocytosis Cysts are confluent, thin walled, associated with pulmonary nodules 1-5mm that may or may not be cavitatory Intervening lung parenchyma is typically normal. Without evidence of fibrosis or septal thickening. Distribution is upper lungs with sparing of costophrenic sulci

Cystic pattern :

Cystic pattern Dr. Varun Lymphangioleiomyomatosis Diffusely distributed cysts throughout the lungs, nodules not a common feature. Centrilobular emphysema Cystic spaces contain a small nodular opacity representing the centrilobular artery. Helps distinguish from the other 2.

Nodular pattern:

Nodular pattern Dr. Varun Multiple round opacities, miliary (millet seeds)– 1-2mm, small, medium or large Further characterized by Margins – smooth/irregular Cavitation Attenuation – GGO or calcification Distribution – centrilobular , perilymphatic or random When associated with irregular shaped thin walled cysts, randomly distributed, consider Langerhan cell histiocytosis Mutiple cavitary nodules Metastases ( squamous cell) Wegener granulomatosis Rheumatoid lung disease Septic emboli Mutlifocal infection

Nodular pattern:

Nodular pattern Dr. Varun Sarcoidosis Multiple small smooth or irregularly marginated nodules in a perilymphatic distribution Nodules represent coalescence of microscopic noncaseating granulomas distributed along the bronchoarterial bundles, interlobular septa and subpleural regions Silicosis/coal workers Similar appearance, with random nodule distribution with upper zone predominance Within affected areas, shows a posterior distribution Coalescence of nodules leads to progressive massive fibrosis

Nodular pattern:

Nodular pattern Dr. Varun Extrinsic allergic alveolitis /respiratory bronchiolitis Numerous small nodules of GGO in a centrilobular distribution typical of acute/sub acute stage Nodules are poorly defined, <3mm

Nodular pattern:

Nodular pattern Dr. Varun Tuberculosis/fungal/metastases Random distribution of miliary nodules in hematogenous spread

Nodular pattern:

Nodular pattern Dr. Varun Mutliple irregular nodules in a bronchovascular distribution Benign lymphoproliferative disorders Lymphoma Leukemia Kaposi sarcoma

Ground glass pattern:

Ground glass pattern Dr. Varun Hazy increased attenuation of lung, with preservation of bronchial and vascular margins Caused by partial filling of air spaces, interstitial thickening, partial collapse of alveoli, normal expiration, or increased capillary blood volume. May be associated with air bronchogram Reflects the presence of abnormalities below the limit of CT resolution Non specific for either interstitium or air space

Ground glass pattern:

Ground glass pattern Dr. Varun Acute causes Pneumonia Pulmonary hemorrhage Pulmonary edema In AIDS, focal or diffuse GGO is highly suggestive of Pneumocystis pneumonia In lung transplant patients CMV pneumonia Acute rejection 1 month following bone marrow transplant Infection Diffuse alveolar hemorrhage Diffuse or patchy GGO Acute/sub acute phase of extrinsic allergic alveolitis Solitary small areas of GGO Early bronchoalveolar carcinoma Atypical adenomatous hyperplasia

Ground glass pattern:

Ground glass pattern Dr. Varun Pulmonary alveolar proteinosis Patchy or geographic GGO distribution Filling of air spaces with proteinaceous material Interlobular septal thickening Crazy paving pattern Desquamative interstitial pneumonia Mild interstitial thickening and filling of airspaces with macrophages Crazy paving pattern

Mosaic pattern of lung attenuation:

Mosaic pattern of lung attenuation Dr. Varun Lung attenuation normally increases during expiration In the presence of air trapping, lung remains lucent on exhalation Air trapping can be patchy/non anatomic; can correspond to lung units or involve entire lung Bronchiectasis is a common association

Mosaic pattern of lung attenuation:

Mosaic pattern of lung attenuation Dr. Varun Pulmonary vessels within the low attenuation areas appear smaller than the more opaque normal lung regions D/Ds Infiltrative processes, airway obstruction & reflex vasoconstriciton Mosaic perfusion due to vascular obstruction (chronic thromboembolic disease) Expiratory CT helps confirm a pulmonary cause and rule out cardiac cause

Tree-in-bud pattern:

Tree-in-bud pattern Dr. Varun Centrilobular nodular and branching linear opacities Infectious processes with endobronchial spread of disease Causes Bronchiolar dilatation Impaction of bronchioles with mucus, pus or other material.

Tree-in-bud pattern:

Tree-in-bud pattern Dr. Varun Suggests endobronchial spread of infection into the bronchioles ABPA Immunological response to endobronchial Aspergillus growth, bronchial wall damage and central bronchiectasis & formation of mucous plugs that contain fungus and inflammatory cells Cystic fibrosis Low water content of airway mucus, mucus plugging, increased infection. Bronchial wall inflammation – bronchiectasis and bronchiolar secretions Aspiration of infected oral secretions or other irritant material, diffuse panbronchiolitis , obliterative bronchiolitis and asthma

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