HRCT LUNGS FINDINGS IN
PULMONARY RENAL SYNDROMES
DR P A CHUI WAN CHEONG OSK
MB BCH BAO DMRD FRCR
• ANATOMY
• BASIC PATTERNS IN HRCT LUNGS
• PULMONARY RENAL SYNDROMES
HRCT LUNGS
• KNOWLEDGE OF LUNG ANATOMY IS ESSENTIAL
FOR UNDERSTANDING HRCT.
• THE SECONDARY LOBULE IS THE BASIC
ANATOMIC UNIT OF PULMONARY STRUCTURE
AND FUNCTION.
• THE INTERPRETATION OF INTERSTITIAL LUNG
DISEASES IS BASED ON THE TYPE OF
INVOLVEMENT OF THE SECONDARY PULMONARY
LOBULE.
• A PRIMARY PULMONARY LOBULE IS A MUCH
SMALLER LUNG UNIT WITH A SINGLE ALVEOLAR
DUCT BUT IS NOT IN COMMON USE.
Lung
Interstitium
PULMONARY LOBULE
- SMALLEST UNIT OF LUNG
STRUCTURE MARGINATED BY
CONNECTIVE TISSUE SEPTA.
- POLYHEDRAL IN SHAPE – UP
TO 2.5CMS IN DIAMETER.
- CLUSTER OF UP TO 30 ACINI
- SUPPLIED BY A DISTAL
PULMONARY ARTERY AND
BRONCHIOLE
- PULMONARY VEIN BRANCHES
AT THE EDGES OF THE UNIT
- LYMPHATICS AT THE EDGES
PULMONARY LOBULE
1. CENTRILOBULAR AREA IS THE
CENTRAL PART OF THE LOBULE
DISEASES COMING FROM AIRWAYS
• HYPERSENSITIVITY PNEUMONITIS
• RESP BRONCHIOLITIS ILD
• CENTRILOBULAR EMPHYSEMA.
2. PERI LYMPHATIC AREA
DISEASES COMING FROM
LYMPHATIC
• SARCOIDOSIS
• LYMPHANGITIC CA
• PULMONARY OEDEMA
HIGH RESOLUTION CT LUNGS
TECHNIQUE
• PLAIN STUDY / LUNG WINDOWS
• HRCT USES THIN SLICE IMAGES OF THE LUNG
PARENCHYMA.
• EXTREMELY HIGH DEFINITION IMAGES OF LUNG
ALVEOLI, AIRWAYS, INTERSTITIUM, AND PULMONARY
VASCULATURE.
• SUPINE POSITION. INSPIRATION IMAGES
• EXPIRATION IMAGES MAY ASSIST IN IDENTIFYING AIR-
TRAPPING IN PATIENTS WITH LUNG DISEASE.
• PRONE – TO DIFFERENTIATE BETWEEN EARLY LUNG
FIBROSIS AND PHYSIOLOGICAL DEPENDENT
ATELECTASIS AT THE LUNG BASES
NORMAL HRCT LUNGS
NORMAL HRCT LUNGS
NORMAL HRCT LUNGS
HRCT BASIC INTERPRETATION
WHAT IS THE DOMINANT
PATTERN ?
– 4 PATTERNS ANY ZONAL PREDOMINANCE?
• RETICULAR • UPPER VS LOWER
• NODULAR • CENTRAL VS PERIPHERAL
• HIGH DENSITY
ANY ANCILLARY FINDINGS?
• LOW DENSITY
• PLEURAL FLUID
WHERE IS IT LOCATED? • CARDIOMEGALY
• CENTRILOBULAR • PULMONARY ARTERIES
• PERILYMPHATIC • LYMPHADENOPATHY
• RANDOM • TRACTION BRONCHIECTASIS
MDTM essential for correct diagnosis.
1. RETICULAR PATTERN – NET LIKE
2. NODULAR PATTERN
LCH
SARCOID
3. HIGH DENSITY PATTERN
GROUND
GLASS
Consolidation
Mosaic
Crazy paving
4. LOW DENSITY PATTERN
PULMONARY RENAL SYNDROMES (PRS)
- RARE MEDICAL SYNDROME WITH A HIGH RATE
OF MORBIDITY AND DEATH
- RESPIRATORY FAILURE DUE TO DIFFUSE
ALVEOLAR HAEMORRHAGE (DAH)
- RENAL FAILURE – GLOMERULONEPHRITIS
PRS – COMMONLY CAUSED BY UNDERLYING AUTO IMMUNE DISEASES
1. PULMONARY VASCULITIDES – CAPILLARITIS
- ANCA ASSOCIATED PULMONARY VASCULITIDES
EG GPA - WEGENER’S, EGPA - CHURG STRAUSS, MICROSCOPIC PA
- NON ANCA PULMONARY VASCULITIDES EG. GOODPASTURE
2. OTHER CAUSES :
SLE
CONNECTIVE TISSUE DISORDERS EG. DERMATOMYOSITIS
POST STREP GN
RHEUMATOID ARTHRITIS
SYSTEMIC SCLEROSIS
3. TOXIC INJURY EG PARAQUAT
4. INFECTION – HANTA VIRUS LEPTOSPIROSIS LEGIONELLA
5. VASCULAR – NEPHROTIC SYNDROME WHERE RENAL VEIN THROMBOSIS
EMBOLISES TO THE LUNG
PRS CAUSES DAH
- CAPILLARITIS
- BLEEDING IS DIFFUSE AND
DIRECTLY INTO THE ALVEOLAR
SPACES
PULMONARY RENAL SYNDROMES (PRS)
HRCT LUNGS
• CXR – OFTEN NON
DIAGNOSTIC
• HEMOPTYSIS MAY BE
LACKING
• PULMONARY
HAEMORRHAGE
• - DIFFUSE INFILTRATIVE
PATTERN
• - MID ZONE PREDILECTION
• - APICAL SPARING
HRCT IN DAH
• CLINICAL CONTEXT IS CRUCIAL IN IMAGE
INTERPRETATION
• HRCT PATTERN CAN VARY WITH TIME OF ONSET OF
HAEMORRHAGE
MOST COMMON FINDINGS:
- PATCHY OR DIFFUSE GGO, CONSOLIDATION OR BOTH
- ILL DEFINED CENTRILOBULAR NODULES
- INTERLOBULAR SEPTAL THICKENING DEVELOPS OVER
DAYS
- GGO + RETICULAR = CRAZY PAVING PATTERN
CAUSES OF
GGO/CRAZY PAVING/CONSOLIDATION
AIP / ARDS
• PULMONARY OEDEMA
• PULMONARY HAEMORRHAGE
• PNEUMONIA EG BACTERIAL MYCOPLASMA VIRAL - COVID 19
• ORGANIZING PNEUMONIA
• EOSINOPHILIC PNEUMONIA
• RADIATION PNEUMONITIS
• NSIP
• UIP/IPF
• RB-ILD / DIP (SMOKER’S LUNG DISEASE)
• HYPERSENSITIVITY PNEUMONITIS – ACUTE SUBACUTE CHRONIC
• BAC – LUNG ADENOCA
• SARCOIDOSIS
• LIPOID PNEUMONIA
• ALVEOLAR PROTEINOSIS
• LYMPHOMA - MALT
Stephano Palmucci et al, Diagnostics Dec 2021
PULMONARY HAEMORRHAGE – DIFFUSE ALVEOLAR
HAEMORRHAGE (DAH)
ACUTE PHASE:
LOBULAR OR LOBAR AREAS OF
GROUND GLASS OPACITIES TO
PREDOMINANT CONSOLIDATION.
Stephano Palmucci et al, Diagnostics Dec 2021
PULMONARY HAEMORRHAGE – DIFFUSE ALVEOLAR
HAEMORRHAGE (DAH)
• SUB ACUTE : 2-3 DAYS
• RETICULAR SHADOWS :
INTRALOBULAR AND
INTERLOBULAR SEPTAL
THICKENING
SUPERIMPOSED ON AREAS
OF GGO.
• CRAZY PAVING PATTERN
• THESE CAN OFTEN
RESOLVE
CHURG STRAUSS
PULMONARY HAEMORRHAGE – DIFFUSE ALVEOLAR
HAEMORRHAGE (DAH)
BETWEEN CHRONIC
RECURRENT BLEEDING
EVENTS:
- ILL DEFINED CENTRILOBULAR
NODULES
- REFLECTING AN INTRA ALVEOLAR
ACCUMULATION OF PULMONARY
MACROPHAGES
- NODULES ARE USUALLY UNIFORM
IN SIZE (1-3 MM)
- MAY CAVITATE
- DIFFUSELY DISTRIBUTED GPA – WEGENER’S
- NO ZONAL PREDOMINANCE
PULMONARY HAEMORRHAGE – DIFFUSE
ALVEOLAR HAEMORRHAGE (DAH)
• WITH SEVERE REPEATED
HAEMORRHAGE CAN LEAD TO
ORGANIZING PNEUMONIA
ORGANIZING PNEUMONIA
• REPRESENTS AN INFLAMMATORY
PROCESS IN WHICH THE HEALING
PROCESS IS CHARACTERIZED BY
ORGANIZATION AND
CICATRIZATION OF THE EXUDATE
RATHER THAN BY RESOLUTION
AND RESORPTION.
• IT IS ALSO DESCRIBED AS
'UNRESOLVED PNEUMONIA'.
• GRANULOMATOUS TISSUE IN THE
AIR SPACES
• FORM MASSON BODIES -
FIBROBLASTS, INFLAMMATORY
CELLS, FIBRIN.
OP : CAUSES
• CRYPTOGENIC – COP - 50%
• PNEUMONIA
• ASPIRATION
• TOXIC FUME INHALATION
• DRUGS
• RADIATION
• CHEMOTHERAPY
• CONNECTIVE TISSUE DISEASE - DAH
• GRAFT VS HOST DISEASE
OP – HRCT PATTERN
MANY TYPES OF APPEARANCES -
• ATOLL SIGN OR REVERSE HALO SIGN
• CENTRAL PERI-BRONCHIAL OR PERIPHERAL
CONSOLIDATION
• PERILOBULAR INTERSTITIAL THICKENING OR
CONSOLIDATION
• LINEAR OR BAND LIKE OPACITIES
• NODULES
Peri broncho vascular consolidation
PERIPHERAL PERI LOBULAR
CONSOLIDATION INTERSTITIAL THICKENING
Post Covid 19 OP
DDay 10
Day 5
OP - Toxic NH3 inhalation
Linear / band like opacities
Day 10
COP – NODULAR PATTERN
? COP
OP – ATOLL SIGN / REVERSE HALO SIGN
OP – ATOLL SIGN / REVERSE HALO SIGN
Mass like consolidation
DIFFUSE ALVEOLAR HAEMORRHAGE (DAH)
• WITH SEVERE REPEATED HAEMORRHAGE:
ORGANIZING PNEUMONIA MAY PROGRESS
TO INTERSTITIAL LUNG FIBROSIS.
VOLUME LOSS
UIP/IPF : TRACTION BRONCHIECTASIS
- CORRUGATED APPEARANCE
HONEYCOMBING – END STAGE LUNG FIBROSIS
Small cystic spaces with irregularly thickened
walls composed of fibrous tissue.
Stephano Palmucci et al, Diagnostics Dec 2021
SUMMARY – PRS
• THE HRCT LUNG PATTERN IN PRS NON
SPECIFIC – MAINLY GGO, CONSOLIDATIONS
AND NODULES.
• THE DIAGNOSIS IS OFTEN DELAYED— AS
OTHER DISEASE COULD HAVE SIMILAR
CLINICAL AND RADIOLOGICAL
MANIFESTATIONS.
• FIBROTIC CHANGES CAN OCCUR AND
OFTEN NOT PATHOGNOMONIC.
• A MULTIDISCIPLINARY APPROACH IS
STRONGLY RECOMMENDED FOR
DIAGNOSIS.
THANK YOU
