Lymphocytic interstitial pneumonia: follow-up CT findings in 14 patients

Evolution of Pulmonary Involvement in Idiopathic Multicentric Castleman Disease-Not Otherwise Specified: From Nodules to Cysts or Consolidation

BACKGROUND

Previous studies about multicentric Castleman disease-associated pulmonary manifestations have been limited by small cohorts and not following the Castleman Disease Collaborative Network classification criteria of multicentric Castleman disease. The pulmonary manifestations in idiopathic multicentric Castleman disease-not otherwise specified (iMCD-NOS), a distinct clinical phenotype in the classification criteria, have not been reported.

RESEARCH QUESTION

Which pulmonary abnormalities in iMCD-NOS are advanced manifestations and which are reversible after effective treatment?

STUDY DESIGN AND METHODS

Patients diagnosed with iMCD-NOS with pulmonary involvement were enrolled. The baseline CT scan was evaluated for the presence and anatomic locations of pulmonary abnormalities. Patients were further divided into different subgroups according to baseline CT scan manifestations. Follow-up CT scan was reviewed to assess the changes in pulmonary lesions among patients without and with treatment.

RESULTS

Of 162 patients with iMCD-NOS, 58 individuals (35.8%) with pulmonary involvement were identified. Pulmonary manifestations included nodules (96.6%), cysts (65.5%), consolidation (22.4%), interstitial thickening (50.0%-87.9%), and ground-glass opacities (55.2%). Patients (n = 58) were further classified into nodule (n = 15), cyst (n = 33), and consolidation (n = 10) subgroups. Patients in the consolidation (median, 67 months) and cyst (median, 23 months) subgroups had a longer duration of symptoms before the baseline CT examination than those in the nodule subgroup (median, 12 months) (P = .016). During follow-up, the evolution of pulmonary lesions from nodules to cysts was observed in two patients without treatment. After treatment, pulmonary lesions, except for cysts, improved in most patients. Moreover, nodules or cysts progressed into consolidation in two patients.

INTERPRETATION

Pulmonary involvement is not rare in iMCD-NOS. Chest CT scan examination is very essential in finding potential pulmonary abnormalities. Pulmonary manifestations follow a unique pattern with evolution from nodules to cysts or consolidation, the latter of which can also form in cystic areas. Timely diagnosis of pulmonary involvement is crucial because of possible reversibility after treatment.

Lymphocytic interstitial pneumonia presenting with a ground glass nodule: A case report and literature review

RATIONALE

Lymphocytic interstitial pneumonia (LIP) is a rare benign lymphoproliferative disorder, often associated with autoimmune diseases. Most LIPs present with multiple bronchial cysts and diffuse interstitial infiltration. It is histologically characterized by widespread diffuse lymphocytic infiltration of the pulmonary interstitium, and the enlargement and widening of the alveolar septum.

PATIENT CONCERNS

A 49-year-old woman was admitted to hospital for finding pulmonary nodules for more than 2 months. 3D imaging chest computed tomography (CT) examination of both lungs showed that there was a middle lobe of the right lung with a size of about 1.5 cm × 1.1 cm ground-glass nodules.

DIAGNOSES

A single operating port thoracoscopic wedge resection biopsy of a right middle lung nodule was performed. The pathology showed diffuse lymphocytic infiltration with varying numbers of small lymphocytes, plasma cells, macrophages and histiocytes infiltrating the alveolar septa, widened and enlarged alveolar septa, and scattered lymphoid follicles. Immunohistochemically, CD20 positive in follicular area, CD3 positive in interfollicular area. LIP was considered.

INTERVENTIONS

The patient was regularly followed without any specific treatment.

OUTCOMES

Follow-up chest CT showed no significant abnormalities in the lungs 6 months after surgery.

LESSONS

To the best of our knowledge, our case may be the second reported case of a patient with LIP presenting with a ground glass nodule on chest CT, and it is speculated that the ground glass nodule may be an early manifestation of idiopathic LIP.

Lymphangioleiomyomatosis and Other Cystic Lung Diseases

Cysts and cavities in the lung are commonly encountered on chest imaging. It is necessary to distinguish thin-walled lung cysts (≤2 mm) from cavities and characterize their distribution as focal or multifocal versus diffuse. Focal cavitary lesions are often caused by inflammatory, infectious, or neoplastic processes in contrast to diffuse cystic lung diseases. An algorithmic approach to diffuse cystic lung disease can help narrow the differential diagnosis, and additional testing such as skin biopsy, serum biomarkers, and genetic testing can be confirmatory. An accurate diagnosis is essential for the management and disease surveillance of extrapulmonary complications.

Cystic lung disease

The term cystic lung disease encompasses a heterogeneous group of entities characterised by round lung lesions that correspond to cysts with fine walls, which usually contain air. The differential diagnosis of these lesions can be challenging, requiring both clinical and radiological perspectives. Entities such as pulmonary emphysema and cystic bronchiectasis can simulate cystic disease. High-resolution computed tomography (HRCT) is the imaging technique of choice for the evaluation and diagnosis of cystic lung disease, because it confirms the presence of lung disease and establishes the correct diagnosis of the associated complications. In many cases, the diagnosis can be established based on the HRCT findings, thus making histologic confirmation unnecessary. For these reasons, radiologists need to be familiar with the different presentations of these entities. A wide variety of diseases are characterised by the presence of diffuse pulmonary cysts. Among these, the most common are lymphangioleiomyomatosis, which may or may not be associated with tuberous sclerosis, Langerhans cell histiocytosis, and lymphocytic interstitial pneumonia. Other, less common entities include Birt-Hogg-Dubé syndrome, amyloidosis, and light-chain deposit disease. This article describes the characteristics and presentations of some of these entities, emphasizing the details that can help differentiate among them.

Imaging of Lung Disease Associated with Connective Tissue Disease

There is a well-known association between the connective tissue disorders (CTDs) and lung disease. In addition to interstitial lung disease, the CTDs may affect the air spaces and pulmonary vasculature. Imaging tests are important not only in diagnosis but also in management of these complex disorders. In the present review, key aspects of the imaging of CTD-reated diseases are discussed.

Lymphocytic interstitial pneumonia: computed tomography findings in 36 patients

Objective

To analyze the computed tomography (CT) findings of lymphocytic interstitial pneumonia (LIP).

Materials and Methods

We retrospectively reviewed the clinical and CT findings of 36 patients with LIP, including 25 women and 11 men, with a mean age of 52.5 years (age range, 22-78 years).

Results

The main associated diseases with LIP were Sjögren syndrome (42%), human immunodeficiency virus infection (17%), amyloidosis (17%), Sjögren syndrome associated with secondary amyloidosis (11%), idiopathic (8%), and systemic lupus erythematosus (5%). The predominant CT abnormalities were multiple cystic airspaces (n = 35), small nodules (n = 15), ground-glass opacities (n = 13), bronchiectasis and/or bronchiolectasis (n = 8), and thickening of the bronchovascular bundles (n = 8). Other CT findings included reticular opacities (n = 7), calcified nodules (n = 4), airspace consolidation (n = 4), emphysema (n = 3), honeycombing (n = 3), lymph node enlargement (n = 2), mosaic attenuation pattern (n = 1), and cavitated nodules (n = 1).

Conclusion

The main CT findings of LIP were multiple cysts, small nodules, and ground-glass opacities.

Ultra-rare cystic disease

Diffuse cystic lung diseases include a group of heterogeneous disorders characterised by the presence of cysts within the lung parenchyma, sometimes showing a characteristic computed tomography scan pattern that allows diagnosis. The pathogenetic mechanisms underlying cyst formation in the lung are still not clear and a number of hypotheses have been postulated according to the different aetiologies: ball-valve effect, ischaemic dilatation of small airways and alveoli related to infiltration and obstruction of small vessels and capillaries that supply the terminal bronchioles and connective tissue degradation by matrix metalloproteases. A wide number of lung cyst diseases have been classified into six diagnostic groups according to the aetiology: neoplastic, congenital/genetic, lymphoproliferative, infective, associated with interstitial lung diseases, and other causes. This article focuses on lymphangioleiomyomatosis, pulmonary Langerhans cell histiocytosis and Erdheim–Chester disease, Birt–Hogg–Dubé, follicular bronchiolitis and lymphocytic interstitial pneumonia, light-chain deposition disease and amyloidosis, congenital lung disease associated with aberrant lung development and growth, and cystic lung disease associated with neoplastic lesion. These cystic diseases are epidemiologically considered as ultra-rare conditions as they affect fewer than one individual per 50 000 or fewer than 20 individuals per million. Despite the rarity of this group of disorders, the increasing use of high-resolution computed tomography has improved the diagnostic yield, even in asymptomatic patients allowing prompt and correct therapy and management without the need for a biopsy.

Diffuse cystic lung diseases show a characteristic CT scan pattern that often allows for diagnosis, even in asymptomatic patients, allowing prompt correct therapy and management without the needing of a biopsyhttps://bit.ly/2wIUKet

Characteristics of primary Sjögren's syndrome related lymphocytic interstitial pneumonia

Objective

This paper is aimed at investigating the clinical characteristics of primary Sjogren’s syndrome (pSS) with lymphocytic interstitial pneumonia (LIP).

Methods

The demographic data, clinical manifestations, laboratory and radiological findings, treatment, and prognosis from 15 cases of pSS-LIP patients were retrospectively analyzed. The data were compared with t test, χ² test, and Pearson/Spearman correlation analysis.

Results

(1) Fifteen cases of patients with pSS-LIP are all females (100%). Compared with pSS with interstitial lung disease(pSS-ILD) patients, the incidence of dry cough, dental caries is higher in pSS-LIP patients. The incidence of shortness of breath, weight loss, and crackles is lower in pSS-LIP patients than that of pSS-ILD patients. (2) Compared with pSS-ILD patients, pSS-LIP patients had higher percentage of patients with ANA, anti-SSA52KD antibody, anti-SSA60KD antibody, and anti-SSB antibody, and the higher concentration of serum globulin. (3) Compared with pSS-ILD patients, the frequency of obstructive ventilation dysfunction is significantly higher and the frequency of diffusion dysfunction is significantly lower in pSS-LIP patients. (4) The most frequent HRCT findings in patients with pSS-LIP is cysts (100%), followed by ground-glass opacities (73.3%), nodular shadow (73.3%) among the pSS-LIP patients. Compared with PSS-ILD patients, the incidence of pulmonary nodule shadow is significantly higher in PSS-LIP patients, while that of grid shadow was significantly lower. (5) Compared with the baseline, the sum of the number, maximum diameter, and diameter of cysts in three levels of pSS-LIP patients showed an increasing trend after treatment. (6) Correlation analysis: The changes of ground-glass opacities were positively correlated with using GC or not, and those were negatively correlated with the dose of GC treatment. Besides, there is a positive correlation between the annual change rate of the maximum diameter of cysts (△Ømax1/t) and the use of CTX; there is a positive correlation between the annual change rate of the total diameter of cysts (△Øsum1/t) and the use of CTX.

Conclusion

To the patients of pSS-LIP, female were more common than male, and the onset of LIP was usually more insidious. Hyperglobulinemia and anti-SSA antibody were more prominent in patients with pSS-LIP. Pulmonary function showed the higher rate of obstructive ventilation dysfunction and the lower rate of diffusion dysfunction. The appearance of ground-glass opacities in pSS-LIP patients suggests that the infiltration of inflammatory cells increases, which may cause airway compression, the expansion of terminal bronchioles, and the formation of cysts. The more ground-glass opacities appear earlier, and the more appearance of new cysts later. Therapy with glucocorticoid may be effective on the ground-glass opacity during acute stage, and therapy with cyclophosphamide may be effective on the cysts during chronic stage. The heavier ground-glass opacity is at baseline, the more likely it will recur during maintenance treatment. So follow-up closely is needed.

Key Points • It is the first clinical study with more cases of patients with pSS-LIP. • Female and hyperglobulinemia and anti-SSA antibody were more prominent in patients with pSS-LIP. • Pulmonary function showed the higher rate of obstructive ventilation dysfunction and the lower rate of diffusion dysfunction. • Therapy with glucocorticoid may be effective on the ground-glass opacity during acute stage, and therapy with cyclophosphamide may be effective on the cysts during chronic stage.

Aspergilloma Superimposed Infection on Lymphoid Interstitial Pneumonia

We describe a case of a 27-year-old female without any prior underlying immunodeficiency syndromes who presented with hemoptysis secondary to subacute invasive pulmonary aspergillosis and subsequently diagnosed with lymphoid interstitial pneumonia (LIP). CT chest demonstrated bilateral interstitial disease with patchy opacities and multiple large cysts and bullae. Diagnosis was confirmed histologically after surgical lung resection of the mycetoma containing cavitation. Therefore, LIP should be suspected in patients presenting with opportunistic infections in the setting of cystic lung disease.

Pulmonary Involvement in Sjögren Syndrome

Sjögren syndrome (SS) is a progressive autoimmune disease characterized by dryness, predominantly of the eyes and mouth, caused by chronic lymphocytic infiltration of the lacrimal and salivary glands. Extraglandular inflammation can lead to systemic manifestations, many of which involve the lungs. Studies in which lung involvement is defined as requiring the presence of respiratory symptoms and either radiograph or pulmonary function test abnormalities quote prevalence estimates of 9% to 22%. The most common lung diseases that occur in relation to SS are airways disease and interstitial lung disease. Evidence-based guidelines to inform treatment recommendations for lung involvement are largely lacking.

Pulmonary manifestations of Sjögren's syndrome

In 9-20% of cases, Sjögren's syndrome is associated with various respiratory symptoms. The most typical manifestations are chronic interstitial lung disease (ILD) and tracheobronchial disease. The most common manifestation of ILD is nonspecific interstitial pneumonia in its fibrosing variant. Other types of ILD, such as organising pneumonia, usual interstitial pneumonia and lymphocytic interstitial pneumonitis, are rare. Their radiological presentation is less distinctive, and definitive diagnosis may require the use of transbronchial or surgical lung biopsy. Corticosteroid therapy is the mainstay of ILD treatment in Sjögren's syndrome, but the use of other immunosuppressive drugs needs to be determined. ILD is a significant cause of death in Sjögren's syndrome. Tracheobronchial disease is common in Sjögren's syndrome, characterised by diffuse lymphocytic infiltration of the airway. It is sometimes responsible for a crippling chronic cough. It can also present in the form of bronchial hyperresponsiveness, bronchiectasis, bronchiolitis or recurrent respiratory infections. The management of these manifestations may require treatment for dryness and/or inflammation of the airways. Airway disease has little effect on respiratory function and is rarely the cause of death in Sjögren's syndrome patients. Rare respiratory complications such as amyloidosis, lymphoma or pulmonary hypertension should not be disregarded in Sjögren's syndrome patients.

Primary Pulmonary Lymphoid Lesions: Radiologic and Pathologic Findings

The pulmonary lymphoid system is complex and is composed of two compartments: the pulmonary lymphatics and the bronchus-associated lymphoid tissue (BALT). Additional important cells that function in the pulmonary lymphoid system include dendritic cells, Langherhans cells, macrophages, and plasma cells. An appreciation of the normal lymphoid anatomy of the lung as well as its immunology is helpful in understanding the radiologic and pathologic findings of the primary pulmonary lymphoid lesions. Primary lymphoid lesions of the lung arise from the BALT and are uncommon. However, they are increasingly recognized within the growing number of posttransplant patients as well as other patients who are receiving immunosuppressive therapies. Primary lymphoid lesions encompass a wide range of benign and malignant lesions. Benign lymphoid lesions of the lung include reactive lymphoid hyperplasia, follicular bronchiolitis, lymphoid interstitial pneumonia, and nodular lymphoid hyperplasia. Malignant lymphoid lesions of the lung include low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT), other non-Hodgkin lymphomas, and Hodgkin lymphoma. Last, a miscellaneous group of primary lymphoid lesions includes lymphomatoid granulomatosis, posttransplant lymphoproliferative disorders, acquired immunodeficiency syndrome (AIDS)-related lymphoma, and intravascular lymphoma/lymphomatosis. These lesions are best evaluated with multidetector chest computed tomography. The radiologic findings of the primary lymphoid lesions are often nonspecific and are best interpreted in correlation with clinical data and pathologic findings. The purpose of this article is to review pulmonary lymphoid anatomy as well as the most common primary pulmonary lymphoid disorders.

Lymphocytic Interstitial Pneumonia

Lymphocytic interstitial pneumonia (LIP) is a rare lung disease on the spectrum of benign pulmonary lymphoproliferative disorders. LIP is frequently associated with connective tissue diseases or infections. Idiopathic LIP is rare; every attempt must be made to diagnose underlying conditions when LIP is diagnosed. Computed tomography of the chest in patients with LIP may reveal ground-glass opacities, centrilobular and subpleural nodules, and randomly distributed thin-walled cysts. Demonstrating polyclonality with immunohistochemistry is the key to differentiating LIP from lymphoma. The 5-year mortality remains between 33% and 50% and is likely to vary based on the underlying disease process.

American Thoracic Society-European Respiratory Society Classification of the Idiopathic Interstitial Pneumonias: Advances in Knowledge since 2002

In the updated American Thoracic Society-European Respiratory Society classification of the idiopathic interstitial pneumonias (IIPs), the major entities have been preserved and grouped into (a) "chronic fibrosing IIPs" (idiopathic pulmonary fibrosis and idiopathic nonspecific interstitial pneumonia), (b) "smoking-related IIPs" (respiratory bronchiolitis-associated interstitial lung disease and desquamative interstitial pneumonia), (c) "acute or subacute IIPs" (cryptogenic organizing pneumonia and acute interstitial pneumonia), and (d) "rare IIPs" (lymphoid interstitial pneumonia and idiopathic pleuroparenchymal fibroelastosis). Furthermore, it has been acknowledged that a final diagnosis is not always achievable, and the category "unclassifiable IIP" has been proposed. The diagnostic interpretation of the IIPs is often challenging because other diseases with a known etiology (most notably, connective tissue disease and hypersensitivity pneumonitis) may show similar morphologic patterns. Indeed, more emphasis has been given to the integration of clinical, computed tomographic (CT), and pathologic findings for multidisciplinary diagnosis. Typical CT-based morphologic patterns are associated with the IIPs, and radiologists play an important role in diagnosis and characterization. Optimal CT quality and a systematic approach are both pivotal for evaluation of IIP. Interobserver variation for the various patterns encountered in the IIPs is an issue. It is important for radiologists to understand the longitudinal behavior of IIPs at serial CT examinations, especially for providing a framework for cases that are unclassifiable or in which a histologic diagnosis cannot be obtained.

Diffuse Cystic Lung Disease. Part II

The diffuse cystic lung diseases have a broad differential diagnosis. A wide variety of pathophysiological processes spanning the spectrum from airway obstruction to lung remodeling can lead to multifocal cyst development in the lung. Although lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis are perhaps more frequently seen in the clinic, disorders such as Birt-Hogg-Dubé syndrome, lymphocytic interstitial pneumonia, follicular bronchiolitis, and light-chain deposition disease are increasingly being recognized. Obtaining an accurate diagnosis can be challenging, and management approaches are highly disease dependent. Unique imaging features, genetic tests, serum studies, and clinical features provide invaluable clues that help clinicians distinguish among the various etiologies, but biopsy is often required for definitive diagnosis. In part II of this review, we present an overview of the diffuse cystic lung diseases caused by lymphoproliferative disorders, genetic mutations, or aberrant lung development and provide an approach to aid in their diagnosis and management.

Cystic and nodular lung disease

Diffuse cystic and nodular lung diseases have characteristic imaging findings. The most common causes of cystic lung disease are lymphangioleiomyomatosis and Langerhans cell histiocytosis. Other less common cystic lung diseases include Birt-Hogg-Dube syndrome, lymphocytic interstitial pneumonitis, and light chain deposition disease. Computed tomography is used to differentiate cystic lung disease from emphysema, honeycombing, cavities, and bronchiectasis, which mimic cystic lung disease. Diffuse nodular lung disease are categorized as centrilobular, perilymphatic, and random types. In diffuse nodular lung disease, a specific diagnosis is achieved through a combination of history, physical examination, and imaging findings.

Lymphoproliferative lung disorders: a radiologic-pathologic overview. Part I: Reactive disorders

Lymphoid tissue is a normal component of the lung and manifests as intrapulmonary lymph nodes, bronchus-associated lymphoid tissue (BALT), peripheral lymphocytic aggregates, solitary lymphocytes, and phagocytic cells. Pulmonary lymphoid lesions are thought to develop as a consequence of anomalous stimulation and response of the bronchus-associated lymphoid tissue and manifests as a spectrum of lymphoproliferative disorders that may be reactive or neoplastic. Reactive disorders are polyclonal abnormalities and include nodular lymphoid hyperplasia, lymphocytic interstitial pneumonia, follicular bronchiolitis, angiofollicular hyperplasia, and enlarged intrapulmonary lymph nodes. Affected patients are often asymptomatic. Imaging findings include focal nodules, diffuse bilateral centrilobular nodules, and hilar or mediastinal masses.

Clinical and radiological features of idiopathic interstitial pneumonias (IIPs): a pictorial review

OBJECTIVES

To illustrate the clinical and radiological features of idiopathic interstitial pneumonias (IIPs), according to the American Thoracic Society (ATS)/European Respiratory Society (ERS) classification updated in 2013.

METHODS

IIPs include a subset of diffuse and restrictive lung diseases, resulting from damage to the parenchyma characterised by inflammation and fibrosis of the interstitium. Classification into major and rare IIPs is based on the 2013 ATS/ERS committee.

RESULTS

The diagnosis of idiopathic pulmonary fibrosis (IPF) needs to exclude other well-known causes of interstitial lung diseases. According to the 2011 evidence-based guidelines, usual interstitial pneumonia (UIP) can be diagnosed by HRCT when all criteria are fulfilled. Non-specific interstitial pneumonia (NSIP) is characterised by patchy ground-glass opacities and irregular linear/reticular opacities. The imaging patterns of respiratory bronchiolitis associated-interstitial lung disease (RB-ILD) and desquamative interstitial pneumonia (DIP) show centrolobular nodules and ground-glass opacities. Cryptogenic organising pneumonia (COP) consists of patchy peripheral or peribronchial consolidations, while ground-glass opacities are typically associated with diffuse lung consolidation, evolving to fibrosis, in acute interstitial pneumonia (AIP). Rare IIPs include lymphoid interstitial pneumonia and idiopathic pleuro-parenchymal fibroelastosis (IPPFE).

CONCLUSIONS

The knowledge of IIP imaging features on HRCT images help radiologists in diagnosis. Moreover, the overlap of imaging features needs a multidisciplinary approach.

TEACHING POINTS

• UIP findings are reticulations, bronchiectasis, honeycombing and absence of inconsistent features. • Bilateral patchy ground-glass areas represent the most encountered features in NSIP. • Poorly defined centrilobular nodules are typical of RB-ILD, whereas a ground-glass appearance is typical of DIP. • HRCT features of COP include characteristic peripheral or peribronchial patchy consolidations. • Rare IIPs include idiopathic LIP and idiopathic pleuro-parenchymal fibroelastosis (PPFE).

CT scans of the chest in carriers of human T-cell lymphotropic virus type 1: presence of interstitial pneumonia

RATIONALE AND OBJECTIVES

To evaluate pulmonary findings on computed tomography (CT) scans in carriers of human T-lymphotropic virus type 1 (HTLV-1).

MATERIALS AND METHODS

This retrospective study was approved by the Institutional Review Board at each institution, and informed consent was waived. Patients who were diagnosed with adult T-cell lymphoma/leukemia or collagen vascular disease were excluded from the study. Chest CT of 106 HTLV-1 carriers (54 females and 52 males; age range 44-94 years) were initially evaluated by two chest radiologists. Assessed CT findings included centrilobular nodules, thickening of bronchovascular bundles, ground-glass opacity, bronchiectasis, interlobular septal thickening, consolidation, honeycombing, crazy-paving appearance, enlarged lymph nodes, pleural effusion, and pericardial effusion. Three chest radiologists secondarily evaluated the CT scans with the abnormal findings to judge the presence of interstitial pneumonia patterns or a bronchiolitis/bronchitis pattern.

RESULTS

Abnormal CT findings were found in 65 (61.3%) patients, including ground-glass opacity (n = 33), bronchiectasis (n = 28), centrilobular nodules (n = 25), and interlobular septal thickening (n = 19). Honeycombing (n = 5) and crazy-paving appearance (n = 3) were also observed. Based on the CT findings, 10 subjects were diagnosed with interstitial pneumonia (usual interstitial pneumonia pattern, n = 3; nonspecific interstitial pneumonia pattern, n = 5; organizing pneumonia pattern, n = 2; respectively). Twenty subjects were diagnosed with the bronchitis/bronchiolitis pattern.

CONCLUSION

Although the bronchiolitis/bronchitis pattern is predominant on chest CT in HTLV-1 carriers, the HTLV-1 infection is associated with various interstitial pneumonias.

Radiological approach to interstitial lung disease: a guide for the nonradiologist

Articles in the past have described the radiological appearances of different interstitial lung diseases (ILDs) in varying levels of detail. However, these articles have generally been written for radiologists with a background in basic chest computed tomography (CT) interpretation. This article summarizes a basic approach for diagnosing ILDs on high-resolution CT (HRCT) for the nonradiologist clinician and discusses the most common HRCT features of common ILDs.

Pulmonary Manifestations in Sjögren’s Syndrome: Correlation Analysis Between Chest Computed Tomographic Findings and Clinical Subsets with Poor Prognosis in 80 Patients

Objective.

Sjögren’s syndrome (SS) has a varied clinical spectrum and has been associated with various chest computed tomography (CT) findings. We sought to delineate the characteristic CT features in various subsets of SS, especially poor prognosis subsets.

Methods.

Retrospectively identified 80 never-smoker SS patients [56 primary SS (1-SS), 24 secondary SS (2-SS)] who underwent chest CT at our institution during a 3-year period from 2004 through 2007 were included in this study. Chest CT findings were qualitatively and semiquantitatively analyzed with comparison between 1-SS and 2-SS, and correlation with anti-SSB/La seropositivity and the presence of clonally derived lymphoproliferative disorder (cLPD), which are known to be pathognomonic and prognostic clinical features of SS patients.

Results.

All patients were women with median age of 60 years. Anti-SSB/La antibodies were found in 17 primary SS patients and 4 2-SS patients. Eleven patients with cLPD were identified and all of them had 1-SS. The most frequent CT finding in both types of patients was interlobular septal thickening. Secondary SS was associated with a significantly greater frequency and extent of honeycombing versus 1-SS. Univariate and multivariate analysis showed a significant association between honeycombing and 2-SS. In patients with 1-SS and in the SS group as a whole, we observed independent and significant associations between cysts and anti-SSB/La seropositivity or cLPD.

Conclusion.

Cysts are significantly associated with anti-SSB/La seropositivity and cLPD. The presence of lung cysts revealed by chest CT might be a prognostic clinical feature, a clue, or a predictor of cLPD in patients with SS.

Pulmonary complications of connective tissue diseases

Lung involvement is common in patients who have complications of connective tissue disease (CTDs) and causes considerable morbidity and mortality. High resolution CT (HRCT) has a pivotal role in the detection of lung fibrosis. In patients who have coexistent pathologic processes, HRCT often allows the predominant process to be identified. HRCT has an important role in detecting possible complications such as opportunistic infection or the development of malignancy. However, the limitations of HRCT should not be overlooked. In many cases, HRCT appearances are nonspecific and may or may not be related to an underlying CTD. Thus, radiologic findings should never be interpreted without knowledge of the clinical picture.

Challenges in pulmonary fibrosis. 3: Cystic lung disease

Cystic lung disease is a frequently encountered problem caused by a diverse group of diseases. Distinguishing true cystic lung disease from other entities, such as cavitary lung disease and emphysema, is important given the differing prognostic implications. In this paper the features of the cystic lung diseases are reviewed and contrasted with their mimics, and the clinical and radiographic features of both diffuse (pulmonary Langerhans' cell histiocytosis and lymphangioleiomyomatosis) and focal or multifocal cystic lung disease are discussed.

Manifestations respiratoires au cours du syndrome de Gougerot-Sjögren

INTRODUCTION

Sjogren's syndrome is a common auto-immune disease.

BACKGROUND

Clinically significant pulmonary involvement affects approximately 10% of patients and may be the first manifestation of the disease, putting the respiratory physician in a position to suspect and confirm the diagnosis. Besides interstitial lung disease and bronchial disorders, cough is a common symptom of the disease and particularly difficult to treat. Lung cysts and amyloid deposits, sometimes associated with lymphoma, have recently been described. The development of a primary pulmonary lymphoma, usually from MALT, is a major complication of the disease.

VIEWPOINT

Characterisation of the pathophysiology of pulmonary involvement in Sjogren's syndrome and the institution of specific treatment merits the interest of the respiratory physician.

CONCLUSION

The respiratory physician should consider the diagnosis of Sjogren's syndrome in many different clinico-pathological situations.

Interstitial lung disease?the new synergy between radiology and pathology

In the last 30 years, high-resolution computed tomography (HRCT) has been the major advance in diagnosis of diffuse parenchymal lung disease (DPLD). We review the diagnostic accuracy of HRCT and discuss how the gold standard in diagnosis of DPLD has shifted from histopathological diagnosis in isolation to a multidisciplinary approach. This latter process is now accepted as providing the highest levels of diagnostic accuracy in patients with DPLD and lung biopsy is primarily reserved for cases with atypical clinical or radiological presentations.

Diffuse Lung Cysts in Lymphoid Interstitial Pneumonia

Lymphoid interstitial pneumonia is part of a spectrum of pulmonary lymphoproliferative disorders that range from benign, small, and airway-centered cellular infiltrates (follicular bronchiolitis, nodular lymphoid hyperplasia) to low-grade malignant lymphoma. Most of the cases occur in patients with underlying autoimmune disease or immunodeficiency. The characteristic high-resolution computed tomography findings consist of diffuse ground-glass opacities, ill-defined centrilobular nodules, bronchovascular thickening, interlobular septal thickening, and scattered thin-walled cysts. The cysts may be seen in up to 80% of the patients and are typically few in number and measure less than 3 cm in diameter. This case illustrates extensive cysts as the predominant high-resolution computed tomography finding of idiopathic lymphoid interstitial pneumonia in a 64-year-old man who underwent unilateral lung transplant. Such extensive cystic disease and lung transplantation treatment has not been previously described.

Current concepts in the classification of interstitial lung disease

The diagnosis and classification of idiopathic interstitial pneumonias continue to be problematic areas for pathologists. The recently proposed American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias defines specific clinical, radiologic, and pathologic criteria for each of the pulmonary disorders that encompass the idiopathic interstitial pneumonias. In this review, the highlights of this classification are presented, along with recommended guidelines for handling lung biopsy specimens and diagnosing interstitial lung diseases.

The respiratory system in connective tissue disorders

The connective tissue disorders (also called collagen vascular diseases) represent an heterogeneous group of immunologically mediated inflammatory disorders with a large variety of affected organs besides the lungs. The respiratory system may be involved in all its components: airways, vessels, parenchyma, pleura, respiratory muscles, etc. The frequency, clinical presentation, prognosis and response to therapy vary, depending on the pattern of involvement as well as on the underlying connective tissue disorders. The subject of this review is to describe the most frequent type of lung disorders observed in patients with connective tissue disease (CTD). We will focus on the most frequent CTD: systemic lupus erythematosus, rheumatoid arthritis, scleroderma, Sjogren's syndrome, dermatopolymyositis and mixed CTD.

Amyloidosis and Lymphoproliferative Disease in Sj??gren Syndrome

OBJECTIVE

To describe the thin-section computed tomography (CT) findings of Sjogren syndrome accompanying pulmonary amyloidosis and lymphoproliferative disease and to compare these with histopathologic findings.

SUBJECTS AND METHODS

The thin-section CT findings of 5 women (age range: 42-59 years, mean age=50 years) with primary Sjogren syndrome accompanying pulmonary amyloidosis and lymphoproliferative disease were reviewed retrospectively by 2 chest radiologists, and decisions on findings were reached by consensus. The pathologic specimens of parenchymal lesions (nodules, dense consolidation, and cystic lesion at CT) obtained using video-assisted thoracoscopic surgery were studied to compare with the thin-section CT findings.

RESULTS

Nodules, observed in all 5 patients, were variable in size and ranged from 3 to 24 mm (mean=9.9 mm) in diameter, with lobulated or irregular margins. Nodular calcifications were present in 3 patients. Cysts, which also were observed in all patients, ranged from 4 to 45 mm (mean=18.6 mm) in diameter, with a thin (1-2 mm) or no visible wall. Multiple cysts were observed, especially in the distal portion of narrowed bronchioles. Nodules and cysts showed a random distribution. Mild bronchial wall thickening with bronchial dilatation was seen in all patients, ground-glass opacities were seen in 3, and consolidation was seen in 1. Nodules, consolidation, and bronchial wall thickening at CT were caused histopathologically by the interstitial and peribronchiolar deposition of mixed amyloid and lymphoproliferative cells. Cysts lined with respiratory epithelium contained amyloid deposition and lymphoproliferative cells in their walls.

CONCLUSION

Sjogren syndrome accompanying pulmonary amyloidosis and lymphoproliferative disease manifests as multiple, large, thin-walled cysts; multiple nodules; parenchymal opacity; and bronchiectasis. These findings are caused by the interstitial or peribronchial infiltration of mixed amyloid and lymphoproliferative cells.

Lymphocytic interstitial pneumonitis in HIV infected adults

OBJECTIVES

To describe current knowledge on the aetiology, pathology, presentation, diagnosis, and treatment of lymphocytic interstitial pneumonitis in HIV infected adults.

METHODS

A Medline search was performed using the key words "HIV," "pneumonitis," and "lymphocytes." A further search was performed with the MESH heading "interstitial lung disorders." Related articles were also searched using Pubmed.

RESULTS

Lymphocytic interstitial pneumonitis is a common complication in HIV infected children. In adults it is uncommon and is described most commonly among black African and Afro-Caribbean patients. The aetiology and pathogenesis of lymphocytic interstitial pneumonitis in HIV infection is not clear. The clinical and radiological presentations may be indistinguishable from Pneumocystis carinii infection and a lung biopsy is necessary to establish the diagnosis. Recent evidence suggests that lymphocytic interstitial pneumonitis in HIV infected patients may respond to combination antiretroviral therapy with dramatic improvements in clinical and radiological abnormalities.

CONCLUSION

Lymphocytic interstitial pneumonitis in HIV infected patients is a treatable condition. This condition should be considered in HIV infected patients presenting with respiratory symptoms as they may gain considerable benefit from antiretroviral therapy.

Classification of idiopathic interstitial pneumonias: making sense of the alphabet soup

Since Liebow and Carrington's original classification of idiopathic interstitial pneumonias, there have been controversies over which histological patterns should be included and how they relate to clinicopathological diseases such as cryptogenic fibrosing alveolitis/idiopathic pulmonary fibrosis (CFA/IPF). Because of these differences and the wealth of overlapping terminology, a consensus classification system has been proposed, devised by a group of clinicians, radiologists and pathologists. Seven histological patterns are recognized: usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP), diffuse alveolar damage (DAD), organizing pneumonia (OP), desquamative interstitial pneumonia (DIP), respiratory bronchiolitis (RB) and lymphocytic interstitial pneumonia (LIP), each with a clinicopathological counterpart, the most well defined being UIP and CFA/IPF. The system is applicable both in terms of the pathologist identifying histological patterns in isolation and in terms of the pathologist's role in contributing to the final clinicopathological diagnosis. It will probably provide greater consistency in diagnosis, early studies suggesting that the system is reproducible, and also identify purer cohorts for studies investigating causation. It also highlights the fact that the 'gold standard for diagnosis' is no longer a surgical lung biopsy in isolation but more the clinicopathological conference, when clinical, imaging and histological data are jointly discussed to produce the final clinicopathological diagnosis.

Pneumonia intersticial linfocítica: correlação da tomografia computadorizada de alta resolução com a anatomopatologia

A proposta do trabalho é apresentar os achados radiológicos observados na tomografia computadorizada de alta resolução do tórax de dois pacientes com pneumonia intersticial linfocítica e correlacioná-los com os aspectos anatomopatológicos, obtidos a partir de biópsias a céu aberto. Um dos pacientes mostrou, na tomografia, basicamente opacidades em vidro fosco difusas, e o outro tinha infiltração ao longo das bainhas conjuntivas peribroncovasculares. Na anatomopatologia o padrão predominante foi o de infiltração intersticial, especialmente ao longo dos septos alveolares, por linfócitos policlonais. O estudo mostrou estreita correlação entre os achados anatomopatológicos e aqueles observados na tomografia computadorizada de alta resolução do tórax.