Fibrosing alveolitis: chest radiography and CT as predictors of clinical and functional impairment at follow-up in 26 patients

ACR Appropriateness Criteria® Diffuse Lung Disease

Diffuse lung disease, frequently referred to as interstitial lung disease, encompasses numerous disorders affecting the lung parenchyma. The potential etiologies of diffuse lung disease are broad with several hundred established clinical syndromes and pathologies currently identified. Imaging plays a critical role in diagnosis and follow-up of many of these diseases, although multidisciplinary discussion is the current standard for diagnosis of several DLDs. This document aims to establish guidelines for evaluation of diffuse lung diseases for 1) initial imaging of suspected diffuse lung disease, 2) initial imaging of suspected acute exacerbation or acute deterioration in cases of confirmed diffuse lung disease, and 3) clinically indicated routine follow-up of confirmed diffuse lung disease without acute deterioration. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Significance of nailfold videocapillaroscopy in patients with idiopathic inflammatory myopathies

Objective

The aim of this study was to investigate the clinical and immunological significance of nailfold videocapillaroscopy (NVC) abnormalities in patients with idiopathic inflammatory myopathies (IIMs).

Methods

Seventy consecutive Japanese patients with untreated IIMs, enrolled between April 2014 and August 2017, were prospectively studied. Clinical features, NVC findings, autoantibody profile by immunoprecipitation and ELISA, and histopathological findings of skin biopsies of DM rash were assessed at baseline and after 1-year of immunosuppressive therapy.

Results

NVC abnormalities were found in 55.7% (39/70) of IIM patients, with significantly higher prevalence in DM (65.4%) compared with PM (27.8%) (P = 0.01). In subsets of patients classified by autoantibody specificities, the prevalence of NVC abnormalities was significantly higher in patients with anti-MDA5 (87.5%) and anti-transcriptional intermediary factor 1γ (88.9%) vs anti-aminoacyl-tRNA synthetase (26.9%, P < 0.001). Perivascular lymphocytic infiltration in the upper dermis of skin rash biopsy of DM was more severe in patients with NVC abnormalities (P < 0.05). Unexpectedly, NVC abnormalities disappeared in 75% of IIM patients after 1-year of immunosuppressive therapy in contrast to stable NVC changes seen in scleroderma patients.

Conclusion

Nailfold microvascular abnormalities were common in DM patients, associated with anti-MDA5 and transcriptional intermediary factor 1γ antibodies, and perivascular inflammation in skin histology. NVC abnormalities in IIMs may become clinically useful markers for defining subsets of DM and understanding the pathogenesis of the clinical features seen in these patients.

Differential diagnoses of fibrosing lung diseases

OBJECTIVES

To describe the challenges inherent in diagnosing fibrosing lung diseases (FLD) on CT imaging and methodologies by which the diagnostic process may be simplified.

METHODS

Extensive searches in online scientific databases were performed to provide relevant and contemporary evidence that describe the current state of knowledge related to FLD diagnosis. This includes descriptions of the utility of a working diagnosis for an individual case discussed in a multidisciplinary team (MDT) setting and challenges associated with the lack of consensus guidelines for diagnosing chronic hypersensitivity pneumonitis.

RESULTS

As well as describing imaging features that indicate the presence of a fibrosing lung disease, those CT characteristics that nuance a diagnosis of the various FLDs are considered. The review also explains the essential information that a radiologist needs to convey to an MDT when reading a CT scan. Lastly, we provide some insights as to the future directions the field make take in the upcoming years.

CONCLUSIONS

This review outlines the current state of FLD diagnosis and emphasizes areas where knowledge is limited, and more evidence is required. Fundamentally, however, it provides a guide for radiologists when tackling CT imaging in a patient with FLD.

ADVANCES IN KNOWLEDGE

This review encompasses advice from recent guideline statements and evidence from the latest studies in FLD to provide an up-to-date manual for radiologists to aid the diagnosis of FLD on CT imaging in an MDT setting.

ACR Appropriateness Criteria® Chronic Dyspnea-Noncardiovascular Origin

Chronic dyspnea may result from a variety of disorders of cardiovascular, pulmonary, gastrointestinal, neuromuscular, systemic, and psychogenic etiology. This article discusses guidelines for the initial imaging of six variants for chronic dyspnea of noncardiovascular origin: (1) Chronic dyspnea of unclear etiology; (2) Chronic dyspnea with suspected chronic obstructive pulmonary disease; (3) Chronic dyspnea with suspected central airways disease; (4) Chronic dyspnea with suspected interstitial lung disease; (5) Chronic dyspnea with suspected disease of the pleura or chest wall; and (6) Chronic dyspnea with suspected diaphragm dysfunction. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Relevance of interferon-gamma in pathogenesis of life-threatening rapidly progressive interstitial lung disease in patients with dermatomyositis

BACKGROUND

Dermatomyositis (DM) with rapidly progressive interstitial lung disease (DM RP-ILD) is a life-threatening condition. Serum cytokine levels are potentially suitable biomarkers for DM RP-ILD. However, the relationships among cytokine levels, lung imaging findings, and lung pathology have not been investigated. The aim of the present retrospective study was to determine the association between hypercytokinemia and lung inflammation in patients with DM RP-ILD.

METHODS

The study subjects were nine patients with life-threatening DM RP-ILD and severe hypoxemia (partial arterial oxygen pressure (PaO₂)/fraction of inspired oxygen (FiO₂) ratio ≤ 200) before receiving intensive care management, who were admitted to our hospital between 2006 and 2015. The controls included 10 patients with DM without RP-ILD and 19 healthy subjects. We assessed the association between serum cytokine levels and computed tomography (CT) scores of the lung (ground glass opacity-score, G-score; fibrosis-score, F-score). Lung, hilar lymph nodes, and spleen from two autopsies were examined by hematoxylin-eosin (H&E) staining and immunostaining.

RESULTS

Serum interferon (IFN)-γ, interleukin (IL)-1β and IL-12 levels were significantly higher in patients with DM RP-ILD than in the other two groups, whereas serum IL-6 levels were elevated in the two patient groups but not in the healthy subjects. Serum levels of IL-2, IL-4, IL-8, IL-10, IFN-α, and TNF (tumor necrosis factor)-α were not characteristically elevated in the DM RP-ILD group. Serum IFN-γ levels correlated with G-scores in patients with DM RP-ILD, while IL-1β was negatively correlation with F-scores. Immunohistochemical staining showed infiltration of numerous IFN-γ-positive histiocytes in the lung and hilar lymph nodes; but not in the spleen. Serum IL-6 levels did not correlate with the CT scores. Numerous IL-6-positive plasma cells were found in hilar lymph nodes, but not in the lungs or spleen.

CONCLUSIONS

Our results suggest strong IFN-γ-related immune reaction in the lungs and hilar lymph nodes of patients with life-threatening DM RP-ILD, and potential IFN-γ involvement in the pathogenesis of DM, specifically in the pulmonary lesions of RP-ILD.

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.

Acute respiratory distress syndrome mimickers lacking common risk factors of the Berlin definition

PURPOSE

Some patients presenting with acute respiratory failure and meeting the Berlin criteria for acute respiratory distress syndrome (ARDS) lack exposure to common risk factors (CRF). These so-called ARDS mimickers often lack histological diffuse alveolar damage. We aimed to describe such ARDS mimickers lacking CRF (ARDS CRF-) in comparison with others (ARDS CRF+).

METHODS

Retrospective study including all patients receiving invasive mechanical ventilation for ARDS admitted to the intensive care units (ICUs) of two tertiary care centers from January 2003 to December 2012.

RESULTS

The prevalence of ARDS CRF- was 7.5 % (95 % CI [5.5-9.5]; n = 50/665). On the basis of medical history, bronchoalveolar lavage fluid cytology, and chest CT scan patterns, four etiological categories were identified: immune (n = 18; 36 %), drug-induced (n = 13; 26 %), malignant (n = 7; 14 %), and idiopathic (n = 12; 24 %). Although the ARDS CRF- patients had a lower logistic organ dysfunction score (4 [3-8] vs. 10 [6-13]; p < 0.0001) and less often shock upon ICU admission (44 vs. 80 %; p < 0.0001) than their counterparts, their overall ICU mortality rate was very high (66 % [46-74]), and the absence of CRF remained associated with ICU mortality by multivariable logistic regression analysis (adjusted OR = 2.06; 95 % CI [1.02-4.18]; p = 0.044). Among ARDS CRF- patients, the presence of potentially reversible lung lesions with corticosteroids (aOR = 0.14; 95 % CI [0.03-0.62]) was associated with ICU survival.

CONCLUSIONS

The absence of CRF among patients with ARDS is common and associated with a higher risk of mortality. For such atypical ARDS, a complete diagnostic workup, including bronchoalveolar lavage fluid cytology and chest CT scan patterns, should be performed to identify those patients who might benefit from specific therapies, including corticosteroids.

The idiopathic interstitial pneumonias: an update and review

Idiopathic interstitial pneumonias (IIPs) are a group of disorders with distinct histologic and radiologic appearances and no identifiable cause. The IIPs comprise 8 currently recognized entities. Each of these entities demonstrates a prototypical imaging and histologic pattern, although in practice the imaging patterns may overlap, and some interstitial pneumonias are not classifiable. To be considered an IIP, the disease must be idiopathic; however, each pattern may be secondary to a recognizable cause, most notably collagen vascular disease, hypersensitivity pneumonitis, or drug reactions. The diagnosis of IIP requires the correlation of clinical, imaging, and pathologic features.

Usual interstitial pneumonia: typical and atypical high-resolution computed tomography features

The computed tomography appearances of usual interstitial pneumonia (UIP) are usually characteristic, with basal-predominant, peripheral-predominant reticular abnormality and honeycombing. Important complications that may be detected by the radiologist include pulmonary hypertension, lung cancer, and acute exacerbation. As the number of surgical lung biopsies performed for typical UIP declines, histologic findings of UIP are increasingly found in subjects with atypical computed tomographic features. Potential reasons for such discordance may include variability in pathologist interpretation, sampling error on biopsy, biopsy obtained from nonrepresentative site, coexistence of multiple pathologies within the same lung, and familial pulmonary fibrosis. Multidisciplinary diagnosis is critical in resolving these cases.

An approach to the development of interstitial lung disease in dermatomyositis: A study of 230 cases in China

Objective:

To study the clinical features of interstitial lung disease (ILD) in patients with dermatomyositis and factors related to its development.

Methods:

Clinical records for patients with dermatomyositis were reviewed retrospectively.

Results:

Records were analysed for 230 patients (mean follow-up period, 18 months). The prevalence of ILD was 49.6%. The presence of ILD correlated positively with the presence of arthralgia, myoasthenia and cough, but negatively with the presence of Gottron’s papules. Patients with ILD had poorer pulmonary function and more frequent positivity for anti-Jo1 antibodies than those without ILD. Patients with ILD characteristically showed linear, patchy, ground-glass opacities and reticular computed tomography (CT) patterns, usually at the bottom or apex of the lung.

Conclusions:

Dermatomyositis patients presenting with heliotrope rash, arthralgia, myoasthenia, cough, dysphagia, anti-Jo1 positivity or abnormal lung function were more likely, whereas those presenting with Gottron’s papules were less likely, to develop ILD. Characteristic CT patterns in dermatomyositis patients with ILD were lines, patches, ground-glass opacities and reticulation.

Idiopathic interstitial pneumonias

The idiopathic interstitial pneumonias (IIPs) are a group of diffuse parenchymal lung diseases of unknown etiology characterized by the presence of various degrees of inflammation and fibrosis. Confident definitive diagnosis of the various IIPs requires dynamic interaction among clinicians, radiologists, and pathologists to arrive at a clinico-radiologic-pathologic diagnosis. The aims of this manuscript are to summarize the characteristic clinical and histologic manifestations, and to describe and illustrate the high-resolution computed tomography manifestations of the IIPs. The focus will be on idiopathic pulmonary fibrosis (idiopathic usual interstitial pneumonia), nonspecific interstitial pneumonia, cryptogenic organizing pneumonia, and acute interstitial pneumonia. High-resolution computed tomography plays an important role in the initial diagnosis, the assessment of disease extent, the likelihood of response to treatment and prognosis, and the assessment of complications.

Progression of native lung fibrosis in lung transplant recipients with idiopathic pulmonary fibrosis

BACKGROUND

Single lung transplant recipients with idiopathic pulmonary fibrosis provide an opportunity to study fibrosis in the native lung over time in the setting of pronounced immunosuppression. Lung transplant patients are treated with a regimen of steroids, an antiproliferative agent and a calcineurin inhibitor. This represents a much greater immunosuppression regime than the typical treatment for IPF. To determine whether this regimen of high dose immunosuppression would arrest the progression of fibrosis, the high-resolution chest CT scans (HRCTs) of these patients were reviewed.

METHODS

HRCTs of 21 patients who underwent single lung transplant for IPF between 1/96 and 1/06 were reviewed. Scans were evaluated by two readers at 6 months intervals, beginning within 1-2 months after transplant. Two calculations were made on the native lung: total volume and percentage of lung affected by fibrosis. Baseline pulmonary function test data was correlated with the immediate post-transplant CT. Patients were followed for an average of 35 months after transplant.

RESULTS

The mean total volume of the native lung just after transplant was 1120cc. This decreased to 875cc by 2 years and 691cc by 4 years after transplant, representing an average decline of 10.8%/year. Initially, 52% of the native lung was affected by fibrosis compared to 92% at 4 years. Excluding scans with 100% of the lung affected by fibrosis, percentage fibrosis increased 11% per year.

CONCLUSION

Fibrotic disease within the native lung progresses rapidly in single lung transplant recipients with IPF despite prolonged high dose immunosuppression.

Progression of fibrosis in usual interstitial pneumonia: serial evaluation of the native lung after single lung transplantation

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive disease with a poor prognosis. Usual interstitial pneumonia (UIP) is the histopathological pattern identifying patients with the clinical entity of IPF. Despite aggressive immunosuppressive therapy the clinical course is usually dismal. For selected patients only lung transplantation improves prognosis and quality of life. After lung transplantation patients often receive a potent cyclosporine-based immunosuppressive therapy. Some reports suggest that cyclosporine has the potential to prevent progression of fibrosis.

OBJECTIVE

In patients with single lung transplantation (sLTx) for UIP we evaluated the effect of cyclosporine-based immunosuppressive therapy on progression of fibrosis using a high-resolution computed tomography (HRCT) scoring system.

METHODS

This retrospective observational study included 13 patients (24-64 years old) with histologically confirmed UIP who had HRCT scans preceding and following sLTx and who survived at least 6 months after sLTx. All patients were initially treated with cyclosporin A, prednisone and azathioprine. Three radiologists analyzed HRCT scans by setting a score regarding fibrosis [fibrosis score (FS); range 0-5 for each lobe] and ground-glass opacity [ground-glass score (GGS); range 0-5 for each lobe]. A comparison of serial changes (interval: 12-96 months posttransplant, 2-4 HRCT examinations/patient) was performed with the sign test.

RESULTS

Mean pretransplant FS and GGS of the nontransplanted lung were 1.80 and 1.61, respectively. Comparing pre- and posttransplant HRCT scans, mean lung FS significantly increased (0.35 +/- 0.15/year; p = 0.00024), while GGS tended to decrease (0.06 +/- 0.26/year; p = 0.5).

CONCLUSION

A cyclosporin A based triple immunosuppressive regimen following sLTx does not seem to prevent progression of the fibrotic changes of the native lung in patients with IPF.

Significance of Ground-glass Opacity on HRCT in Long-term Follow-up of Patients With Systemic Sclerosis

Despite little supportive evidence, ground-glass opacity at high-resolution computed tomography, without other signs of fibrosis, has been equated with potentially reversible disease, and in systemic sclerosis, frequently prompts aggressive anti-inflammatory treatment to prevent pulmonary fibrosis. Our study evaluates ground-glass opacity on sequential high-resolution computed tomography in 41 patients with systemic sclerosis over a mean follow-up period of 27 months (r6 to 60 mo). Ground-glass opacity was the most common imaging finding, present in 66%, and usually associated with other signs of interstitial disease, including nonfibrotic interstitial opacities in 27% and fibrotic interstitial opacities in 32%. Improvement was only documented in 2(5%) patients with ground glass and nonfibrotic interstitial opacities. In systemic sclerosis, ground-glass opacity is most commonly associated with irreversible disease. Disease progression or improvement could not be predicted by the presence of ground-glass opacity.

Is HRCT the best way to diagnose idiopathic interstitial fibrosis?

PURPOSE OF REVIEW

High-resolution computed tomography (HRCT) has been the major advance in the diagnosis of idiopathic interstitial pneumonias in the last two decades. In diffuse lung diseases, HRCT now has a central role in routine diagnostic evaluation, and a major impact on the utility of other diagnostic tests, especially bronchoalveolar lavage and surgical lung biopsy.

RECENT FINDINGS

Numerous published studies have evaluated the accuracy of HRCT. The clinical information was not always utilized to generate a noninvasive diagnosis, however. Despite failure to identify idiopathic pulmonary fibrosis on HRCT in a significant minority of cases, given compatible clinical data, characteristic HRCT appearances justify noninvasive diagnosis in most patients. The limitations of the published studies highlight importance of integrating HRCT data with baseline clinical information and, in selected cases, histopathologic findings.

SUMMARY

When HRCT and clinical findings are both typical of an individual diffuse lung disease, i.e. 'pathognomonic', it is generally appropriate to institute management based on a confident noninvasive diagnosis. When clinical and HRCT data are divergent, or when HRCT features are 'indeterminate', however, histologic evaluation continues to play an essential role. Integration of histology with radiologic and clinical data is the best way to formulate the final diagnosis in these cases.

Clearance of technetium-99m-DTPA and HRCT findings in the evaluation of patients with Idiopathic Pulmonary Fibrosis

BACKGROUND

Clearance of inhaled technetium-labeled diethylenetriamine pentaacetate (99mTc-DTPA) is a marker of epithelial damage and an index of lung epithelial permeability. The aim of this study was to investigate the role of 99mTc-DTPA scan in patients with Idiopathic Pulmonary Fibrosis (IPF). Our hypothesis is that the rate of pulmonary 99mTc-DTPA clearance could be associated with extent of High Resolution Computed Tomography (HRCT) abnormalities, cell differential of bronchoalveolar lavage fluid (BALF) and pulmonary function tests (PFTs) in patients with IPF.

METHODS

We studied prospectively 18 patients (14 male, 4 female) of median age 67 yr (range 55-81) with histologically proven IPF. HRCT scoring included the mean values of extent of disease. Mean values of these percentages represented the Total Interstitial Disease Score (TID). DTPA clearance was analyzed according to a dynamic study using a Venticis II radioaerosol delivery system.

RESULTS

The mean (SD) TID score was 36 +/- 12%, 3 patients had mild, 11 moderate and 4 severe TID. Abnormal DTPA clearance half-time (t1/2 < 40 min) was found in 17/18 (94.5%) [mean (SD) 29.1 +/- 8.6 min]. TID was weakly correlated with the DTPA clearance (r = -0.47, p = 0.048) and with % eosinophils (r = 0.475, p = 0.05). No correlation was found between TID score or DTPA and PFTs in IPF patients.

CONCLUSION

Our data suggest that 99mTc-DTPA lung scan is not well associated with HRCT abnormalities, PFTs, and BALF cellularity in patients with IPF. Further studies in large scale of patients are needed to define the role of this technique in pulmonary fibrosis.

Usual interstitial pneumonia and non-specific interstitial pneumonia: serial thin-section CT findings correlated with pulmonary function

Objective

We wanted to demonstrate and compare the serial high-resolution CTs (HRCT) and the pulmonary function test (PFT) findings of the usual interstitial pneumonia (UIP) and the non-specific interstitial pneumonia (NSIP).

Materials and Methods

The serial HRCT scans and the PFT results were retrospectively analysed and compared for 35 patients having UIP without significant honeycombing (UIP-w/o hc, < 5% of honeycombing at CT), 35 patients having UIP with honeycombing (UIP-w/i hc, ≥ 5% of honeycombing), and 25 patients with NSIP. The mortality rates were also compared. Follow-up CT scans were available in 75 patients (29 UIP-w/o hc patients, 22 UIP-w/i hc patients and 24 NSIP patients) and the follow-up periods ranged from 150 to 2,370 days. The initial and follow-up PFT data were available for 71 patients.

Results

On the initial CT, significant differences were present between the UIP-w/i hc patients and both the UIP-w/o hc patients and the NSIP patients in the overall extent, ground-glass opacity (GGO) away from the reticulation, reticulation and honeycombing (all p < 0.05). Improvement was noticed in five (17%) of 29 UIP-w/o hc patients, none of 22 UIP-w/i hc patients, and 9 (37%) of 24 NSIP patients; deterioration was noted in six (21%) UIP-w/o hc patients, two (9%) UIP-w/i hc patients and three (13%) NSIP patients (p = 0.044 between UIP-w/o and UIP-w/i hc; p = 0.637 between UIP-w/o hc and NSIP; p = 0.007 between UIP-w/i hc and NSIP). The serial changes of the pulmonary function in the NSIP patients were different from those noted for the UIP-w/i hc and UIP-w/o hc patients (p = 0.440 between UIP-w/o and UIP-w/i hc; p = 0.022 between UIP-w/o hc and NSIP; p = 0.003 between UIP-w/i hc and NSIP). Five (14%) of the 35 patients with UIP-w/o hc, 16 (46%) of the 35 patients with UIP-w/i hc and three (12%) of the 25 patients with NSIP died (p = 0.002, comparison for the three groups).

Conclusion

On CT, NSIP and UIP-w/o hc patients have similar patterns of parenchymal abnormalities and a similar likelihood of change in the extent of disease on follow-up. Patients with UIP-w/i hc have distinctive features and a worst prognosis.

Clinical aspects of lung involvement: lessons from idiopathic pulmonary fibrosis and the scleroderma lung study

Interstitial lung disease (ILD) occurs frequently among patients with systemic slcerosis (SSc) and accounts for significant morbidity and mortality. SSc-ILD resembles idiopathic pulmonary fibrosis (IPF) in many respects; each is characterized by a restrictive ventilatory defect that results from an active fibrosing process in the lung interstitium, and each is characterized by ground glass opacification on high resolution computed tomography (HRCT) and inflammatory cells in bronchoalveolar lavage fluid (BALF). Differences in the classification of lung histo-pathology are noted frequently and may account for some of the difference in outcome for patients with SSc-ILD and IPF. Optimal treatment of SSc-ILD remains to be determined, but cyclophosphamide has been reported to be effective in a number of case series. A randomized controlled trial, the Scleroderma Lung Study (SLS), will be completed in 2005; the outcome of the SLS should define the efficacy of daily oral cyclophosphamide for SSc-ILD patients with alveolitis defined by BALF and HRCT.

Thoracic high-resolution computed tomographic findings in dogs with canine idiopathic pulmonary fibrosis

OBJECTIVES

To identify features of canine idiopathic pulmonary fibrosis (CIPF) using high-resolution computed tomography (HRCT), and to correlate these features with clinical stages of the disease.

METHODS

Ten dogs with signalment, history and clinical signs highly suggestive of CIPF were investigated. Thoracic radiography, haematology and biochemistry profiles, bronchoscopy and bronchoalveolar lavage and HRCT were performed in each case. The dogs were classified as having mild, moderate or severe stages of the disease based on their clinical presentation and radiographic signs. Features identified by HRCT were correlated with these disease stages.

RESULTS

HRCT showed a spectrum of pulmonary changes and it was possible to match some of these to the stage of CIPF.

CLINICAL SIGNIFICANCE

HRCT is used extensively in humans in the diagnosis and treatment planning of idiopathic pulmonary fibrosis. This preliminary study identifies the high-resolution computed tomographic features of CIPF in a small group of dogs. With further work it may be possible to use HRCT as a non-invasive tool for diagnosing, staging and therapeutically monitoring CIPF.

Idiopathic Interstitial Pneumonias: CT Features

Idiopathic interstitial pneumonias comprise usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), desquamative interstitial pneumonia (DIP), respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), cryptogenic organizing pneumonia (COP), acute interstitial pneumonia (AIP), and lymphoid interstitial pneumonia (LIP). Each of these entities has a typical imaging and histologic pattern, although in practice the imaging patterns may be variable. Each entity may be idiopathic or may be secondary to a recognizable cause such as collagen vascular disease or inhalational exposure. The diagnosis of idiopathic interstitial pneumonia is made by means of correlation of clinical, imaging, and pathologic features. The characteristic computed tomographic (CT) features of UIP are predominantly basal and peripheral reticular pattern with honeycombing and traction bronchiectasis. NSIP is characterized by predominantly basal ground-glass opacity and/or reticular pattern, often with traction bronchiectasis. DIP and RB-ILD are smoking-related lung diseases characterized by ground-glass opacity and centrilobular nodules. COP is characterized by patchy peripheral or peribronchovascular consolidation. AIP manifests as diffuse lung consolidation and ground-glass opacity. LIP is associated with a CT pattern of ground-glass opacity sometimes associated with perivascular cysts.

The Medical Research Council dyspnea scale in the estimation of disease severity in idiopathic pulmonary fibrosis

BACKGROUND

Medical Research Council (MRC) chronic dyspnea scale, used for the estimation of disability due to dyspnea, may serve as a simple index of disease severity and extent in patients with idiopathic pulmonary fibrosis (IPF). However, its relationship with other commonly used measures has not been evaluated.

METHODS

The association of MRC chronic dyspnea scale with lung function indices and high-resolution computerized tomography (HRCT) scores such as the total interstitial disease score (TIDs) and the fibrosis score (Fs) was examined in 26 untreated patients with IPF sequentially recruited over a period of 3 years. The aim of this observational study was to explore the relationship between dyspnea, impairment of lung function and CT estimation of disease severity in patients with IPF.

RESULTS

The MRC dyspnea score was significantly associated with FVC, FEV1, TLC, DLCO, PaO2, and PaCO2 and with both HRCT scores. In multiple regression analysis only the FVC (OR = 0.85, 95% CI = 0.75-0.95, P = 0.004) and PaCO2 (OR = 0.69, 95% CI = 0.50-0.95, P = 0.02) correlated with dyspnea. Furthermore, both TIDs and Fs were negatively associated with FVC, FEV1, TLC and PaO2. In multiple regression analysis only the FVC correlated with both TIDs (r2 = 0.57, P = 0.0001) and Fs (r2 = 0.46, P = 0.0005).

CONCLUSIONS

These observations suggest that the MRC dyspnea scale could offer useful information about the estimation of severity in patients with IPF. Furthermore among functional indices the FVC seems to be the best estimator of disease severity and extent.

Pneumoconiosis in Rush Mat Workers Exposed to Clay Dye “Sendo” Dust

STUDY OBJECTIVES

The purpose of this study was to describe the clinical, chest radiographic, high-resolution CT, and histopathologic features of clay dye "sendo" dust pneumoconiosis in seven rush mat ("tatami") workers.

PATIENTS

Seven patients with a history of occupational exposure to sendo dust and radiographic changes suggestive of pneumoconiosis were retrospectively reviewed.

RESULTS

The duration of exposure ranged from 15 to 45 years (median, 30 years). Three patients had cough, and four patients had abnormal pulmonary function test results. Chest radiographs showed nodular opacities < 3 mm in diameter (types p and q) in all patients. The standard International Labor Office profusion score ranged from 0/1 to 1/1 (median, 1/0). High-resolution CT demonstrated small nodular opacities (types p and q) in all seven patients. In four patients, high-resolution CT demonstrated branching centrilobular structures, airway ectasia, airway wall thickening, and emphysematous changes. None of the patients had conglomerate nodules, large opacities, honeycombing, pleural effusion, or lymphadenopathy. Microscopic examination of the specimens obtained by open lung biopsy or transbronchial lung biopsy revealed nodular fibrosis with accumulation of dust-laden macrophages, but no silicotic nodules. Needle-like particles of 1 to 20 microm in length were evident among the dust deposits, and birefringent crystals were identified under polarizing microscopy. Four of seven patients showed intra-alveolar fibroblastic foci similar to Masson bodies, accompanied by dust deposition.

CONCLUSION

Rush mat workers' sendo dust pneumoconiosis is caused by dust containing free silica. The radiographic and high-resolution CT findings consist of small nodular opacities < 3 mm in diameter and bronchial and bronchiolar abnormalities.

Interstitial lung disease in systemic sclerosis

PURPOSE

To evaluate high-resolution CT (HRCT) parameters of inflammation and fibrosis in systemic sclerosis (SSc), for correlation with lung function, skin scores and exercise tolerance.

MATERIAL AND METHODS

45 SSc patients (40 women, 48.5+/-13.4 years), underwent thoracic HRCT, lung function assessment, and modified Rodnan skin scores. Exercise tolerance was also graded. HRCT were scored for extent of 4 HRCT patterns of interstitial lung disease (ILD): ground glass opacification (GGO), reticular, mixed and honeycomb pattern in each lobe. Total HRCT score, inflammation index (GGO and mixed score) and fibrosis index (reticular and honeycomb scores) were correlated with lung function and clinical parameters.

RESULTS

ILD was present in 39/45 (86.7%) patients. Abnormal (<80% predicted) forced vital capacity (FVC), total lung capacity (TLC) and carbon monoxide diffusion factor (DLco) were detected in 30%, 22% and 46% of patients. Total HRCT score correlated with FVC (r=-0.43, p=0.008), FEV1 (forced expiratory volume) (r=-0.37, p=0.03), TLC (r=-0.47, p=0.003), and DLCO (r=-0.43, p=0.008); inflammatory index with DLCO (r=-0.43, p=0.008) and exercise tolerance (r=-0.39, p < 0.05); and fibrosis index with FVC (r=-0.31, p=0.05) and TLC (r=-0.38, p=0.02). Higher total HRCT score, and inflammation and fibrosis indices were found in patients with abnormal lung function.

CONCLUSION

Qualitative HRCT is able to evaluate inflammation and fibrosis, showing important relationships with diffusion capacity and lung volume, respectively.

Hermansky-Pudlak syndrome: radiography and CT of the chest compared with pulmonary function tests and genetic studies

OBJECTIVE

The objective of our study was to describe the chest radiographic and high-resolution CT findings in patients with Hermansky-Pudlak syndrome and to correlate the radiologic findings with age, causative gene, and pulmonary function.

SUBJECTS AND METHODS

Sixty-seven patients with Hermansky-Pudlak syndrome underwent high-resolution CT of the chest. A scoring system based on the extent of pulmonary involvement and specific high-resolution CT findings was used, and the findings were compared with patient age and the results of pulmonary function and genetic studies. Fifty-eight (87%) of the 67 patients also underwent chest radiography. These radiographs were compared with the high-resolution CT scans.

RESULTS

High-resolution CT was more sensitive than chest radiography in evaluating the extent of pulmonary disease in patients with Hermansky-Pudlak syndrome. All patients with mild findings on high-resolution CT scans had normal findings on chest radiographs. Common chest radiographic findings included reticulonodular interstitial pattern, perihilar fibrosis, and pleural thickening. High-resolution CT showed septal thickening, ground-glass opacities, and peribronchovascular thickening. For patients with Hermansky-Pudlak syndrome who were 30 years old or younger, high-resolution CT findings were usually minimal. Among patients who were older than 30 years, the 34 patients with HPS1 mutations had a score of 1.38+/-0.18 (mean+/-standard error of the mean) on high-resolution CT. This score is significantly greater than the score for the 11 patients without HPS1 mutations (0.36 +/- 0.15) (p < 0.001). The score based on high-resolution CT findings inversely correlated with percentage of forced vital capacity and was useful in defining the progression of interstitial disease.

CONCLUSION

High-resolution CT provides a good radiologic monitor of disease status and progression in patients with Hermansky-Pudlak syndrome and correlates well with patient age, extent of pulmonary dysfunction, and genetic findings.

Progression of idiopathic pulmonary fibrosis in native lungs after single lung transplantation

This retrospective, single-center study was conducted to assess the response of native idiopathic pulmonary fibrosis (IPF) lungs to a potent cyclosporine-based immunosuppressive regimen in single-lung transplantation recipients. The study included IPF patients who had undergone single-lung transplantation and had chest CT scans before and after transplantation. Five patients underwent single-lung transplantation for IPF between April 1992 and January 2001, and met entry criteria. All patients were placed on an immunosuppressive regimen consisting of prednisone, azathioprine, and cyclosporine. In two of the five patients, ground glass attenuation in the native IPF lung improved post-transplantation. However, fibrotic changes progressed in all five patients. In patients with advanced IPF, a potent cyclosporine-based immunosuppressive regimen is not likely to have an effect on the progression of the disease.

High-resolution CT of idiopathic interstitial pneumonias

Important recent changes have occurred in our understanding of the IIPs. IPF (characterized histologically as UIP) is recognized as a progressive disease with a relatively poor prognosis, and with a characteristic CT appearance. The radiologist must be able to distinguish between UIP and the other IIPs. Complications of IPF include accelerated progression, lung cancer, and secondary infection. NSIP has a better prognosis than IPF, and has ground-glass attenuation as its salient CT feature. COP (formerly known as BOOP) is included as an IIP because its clinical, physiologic, and imaging features overlap with those of the other IIPs. It is characterized on CT by consolidation and ground-glass attenuation. AIP is the idiopathic form of ARDS. LIP and DIP are less common IIPs, both characterized by ground-glass attenuation.

CT of cystic diseases of the lung

Cystic lung diseases are caused by a number of abnormalities. Many of the cystic lung diseases and their mimics can be reliably diagnosed based on their HRCT findings. In the appropriate clinical setting this could obviate biopsy.

Predicting survival in idiopathic pulmonary fibrosis: scoring system and survival model

Our purpose was to identify clinical, radiological and physiological (CRP) determinants of survival and to develop a CRP scoring system that predicts survival in newly diagnosed cases of idiopathic pulmonary fibrosis (IPF). The study population consisted of 238 patients with biopsy confirmed usual interstitial pneumonia. For each patient, clinical manifestations, chest radiographs, and pulmonary physiology were prospectively assessed. We used Cox proportional-hazards models to assess the effect of these parameters on survival. The effects of age and smoking were included in the analysis. Survival was related to age, smoking status (longer in current smokers), clubbing, the extent of interstitial opacities and presence of pulmonary hypertension on the chest radiograph, reduced lung volume, and abnormal gas exchange during maximal exercise. A mathematical CRP score for predicting survival was derived from these parameters. We showed that this CRP score correlated with the extent and severity of the important histopathologic features of IPF, i.e., fibrosis, cellularity, the granulation/connective tissue deposition, and the total pathologic derangement. Using these models, clinicians are in a better position to provide prognostic information to patients with IPF and to improve the selection of the most appropriate patients for lung transplantation or other standard or novel therapeutic interventions.

Corticosteroids in idiopathic pulmonary fibrosis

Corticosteroids were the mainstay of therapy for idiopathic pulmonary fibrosis (IPF) for more than four decades, but their efficacy is unproven and toxicities are substantial. The course of IPF is characterized by progressive respiratory insufficiency, leading to death within 3 to 8 years from the onset of symptoms. Although a subset (10-20%) of patients survives more than 10 years, there is no evidence that any form of therapy alters the natural history of the disease. Nonetheless, given the poor prognosis, a trial of corticosteroids is often given. Because of the rarity of IPF, randomized, placebo-controlled therapeutic trials have not been done. Further, no studies have compared differing dosages or duration of corticosteroid in matched patients. Interpretation of therapy efficacy is obscured by several factors including heterogeneous patient populations, inclusion of patients with histologic entities other than usual interstitial pneumonia, lack of objective, validated endpoints, different criteria for "response." We review published data regarding corticosteroid therapy for IPF and present a rationale for stratifying therapy based on host, demographic, and clinical factors that influence prognosis as well as risk for corticosteroid complications.

High-Resolution Computed Tomography and Survival in Fibrosing Alveolitis

High-resolution computed tomography findings were reviewed in 32 patients with cryptogenic fibrosing alveolitis and 18 with fibrosing alveolitis associated with connective tissue diseases (other than scleroderma). The percentage of abnormal lung, total ground-glass attenuation, ground-glass attenuation not associated with fibrosis, and fibrosis (reticular pattern and honeycombing) were compared with lung function and survival. In cryptogenic fibrosing alveolitis, 1-year mortality tended to be higher in patients with predominantly fibrotic lesions (39%) compared to mainly ground-glass attenuation (11%). Similar results were obtained in fibrosing alveolitis associated with connective tissue disease (1-year mortality 44% for fibrosis versus 22% for ground-glass attenuation), but the differences were not statistically significant. In cryptogenic fibrosing alveolitis, the extent of abnormal lung on initial computed tomography was 67% ± 20% in survivors at 1 year and 86% ± 8% in nonsurvivors (p < 0.005); this difference was still significant at 4 years. In fibrosing alveolitis associated with connective tissue disease, the degree of lung involvement between survivors and nonsurvivors was different at 1 year only, thus other factors seem to determine survival. Ground-glass attenuation associated with fibrosis adversely affected survival in cryptogenic fibrosing alveolitis, in contrast to isolated ground-glass attenuation.

Eosinophilic pneumonia-like areas in idiopathic usual interstitial pneumonia

Usual interstitial pneumonia is the most common idiopathic chronic interstitial pneumonia, characterized by a temporally heterogenous pattern of interstitial injury with interstitial mononuclear infiltrates, septal fibromyxoid nodules, and parenchymal scarring. This report details the presence of focal eosinophilic pneumonia in six cases of usual interstitial pneumonia in the absence of known causes of this reaction. The relationship of eosinophilic infiltrates in usual interstitial pneumonia with regard to pathogenesis, differential diagnosis, and prognosis is discussed.

Fatores prognósticos em fibrose pulmonar idiopática

Com o objetivo de avaliar quais fatores prognósticos são significativos na sobrevida de pacientes com fibrose pulmonar idiopática (FPI), foram estudados 117 casos com comprovação histológica da doença, internados no Pavilhão Pereira Filho entre 1970 e 1996. Todos os pacientes realizaram radiologia convencional de tórax, espirometria e preencheram um questionário padronizado no momento da internação. Foram também realizados medida da difusão (34 casos), capacidade pulmonar total (28), gasometria (106), lavado broncoalveolar (39), provas reumatismais (45) e tomografia computadorizada de tórax (24). Para uma análise mais específica, os pacientes foram dividos em dois grupos: grupo A (sobrevida até dois anos) - 55 pacientes e grupo B (sobrevida maior que cinco anos) - 24 pacientes, sendo estas características também analisadas de acordo com a significância em relação à sobrevida. Foram considerados fatores indicativos de pior prognóstico a idade avançada, a duração prolongada de sintomas, a gravidade da dispnéia, a redução da CVF, da DCO, da PaO2 e da SaO2, a intensidade do faveolamento e o grau de profusão do padrão reticular na TCAR. Estiveram também associados à menor sobrevida os valores menores de VEF1 e CPT. A utilização destes critérios de gravidade que apresentaram significância estatística, quando utilizados em conjunto, pode determinar uma avaliação prognóstica mais apurada em pacientes portadores de FPI, com implicações terapêuticas e sociais relevantes para seu manejo e acompanhamento.

Cyclophosphamide in the treatment of idiopathic pulmonary fibrosis: a prospective study in patients who failed to respond to corticosteroids

STUDY OBJECTIVES

To prospectively examine the role of cyclophosphamide in patients with idiopathic pulmonary fibrosis that is unresponsive to or intolerant of high-dose steroid treatment.

DESIGN

Prospective study.

SETTING

Tertiary referral center.

PATIENTS

Nineteen patients with biopsy specimen-proven usual interstitial pneumonia who failed to respond (n = 16) or experienced adverse effects (n = 3) from corticosteroid treatment (1 mg/kg/d for 3 months).

INTERVENTION

Steroid therapy was tapered quickly, and oral cyclophosphamide, 2 mg/kg/d, was prescribed (mean duration of treatment, 6.0 +/- 0.9 months).

MEASUREMENTS AND RESULTS

In 10 patients, response to therapy was determined by pretreatment and posttreatment clinical (dyspnea), radiographic (chest radiograph), and physiologic (pulmonary function, including exercise saturation) scores (CRP). Response was defined as a > 10-point drop in CRP; stable as +/- 10-point change in CRP; and nonresponders as > 10-point rise in CRP. In nine patients, physiologic criteria were used to assess response; significant changes in pulmonary function were defined as follows: total lung capacity, +/- 10% of baseline value; FVC, +/- 10% of baseline value, diffusion capacity of the lung for carbon monoxide, +/- 20% of baseline value; and resting pulse oximetry, +/- 4% of baseline value. Patients who died while receiving or shortly after discontinuing cyclophosphamide were classified as nonresponders (n = 2). Among 19 patients treated with cyclophosphamide, only 1 patient demonstrated sustained response; 7 patients remained stable and 11 deteriorated while receiving the drug. Toxicity associated with cyclophosphamide was substantial; more than two thirds of the patients developed drug-related adverse effects, and almost half discontinued the drug prematurely due to side effects. In the remaining patients, cyclophosphamide therapy was discontinued due to lack of improvement or progressive deterioration.

CONCLUSIONS

Cyclophosphamide therapy is of limited efficacy in patients with idiopathic pulmonary fibrosis who fail to respond or who experience adverse effects from corticosteroid treatment, and adverse effects often complicate its use.

Thoracic involvement of systemic lupus erythematosus: clinical, pathologic, and radiologic findings

Thoracic involvement occurs more frequently in systemic lupus erythematosus than in any other connective tissue diseases, and more than half of patients with the disease suffer from the involvement. Primary intrathoracic manifestations include pleural disease (effusions and/or thickening), acute lupus pneumonitis, subacute interstitial lung disease including bronchiolitis obliterans organizing pneumonia and non-specific interstitial pneumonia with fibrosis, chronic interstitial lung disease of usual interstitial pneumonia, pulmonary hemorrhage, pulmonary vascular disease, small airway disease of bronchiolitis obliterans, and pulmonary arterial hypertension. Secondary intrathoracic manifestations include atelectasis due to diaphragmatic dysfunction, opportunistic pneumonia, drug and oxygen toxicity, aspiration, and pleuropulmonary consequences of cardiac and renal failure.

Serial high resolution CT findings in nonspecific interstitial pneumonia/fibrosis

PURPOSE

The purpose of this work was to evaluate the radiographic and serial high resolution CT (HRCT) findings in patients with nonspecific interstitial pneumonia/ fibrosis (NSIP).

METHOD

We identified 15 patients with biopsy-proven NSIP. Radiography and initial and follow-up CT findings were reviewed.

RESULTS

Predominant radiographic findings were bilateral infiltrates distributing in the middle and lower lung zones and decreased lung volumes. At initial CT, predominant patterns were peribronchovascular interstitial thickening (n = 6), parenchymal bands (n = 8), intralobular interstitial thickening (n = 12), and traction bronchiectasis (n = 14). Mixed pattern of ground-glass opacity and consolidation (n = 11) were predominant findings of increased lung opacity. At follow-up CT in 14 cases, the abnormalities had disappeared completely in 3, improved in 9, persisted in 1, and worsened in 1.

CONCLUSION

The pulmonary abnormalities observed in NSIP on HRCT can disappear or be diminished in most cases after corticosteroid therapy. Intralobular interstitial thickening and traction bronchiectasis, which have been considered to be indicators of irreversible fibrosis, also show favorable responses.

Pulmonary function and high-resolution CT findings in patients with an inherited form of pulmonary fibrosis, Hermansky-Pudlak syndrome, due to mutations in HPS-1

OBJECTIVE

To describe and correlate pulmonary function and high-resolution CT (HRCT) scan scores in individuals with a high risk for development of pulmonary fibrosis, ie, Hermansky-Pudlak syndrome (HPS) patients with mutations in the HPS-1 gene.

DESIGN

Cross-sectional analysis of consecutive, eligible patients.

PATIENTS

Thirty-eight HPS inpatients at the National Institutes of Health Clinical Center with HPS-1 mutations.

RESULTS

Thirty-seven patients were Puerto Rican and exhibited the typical 16-base pair (bp) duplication in exon 15 of HPS-1. One non-Puerto Rican was homozygous for a different mutation (intervening sequence 17 -2 A-->C) previously reported in the HPS-1 gene; he died at age 35 of pulmonary insufficiency. For the 23 patients who had pulmonary symptoms, the mean age of onset was 35 years. For all 38 patients (mean age, 37 +/- 2 years), the mean FVC was 71% of predicted; the mean FEV(1), 76%; mean total lung capacity (TLC), 72%; mean vital capacity (VC), 68%; and mean diffusing capacity of the lung for carbon monoxide (DLCO), 72%. When patients were grouped according to the extent of their reduction in FVC, the other four pulmonary function parameters followed the FVC. Seventeen patients had abnormal chest radiographs, and 31 (82%) had abnormal HRCT scans of the chest, for which a scoring system of 0 (normal) to 3 (severe fibrosis) is presented. The mean +/- SEM HRCT score for 38 patients was 1.30 +/- 0.17. HRCT scores correlated inversely with FVC and DLCO.

CONCLUSIONS

Mutations in the HPS-1 gene, whether or not they involve the typical 16-bp duplication seen in Puerto Rican patients, are associated with fatal pulmonary fibrosis. In affected patients, the FVC, FEV(1), TLC, VC, and DLCO fall in concert, and this functional deficit correlates with HRCT scan evidence of progression of interstitial lung disease.

High-resolution computed tomography in the evaluation of fibrosing alveolitis

High-resolution computed tomography (HRCT) is now widely used in the investigation of patients with suspected or known diffuse lung disease. This article reviews some of the technical aspects of HRCT and the pathologic considerations that should be appreciated in the context of diagnosing fibrosing alveolitis. The precise quantitation of disease extent and characterization of disease pattern on HRCT has been used to provide new insights about the prognosis and pathophysiology of fibrosing lung disease.

A histologic pattern of nonspecific interstitial pneumonia is associated with a better prognosis than usual interstitial pneumonia in patients with cryptogenic fibrosing alveolitis

This study aimed to investigate whether there was a difference in outcome related to histologic pattern in cryptogenic fibrosing alveolitis (CFA) and to see whether there were correlations between clinical and radiologic findings and histology. One hundred thirteen lung biopsies from consecutive patients taken for the diagnosis of diffuse lung disease were reviewed and reclassified using the Katzenstein and Myers criteria for interstitial pneumonias. Patients lacking full investigational data at presentation and those with conditions predisposing to lung fibrosis were excluded, leaving 15 patients diagnosed with nonspecific interstitial pneumonia (NSIP) and 15 with usual interstitial pneumonia (UIP). Clinical and radiologic findings at presentation and serial lung function information and survival status in November 1998 were compared for the two groups. Survival was found to be significantly greater in the NSIP group compared with the UIP group (p < 0.001). This could not be explained by differences in treatment. Patients with UIP showed a progressive deterioration in lung function whereas those with NSIP remained stable. CT scans of patients with UIP showed more fibrosis than those of patients with NSIP (p < 0.011). A histologic diagnosis of NSIP is associated with a better prognosis than UIP. This subclassification of CFA is clinically useful.

Pulmonary function tests and CT scan in the management of idiopathic pulmonary fibrosis

Relationships between pulmonary function testing and high-resolution computed tomography (HRCT) were studied in 39 untreated patients with idiopathic pulmonary fibrosis (IPF) at diagnosis, 23 of whom were followed during 7.5 +/- 0.3 mo (mean +/- SEM). At diagnosis, the extent of overall lung involvement in the HRCT scans showed a moderate but significant correlation only with FVC (r = -0.46, p = 0. 003) and DLCO (r = -0.40, p = 0.03). The extent of ground glass pattern also correlated with FVC (r = -0.58, p = 0.0001). Arterial PO2 at peak exercise (n = 13 patients) showed a significant association with the extent of both ground-glass pattern and overall lung involvement in HRCT (r = -0.60, p = 0.02; and r = -0.64, p = 0. 01, respectively). On multivariate analysis a significant independent correlation between the global disease extent in HRCT and both FVC and DLCO was observed. Changes over time in the total extent of the disease evaluated with HRCT scans were also related to those observed in DLCO and in FVC (r = -0.57, p = 0.01, and r = -0. 51, p = 0.01, respectively). The present study suggests that FVC and DLCO are the physiological variables that best reflect the global extent of disease in IPF and thus may provide significant information for the assessment of the disease's progression.

Genetic defects and clinical characteristics of patients with a form of oculocutaneous albinism (Hermansky-Pudlak syndrome)

BACKGROUND

Hermansky-Pudlak syndrome is characterized by oculocutaneous albinism, a storage-pool deficiency, and lysosomal accumulation of ceroid lipofuscin, which causes pulmonary fibrosis and granulomatous colitis in some cases. All identified affected patients in northwest Puerto Rico are homozygous for a 16-bp duplication in exon 15 of a recently cloned gene, HPS. We compared the clinical and laboratory characteristics of these patients with those of patients without the 16-bp duplication.

METHODS

Forty-nine patients -- 27 Puerto Ricans and 22 patients from the mainland United States who were not of Puerto Rican descent -- were given a diagnosis on the basis of albinism and the absence of platelet dense bodies. We used the polymerase chain reaction to determine which patients carried the 16-bp duplication.

RESULTS

Twenty-five of the Puerto Rican patients were homozygous for the 16-bp duplication, whereas none of the non-Puerto Rican patients carried this mutation. Like the patients without the duplication, the patients with the 16-bp duplication had a broad variation in pigmentation. Nine of 16 adults with the duplication, but none of the 10 without it, had a diffusing capacity for carbon monoxide that was less than 80 percent of the predicted value. High-resolution computed tomography in 12 patients with the 16-bp duplication revealed minimal fibrosis in 8, moderate fibrosis in 1, severe fibrosis in 1, and no fibrosis in 2. Computed tomography in eight patients without the duplication revealed minimal fibrosis in three and no fibrosis in the rest. Inflammatory bowel disease developed in eight patients (four in each group) between 3 and 25 years of age.

CONCLUSIONS

The 16-bp duplication in exon 15 of HPS, which we found only in Puerto Rican patients, is associated with a broad range of pigmentation and an increased risk of restrictive lung disease in adults.