Diffuse lung disease

17
Introduction
The purposes of this chapter are to explain optimal
CT technique to evaluate diffuse lung disease, to
describe and illustrate the common radiologic
signs of diffuse lung disease, and to show how
imaging can help elucidate some common clini-
cal problems.
CT Techniques
The technique of high resolution CT (HRCT)
requires thin (1–1.5 mm) sections and a special
reconstruction algorithm to maximize detail in
the lung parenchyma [1] (Fig. 2.1). HRCT images
may be reconstructed from a volumetric dataset
or may be acquired using noncontiguous images
at 1–2 cm intervals. If volumetric acquisition is
performed, coronal and sagittal reconstructions
may be obtained, and may be very helpful in
understanding distribution of disease.
Careful attention to technique is required
to ensure high quality images. In particular,
Abstract
High resolution CT is useful for early detection and characterization of
diffuse lung diseases. Optimal CT evaluation requires careful attention to
technique. Radiologic diagnosis is based on the use of standard descriptive
terms and the distribution of abnormality in the craniocaudal and axial
planes. Confident CT diagnoses of several diffuse diseases, including
usual interstitial pneumonia, sarcoidosis, hypersensitivity pneumonitis,
smoking-related lung injury, Langerhans histiocytosis, lymphangioleio-
myomatosis, based on typical CT findings and made in the appropriate
clinical context, are usually correct. However, certain other radiologic
findings, particularly ground-glass abnormality, consolidation and reticu-
lar abnormality, are relatively nonspecific and will usually require further
diagnostic evaluation.
Keywords
High resolution CT • Diagnosis • Usual interstitial pneumonia • Sarcoidosis
• Hypersensitivity pneumonitis
D.A. Lynch (*)
Department of Radiology, National Jewish Health,
Denver, CO, USA
e-mail: lynchd@njhealth.org
2Radiologic Evaluation
David A. Lynch
R.P. Baughman and R.M. du Bois (eds.), Diffuse Lung Disease: A Practical Approach,
DOI 10.1007/978-1-4419-9771-5_2, © Springer Science+Business Media, LLC 2012

18 D.A. Lynch
technologists must work with the patient to ensure
the absence of respiratory motion, which is the
commonest cause of suboptimal images. Because
atelectasis in the dependent lung can obscure detail,
prone HRCT imaging is frequently performed
to evaluate the posterior lung, where the early
changes of asbestosis, collagen vascular-related
lung disease, and idiopathic interstitial pneumo-
nias may be first seen. Expiratory CT is often
pivotal in identifying gas trapping in obstructive
lung disease and hypersensitivity pneumonitis
and sarcoidosis.
Radiologic Signs of Diffuse
Lung Disease
Specificity of radiologic descriptors enhances the
ability of radiologists to communicate their findings
and generate appropriate differential diagnoses.
The Fleischner Society has published a helpful
glossary of descriptors used in thoracic imaging,
which serves as standardized terminology [2].
Nonspecific terms such as alveolitis are best
avoided. Table 2.1 illustrates the differential diag-
nosis of common patterns in diffuse lung disease.
Consolidation/Ground-Glass
Attenuation
The term parenchymal opacification [3, 4] is
applied to any homogeneous increase in lung
density on chest radiographs or chest CT. When
this parenchymal opacification is dense enough
to obscure the vessels and other parenchymal
structures, it is called consolidation (Fig. 2.2).
Since consolidation is usually due to a pathologic
process filling the alveoli its differential diagnosis
is broad, but may be narrowed when seen in rela-
tively healthy outpatients, as given in Table 2.1.
Ground-glass attenuation is defined as an
increase in lung density not sufficient to obscure
vessels (see Fig. 2.2). Ground-glass attenuation is
commonly, though not always, associated with
reversible or potentially reversible lung disease.
Because ground-glass attenuation may be due to
any infiltrative process involving alveoli or alveo-
lar septa, the differential diagnosis is broad. The
differential presented in Table 2.1 may be applied
to relatively healthy outpatients.
Nodules
Nodules seen on HRCT can be classified accord-
ing to their size (micronodules or larger nodules),
density (ground glass, soft tissue, or calcific den-
sities), definition (well defined or poorly defined),
and distribution. Micronodules measure less than
3 mm in diameter [5]. Gruden et al. [6] classified
nodules on the basis of their location (random,
perilymphatic, centrilobular, or airways associ-
ated). Perilymphatic micronodules are seen in
subpleural and septal locations, most commonly
in subjects with sarcoidosis (Fig. 2.3) or lymp-
hangitic carcinoma, but may also be seen in pneu-
moconiosis. Scattered subpleural micronodules
may be seen in normal subjects. Centrilobular
nodules (see Table 2.2) are recognized by their
characteristic location (Fig. 2.4), approximately
1–2 mm from each other, and separated by about
the same distance from pleura and vessels. They
are often of ground-glass attenuation. Small air-
ways-associated nodules are identified when the
tree-in-bud pattern is present (nodules closely
related to small branching structures) (Fig. 2.5).
These nodules are usually centrilobular.
Nodules of ground-glass density are typically
seeninhypersensitivitypneumonitis(seeFig.2.4),
but may also be seen in respiratory bronchiolitis.
Soft tissue density nodules are seen in patients
with granulomatous lung diseases, malignancy,
Fig. 2.1 Normal high resolution CT

192 Radiologic Evaluation
Table 2.1 Differential diagnosis of infiltrative lung disease based on CT pattern
CT findings Differential diagnosis
Consolidationa
Chronic infection (mycobacterial, fungal)
Organizing pneumonia
Sarcoidosis (pseudoalveolar)
Bronchioloalveolar carcinoma
Lymphoma
Eosinophilic pneumonia
Vasculitis
Chronic aspiration (esp. lipid)
Ground-glass attenuationa
Hypersensitivity pneumonitis
Nonspecific interstitial pneumonia
Desquamative interstitial pneumonitis/respiratory
bronchiolitis interstitial lung disease
Hemorrhage
Drug toxicity
Nodules Malignancy
Silicosis
Coal workers’ pneumoconiosis
Granulomatous infection
Sarcoidosis
Berylliosis
Langerhans cell histiocytosis
Centrilobular nodules (see Table 2.3)
Fibrotic disease (reticular pattern,
traction bronchiectasis, architectural
distortion)
Usual interstitial pneumonia
Nonspecific interstitial pneumonia
Asbestosis
Collagen vascular disease
Sarcoidosis
Chronic hypersensitivity pneumonitis
Honeycombing Usual interstitial pneumonia
Sarcoidosis
Cysts Lymphangioleiomyomatosis
Lymphoid interstitial pneumonia
Desquamative interstitial pneumonia
Crazy paving patterna
Pulmonary alveolar proteinosis
Lipoid pneumonia
Bronchioloalveolar carcinoma
Decreased lung attenuation/mosaic
attenuation
Obliterative bronchiolitis
Thromboembolic disease
Panlobular emphysema
Adapted from Lynch DA. Imaging of diffuse parenchymal lung diseases. In: Schwarz M, King T,
editors. Interstitial lung disease. 5th ed. McGraw Hill; 2011. p. 105–49.
a
The differential diagnosis provided here for consolidation, ground-glass attenuation, and crazy
paving pattern is for relatively healthy patients presenting for routine high resolution CT
evaluation. In acutely ill patients, the differential diagnosis of these findings is broader

20 D.A. Lynch
or pneumoconiosis. Calcific nodules are seen in
prior granulomatous infection or in pulmonary
alveolar microlithiasis.
Lines
A variety of linear densities may be seen on
HRCT. Thickened interlobular septa (Fig. 2.6)
are identified because they are perpendicular to
Fig. 2.2 Consolidation and ground-glass attenuation in a
patient with cryptogenic organizing pneumonia. (a) Axial
CT shows patchy consolidation and some ground-glass
attenuation in the left upper lobe. (b) CT obtained 3 months
later, after steroid treatment, shows resolution of the con-
solidation, but residual ground-glass attenuation
Fig. 2.3 Perilymphatic nodules in a patient with sarcoi-
dosis. Coronal CT reconstruction shows bilateral upper
lung predominant nodules, predominantly clustered along
bronchovascular bundles and in the subpleural region
(arrowheads)
Table 2.2 Lobular anatomy in differential diagnosis of
infiltrative lung diseases on HRCT
Centrilobular nodules:
soft tissue attenuation
Pneumoconiosis
Centrilobular nodules:
ground-glass attenuation
Respiratory bronchiolitis
Centrilobular nodules
with tree-in-bud pattern
Infection
Aspiration
Diffuse panbronchiolitis
Noninfectious bronchiolitis
Septal thickening Left heart failure
Lymphangitic carcinoma
Acute eosinophilic pneumonia
Drug hypersensitivity
Sarcoidosis
Adapted from Lynch DA. Imaging of diffuse parenchymal
lung diseases. In: Schwarz M, King T, editors. Interstitial
lung disease. 5th ed. McGraw Hill; 2011. p. 105–49
Fig. 2.4 Centrilobular ground-glass nodules in an individ-
ual with hypersensitivity pneumonitis. There are numerous
poorly defined centrilobular nodules, most of which are of
ground-glass attenuation (i.e., lower in attenuation than
the vessels)

the pleura [7] or by the fact that they form polygonal
structures [8]. Reticular lines are probably the
commonest type of linear abnormality (Fig. 2.7).
These lines are less than 5 mm long, forming a
fine lace-like network which usually does not
conform to lobular anatomy. They are seen in all
types of fibrotic lung conditions, particularly
idiopathic pulmonary fibrosis [9], collagen vascular
disease, and asbestosis. They are usually associ-
ated with other evidence of lung fibrosis such as
architectural distortion or traction bronchiectasis.
Reticular lines are also a prominent CT feature in
patients with the crazy paving pattern (Fig. 2.8)
Fig. 2.5 Tree-in-bud pattern in a patient with nontuber-
culous mycobacterial infection. Axial CT shows multifo-
cal tree-in-bud pattern in the right lung (arrowheads).
There are some centrilobular nodules in the left lung
Fig. 2.6 Interlobular septal thickening in a patient with
lymphangitic carcinoma from lung cancer. CT through the
right lower lung shows smooth and nodular thickening of
numerous interlobular septa, recognized as lines perpen-
dicular to the pleura forming polygonal structures. The
bronchovascular bundles are thickened. There is no traction
bronchiectasis or architectural distortion to suggest fibrosis
Fig. 2.7 Reticular pattern in a patient with usual interstitial
pneumonia (UIP). Traction bronchiectasis is seen in the
right lower lobe. Honeycombing is not present
Fig. 2.8 Crazy paving pattern in a patient with pulmonary
alveolar proteinosis. CT through the mid-lungs shows geo-
graphic areas of reticular abnormality, formed by thickened
interlobular septa and interlobular lines, superimposed on
a background of ground-glass attenuation. Traction bron-
chiectasis and architectural distortion are notably absent.
The distribution is predominantly peribronchovascular

22 D.A. Lynch
(discussed below), but architectural distortion
and traction bronchiectasis are absent.
Traction Bronchiectasis/
Bronchiolectasis
Traction bronchiectasis and bronchiolectasis
(Fig. 2.9) refers to dilatation and distortion of the
bronchiandbronchiolesinareasoffibrosis,presumed
to be due to the forces of increased elastic recoil
acting on these structures [10]. It is usually associated
with a reticular pattern or with ground-glass atten-
uation, and is reliable evidence of lung fibrosis [11].
Honeycombing
Honeycombing is defined as a subpleural cluster
or row of cysts (Fig. 2.10). Honeycomb cysts are
usually very small (less than 5 mm in diameter).
This CT finding correlates with histologic honey-
combing and is found in end-stage lung of any
cause [12]. Larger honeycomb cysts may some-
times be found in patients with sarcoidosis.
Cysts
The cysts of interstitial lung disease are air-
containing lucencies with a well-defined, complete
wall (Fig. 2.11). They are usually round, but may
sometimes be irregular in shape, particularly in
Langerhans histiocytosis. They must be distin-
guished from the “moth-eaten” lucencies of cen-
trilobular emphysema, which are usually irregular
in outline and do not have a definable wall
(Fig. 2.12). Cysts may be distinguished from
bronchiectatic bronchi by the fact that bronchi
are usually accompanied by a smaller pulmonary
artery, and can usually be traced back to the hilum
on serial CT sections.
Crazy Paving Pattern
The crazy paving pattern is a distinctive pattern
characterized by thickened interlobular and
intralobular lines forming a geographic network
superimposed on a background of ground-glass
attenuation (see Fig. 2.8) [13]. In the correct clin-
ical context, this pattern is strongly of pulmonary
alveolar proteinosis. Lipoid pneumonia, and,
rarely, bronchioloalveolar carcinoma may cause
an identical appearance. The pattern can also be
Fig. 2.9 Traction bronchiectasis in a patient with NSIP.
CT shows marked ground-glass attenuation. The associ-
ated marked dilation of numerous bronchi indicates that
this abnormality is due to fibrosis rather than an inflam-
matory process
Fig. 2.10 Honeycombing in a patient with idiopathic
pulmonary fibrosis (UIP). Axial CT through the right
mid-lung shows clustered subpleural honeycomb cysts
(arrowheads)

seen in patients with other lung diseases includ-
ing resolving pneumonia, ARDS, and mucinous
bronchioloalveolar carcinoma, but in those con-
ditions it is usually associated with other types of
CT abnormality [14–16].
Decreased Lung Attenuation/Mosaic
Pattern
The attenuation (density) of a given area of lung
depends on the amount of parenchymal tissue,
air, and blood in that area. Therefore, decreased
attenuation of the lung may be due to lung
destruction (in panlobular emphysema), to
decreased blood flow (in vascular disease such as
pulmonary thromboembolism), or to decreased
ventilation with air trapping and reflex pulmo-
nary oligemia (in small airways diseases with
constrictive bronchiolitis) (Fig. 2.13). Panlobular
emphysema differs from vascular lung disease
and small airway disease in that it usually causes
a diffuse decrease in lung attenuation (increased
blackness), while thromboembolic disease and oblit-
erative bronchiolitis are commonly (though not
always) more patchy in distribution. Vascular dis-
ease can often be distinguished from airways
disease by comparing inspiratory and expiratory
scans. In airways disease, one will expect to see
air trapping on the expiratory scans, resulting in
an increase in the number of areas of decreased
attenuation. In patients with occlusive vascular
disease, the areas of decreased attenuation should
not increase on expiration [17].
Patients with thromboembolic disease and
obliterative bronchiolitis commonly present with
a mosaic pattern, with lobules of normal attenua-
tion adjacent to lobules or subsegments of
decreased attenuation (see Fig. 2.13). A similar
mosaic pattern may be caused by parenchymal
disease which causes lobular areas of ground-
glass attenuation (particularly hypersensitivity
pneumonitis) (Fig. 2.14). With the mosaic pat-
tern, it can be difficult to decide whether the
abnormal areas are those of decreased attenua-
tion or those of increased attenuation. This dis-
tinction can be made by observing the pulmonary
Fig. 2.11 Pulmonary cysts in a patient with lymphangio-
leiomyomatosis. (a) Axial CT through the mid-lungs
shows numerous randomly distributed discrete cysts of
varying sizes. Each cyst has a thin, well-defined wall.
(b) Coronal image shows that distribution in the cranio-
caudal plane is diffuse
Fig. 2.12 Centrilobular emphysema. CT through the
right upper lung shows well-defined lucencies without a
discrete wall

24 D.A. Lynch
vessels, which will be reduced in size in areas
affected by vascular occlusive disease or oblitera-
tive bronchiolitis, but will be normal in size in
patients with parenchymal infiltrative lung dis-
eases [17]. One can then use expiratory images to
distinguish between airway obstruction and
thromboembolic disease [18]. Of course, physi-
ologic evaluation will also help to distinguish
between vascular disease, airways obstruction,
and parenchymal infiltration.
Distribution of Lung Diseases
Evaluation of disease distribution in the cranio-
caudal and axial planes is remarkably valuable
for differential diagnosis of diffuse lung disease
(Table 2.3). In the craniocaudal plane, distribu-
tion of disease may be characterized as upper
lung predominant (Fig. 2.15), lower lung pre-
dominant (Fig. 2.16), or (uncommonly) mid-lung
predominant. In the axial plane, disease distri-
bution may be characterized as predominantly
subpleural or perilymphatic. Perilymphatic abnor-
malities are usually predominantly distributed
along the bronchovascular bundle (where most of
the lymphatics of the lung reside), often associ-
ated with subpleural nodules and interlobular
septal thickening (see Figs. 2.3 and 2.15).
Assessment of the secondary pulmonary lob-
ule may also be valuable in some diffuse diseases
(see Table 2.2) [19, 20]. The secondary pulmo-
nary lobule is a basic anatomic and physiologic
unit of mammalian lung [21]. In humans, it is
an irregularly polyhedral structure composed of
several acini, each supplied by a terminal bron-
chiole. In the center of the secondary pulmonary
lobule are the distal bronchus and its terminal
bronchioles with the associated distal pulmonary
Fig.2.13 Mosaic attenuation in a patient with bronchiolitis
obliterans related to rheumatoid arthritis. (a) Inspiratory
CT shows patchy geographic decrease in lung attenuation.
Pulmonary vessels are decreased in size in the more lucent
parts of lung. (b) Expiratory CT confirms that the areas
of decreased attenuation on inspiratory images show gas
trapping on expiration
Fig. 2.14 Mosaic pattern in hypersensitivity pneumoni-
tis. CT through the lower lungs shows diffuse ground-
glass abnormality. However, there is focal decreased
attenuation in the anterior right lower lobe

artery branches. These structures are often called
centrilobular or core structures and may be visible
on HRCT as a dot or branching structure 1 to
3 mm deep to the pleural surface. In patients with
inflammation or plugging of small airways, the
normally invisible centrilobular structures
become visible as nodules or short branching
structures. The centrilobular nodules may either
be of soft tissue attenuation or of ground-glass
attenuation. When these branching structures ter-
minate in a nodule, the “tree-in-bud” sign is pres-
ent (see Fig. 2.5). The tree-in-bud sign is usually
due either to infection or aspiration [22]. Nodules
that are centrilobular without a “tree-in-bud”
appearance are usually due to some form of inha-
lational disease (see Fig. 2.4).
The secondary lobules are separated from
each other by interlobular septa, which contain
branches of the pulmonary veins and lymphatics.
On normal HRCT [21], the interlobular septa
may be visible in the normal anterior lung as
scattered, thin nontapering lines, 1–2 cm long,
perpendicular to the pleura and often contacting
the pleural surface. Thickening of interlobular
Table 2.3 Differential diagnosis of infiltrative lung dis-
eases by distribution within the lung
Peripheral distribution UIP
OP
Asbestosis
Perilymphatic
distribution
Sarcoidosis
Lymphoproliferative
disorders
Upper lobe
predominance
Sarcoidosis
Coal workers’
pneumoconiosis
Silicosis
Lower lobe
predominance
UIP
NSIP
OP
Asbestosis
UIP usual interstitial pneumonia, OP organizing pneumonia,
NSIP nonspecific interstitial pneumonia
Fig. 2.15 Upper lung predominant nodules and con-
glomerate masses in a patient with silicosis. Coronal CT
image shows the typical perilymphatic distribution, with
predominance of the nodules along bronchovascular bun-
dles, interlobular septa and pleura
Fig. 2.16 Lower lung predominant reticular abnormality
and honeycombing in a patient with idiopathic pulmonary
fibrosis

26 D.A. Lynch
septa is usually due to edema or infiltration of
the lymphatic structures, and is often associated
with thickening of the other lymphatic path-
ways (subpleural and peribronchovascular) (see
Fig. 2.6).
Specific Imaging Issues in Evaluation
of Diffuse Lung Disease
Detection of Early Interstitial Lung
Disease
The chest radiograph is relatively insensitive for
detection of diffuse lung disease. Although it is
commonly stated that the chest radiograph is nor-
mal in 10–15% of patients with diffuse lung dis-
ease, the true sensitivity of the chest radiograph
depends on the severity and type of disease pres-
ent in the population being studied. CT has been
shown to be more sensitive than the chest radio-
graph in many diseases including asbestosis [23],
silicosis [24], sarcoidosis [25], scleroderma [26,
27], and hypersensitivity pneumonitis [28, 29]. In
asbestosis, HRCT may detect abnormality before
resting pulmonary function tests become abnor-
mal [23, 30]. It is also clear that the HRCT scan
may be normal despite the presence of biopsy-
proven interstitial disease. In a population-based
study of subjects with hypersensitivity pneu-
monitis who had normal resting pulmonary func-
tion the sensitivity of HRCT was 38% [31].
Similarly, in a paper by Gamsu and colleagues,
CT scanning was normal or near normal in 5 of
25 patients with histologic asbestosis. These
studies emphasize the fact that there is a phase in
the evolution of any lung disease when the degree
of parenchymal infiltration is too slight or too
focal to cause a recognizable increase in lung
attenuation on CT. Therefore, although CT is
substantially more sensitive than the chest radio-
graph for ILD, normal findings on HRCT cannot
be used to exclude ILD. In future, it is possible
that computer-based characterization systems
might help to detect lung disease in patients with
visually normal CT.
Characterization of Interstitial
Lung Disease
Several large retrospective studies have compared
the diagnostic accuracy of chest CT and chest
radiography for diagnosis of specific lung dis-
eases. Mathieson et al. [32] examined the chest
radiographs and CT scans of 118 patients with
diffuse infiltrative lung diseases. For usual inter-
stitial pneumonitis, the first choice diagnosis was
correct in 75% of the cases on chest radiograph
and 89% of the cases on CT. For silicosis, the
corresponding figures were 63 and 93%, and sar-
coidosis, 61 and 77%. For lymphangitic carcino-
matosis, the first choice diagnosis was correct in
56% of cases on the chest radiograph and 85% on
CT. In addition, interobserver variation appeared
to be less for CT scanning than for chest radio-
graphs. Overall, a correct first choice diagnosis
was made with 57% of radiographs and 76% of
CT scans.
One of the defects of these earlier studies was
that they may have included patients with well-
established disease. In a more recent study of 85
patients who were scanned prior to surgical lung
biopsy, the accuracy of a confident first choice
diagnosis of disease was 90%, but such a confi-
dent diagnosis was made in only about 25% of
cases [33]. This relatively low level of diagnostic
confidence was most likely due to selection bias
(patients in whom confident CT diagnoses can be
made are unlikely to undergo biopsy). However, it
is also possible that confident diagnoses are more
difficult to make in those with earlier disease.
A prospective, multicenter study of the accu-
racy of diagnosis of usual interstitial pneumonia
(UIP) found that a confident CT diagnosis of UIP,
based on typical features, was correct in 96% of
cases [34], consistent with the results of several
other studies indicating that the correctness of a
confident first choice diagnosis of UIP, made by
an experienced radiologist, is greater than 90%
[33, 35, 36]. Univariate and multivariate analysis
showed that radiologic features were the primary
discriminants between UIP and other causes of
diffuse lung disease [37]. However, it should be
noted that in this study, a confident CT diagnosis

of UIP was made in only about 50% of cases.
In other cases of histologically confirmed UIP,
the CT features were not typical enough to make
a confident diagnosis. Similar findings were
reported in a study by Raghu et al. [38]. Other
diseases in which a confident CT diagnosis is
highly likely to be correct include lymphangitic
carcinoma [8], Langerhans histiocytosis [39],
lymphangiomyomatosis [39], and hypersensitivity
pneumonitis (with micronodules) [40]. Advanced
cases of sarcoidosis may also be diagnosed with
confidence (see Fig. 2.17).
It must be clearly understood that even a con-
fident CT diagnosis should be integrated with the
available clinical information. Patients with dis-
crepant findings on clinical evaluation and CT
should usually undergo biopsy. Biopsy is also
indicated in patients with nonspecific CT find-
ings. HRCT can be valuable for predicting
whether transbronchial biopsy would be helpful
(insuspectedsarcoidosisorlymphangiticcarcinoma),
and for identifying a suitable site for biopsy by
the bronchoscopist or surgeon. When a biopsy is
performed, it is important to review the biopsy
inconjunctionwiththeCTfindings.Discrepancies
between the CT pattern and the biopsy findings
may be due to sampling of a nonrepresentative
part of the lung.
CT of Specific Lung Diseases
Idiopathic Interstitial Pneumonias
UIP often has a characteristic appearance on CT
[41]. The predominant CT pattern is usually
either reticular abnormality, almost always asso-
ciated with traction bronchiectasis, and frequently
associated with honeycombing (see Figs. 2.7,
2.10, and 2.16) [42]. Pure ground-glass attenua-
tion, if present, is usually sparse. The distribution
of the abnormalities is basal predominant in most,
but may be diffuse in the craniocaudal plane.
Peripheral, subpleural predominance is present in
over 90%. The fibrosis is asymmetric in up to
25% of cases [43]. In contrast to the homogenous
appearance of nonspecific interstitial pneumonia
(NSIP), the abnormalities of UIP often have a
patchy distribution. As the disease progresses, it
often appears to “creep” up the periphery of the
lung, causing subpleural reticular abnormality in
the upper lungs [37].
Multiple prospective and retrospective studies
have shown that a confident or highly confident
diagnosis of UIP, based on the CT features out-
lined earlier, has a specificity of over 90% for the
pathologic diagnosis of UIP [33–35, 38, 40, 42].
Honeycombing in the lower lobes, and linear
Fig. 2.17 Fibrotic sarcoidosis. Axial (a) and coronal (b) CT reconstructions demonstrate upper lobe predominant
perihilar conglomerate masses associated with marked bronchovascular distortion

28 D.A. Lynch
abnormality in the upper lobes, are the most
reliable features for differentiating between UIP
and its clinical mimics (see Fig. 2.10) [37]. In a
study by Flaherty et al., the observation of honey-
combing on HRCT indicated the presence of UIP
with a sensitivity of 90% and specificity of 86%
[44]. However, there is a substantial minority
(30–50%) of cases with histologic UIP (without
honeycombing) in whom a confident diagnosis of
UIP cannot be made based on the CT appear-
ances (see Fig. 2.7). In these patients, the CT
appearances of UIP overlap with those of NSIP
and chronic hypersensitivity pneumonitis, and the
diagnosis can only be established by lung biopsy.
Published descriptions of the CT appearances
of NSIP have varied quite widely [42, 45–52],
probably because of differing pathologic diag-
nostic criteria. However, a multidisciplinary
workshop identified a relatively typical CT
appearance among 67 patients who received a
clinical–radiologic–pathologic consensus diag-
nosis of NSIP [53]. In this group, the CT appear-
anceswerecharacterizedbyconfluent,symmetric,
basal predominant, ground-glass and reticular
abnormality with traction bronchiectasis and
lower lobe volume loss (see Fig. 2.9). In contrast
to UIP, the subpleural lung is often spared.
Consolidation is the radiologic hallmark of
cryptogenic organizing pneumonia, seen in about
80% of cases (see Fig. 2.2). It generally shows no
craniocaudal predilection though some series
have shown a basal predominance [54–56]. The
consolidation may have a perilymphatic distribu-
tion [57–61]. Other suggestive features may
include a perilobular pattern (poorly defined
opacity along interlobular septa) and the reverse
halo sign (ring-like opacity with central ground-
glass abnormality) [62, 63].
Lymphoid interstitial pneumonia is character-
ized by ground-glass abnormality. Discrete cysts
may be seen in two-thirds of cases [64], and may
be the dominant or only finding. The cysts typi-
cally have a perilymphatic distribution and usu-
ally lower lung predominant. Mediastinal or hilar
lymphadenopathy is often seen.
Collagen Vascular Disease
Involvement of the respiratory system in the col-
lagen vascular diseases is common. Most of the
parenchymal manifestations of collagen vascular
disease are similar to those found in idiopathic
interstitial pneumonias [65] and can be classified
using the same system [66]. Although any pattern
of lung injury may occur with any of the collagen
vascular diseases, each specific collagen vascular
disease tends to be associated with two or three
specific patterns of injury, summarized in
Table 2.4.
Sarcoidosis
The manifestations of sarcoidosis in the lung
are diverse. However, the salient features are
lymphadenopathy and nodules. Hilar and
mediastinal lymphadenopathy is typically sym-
metric and may be partially calcified. The nod-
ules are characteristically clustered in a
perilymphatic distribution (see Fig. 2.3) [5],
and often regress at least partially with treat-
ment. Other potentially reversible findings in
sarcoidosis include large nodular opacities,
Table 2.4 Patterns of lung injury most commonly associ-
ated with specific collagen vascular diseases
Disease entity Lung pattern
Diffuse scleroderma Nonspecific interstitial
pneumonia
Pulmonary hypertension
Limited scleroderma Pulmonary hypertension
Rheumatoid arthritis Usual interstitial pneumonia
Obliterative bronchiolitis
Follicular bronchiolitis
Polymyositis/
dermatomyositis
Nonspecific interstitial
pneumonia
Sjögren’s syndrome LIP
Follicular bronchiolitis
Systemic lupus
erythematosus
Pulmonary hemorrhage

septal thickening ground-glass abnormality,
and consolidation [67].
In fibrotic sarcoidosis, perihilar clustered
nodules form conglomerate masses, associated
with bronchovascular distortion (Fig. 2.17) [68].
While the size of these fibrotic masses may
decrease with time, the associated bronchial dis-
tortion usually persists or increases. Honey-
combing may also be seen [69].
Hypersensitivity Pneumonitis
Hypersensitivity pneumonitis may be diagnosed
on CT with high confidence in the presence of
either of the following findings:
Profuse, diffuse, poorly defined centrilobular•
nodules of ground-glass attenuation (see
Fig. 2.4).
Ground-glass attenuation associated with wide-•
spread multilobular decreased lung attenuation
and expiratory air trapping (see Fig. 2.14).
A proportion of subjects with chronic hyper-
sensitivity pneumonitis have lung fibrosis, which
may be difficult to distinguish from UIP or NSIP.
Features that help to distinguish chronic fibrotic
HP from UIP and NSIP include upper or mid-
lung predominance, sparing of the extreme lung
bases, and the presence of multiple lobules of
decreased attenuation and air trapping [36, 70].
Smoking-Related Lung Diseases
Infiltrative lung diseases caused by cigarette
smoking include respiratory bronchiolitis, respi-
ratory bronchiolitis-interstitial lung disease,
desquamative interstitial pneumonia, and pulmo-
nary Langerhans cell histiocytosis (PLCH). On
CT scanning, patients with asymptomatic respira-
tory bronchiolitis generally show mild centrilobu-
lar nodularity and small patches of ground-glass
attenuation [71].
In RB-ILD, centrilobular nodularity and
ground-glass attenuation are usually more exten-
sive than in asymptomatic RB (Fig. 2.18) [72].
Emphysema, bronchial wall thickening, and areas
of decreased lung attenuation are commonly also
present [73]. When patchy abnormalities of this
type are present in heavy smokers with impaired
pulmonary function, RB-ILD may be diagnosed
with a high degree of confidence. The CT find-
ings of RB-ILD are at least partially reversible in
patients who stop smoking [73, 74].
Ground-glass attenuation is seen in all pati
ents with DIP [46], with lower lobe predomi-
nance in about 75% of the patients (Fig. 2.19).
Peripheral predominance is seen in about 60%.
Fig. 2.18 Respiratory bronchiolitis interstitial lung disease
in a patient with a 38 pack-year history of cigarette smoking.
CT through the upper lungs shows marked airway wall
thickening, with widespread poorly defined ground-glass
attenuation, and smudgy centrilobular nodularity
Fig. 2.19 Desquamative interstitial pneumonia in a ciga-
rette smoker. CT through the mid-lungs shows diffuse
ground-glass attenuation. Numerous cysts are seen within
the areas of ground glass. In contrast to honeycomb cysts,
these cysts do not show subpleural clustering

30 D.A. Lynch
Cysts are seen within areas of ground-glass
attenuation in at least 50% of cases (Fig. 2.19).
Cystic Lung Diseases
The most common cystic lung diseases are PLCH,
lymphangioleiomyomatosis (LAM), and lym-
phoid interstitial pneumonia. The combination of
pulmonary nodules and cysts, predominating in
the upper lungs is virtually diagnostic of PLCH
(Fig. 2.20) [75–78]. The nodules may be well
defined, poorly defined, or stellate, and may be
cavitary. The cysts are often irregular or lobulated
in outline. PLCH may be distinguished from
LAM by the presence of nodules, by the irregular
outline of the cysts, and by the sparing of the
lung bases.
Cysts are the pathognomonic feature of LAM
(see Fig. 2.11) [79–85]. The cysts are usually
multiple and distributed in a uniform fashion in
lung that is otherwise normal. Cysts are clearly
demarcated by a thin even wall (1–2 mm thick)
and are usually rounded. Vessels are often seen at
the margins of the cysts. The cysts are usually
5–15 mm, but may range from 2 to 50 mm. The
number of cysts varies widely, depending on the
clinical presentation; cysts are usually extensive
in those who present with symptoms of pulmo-
nary impairment, but often quite sparse in those
who present with complications such as pneu-
mothorax, pleural effusion, etc. CT has enhanced
awareness of the intra-abdominal manifestations
of LAM. In addition to renal angiomyolipomas
(found in 30–50% of patients), other manifesta-
tions include hepatic angiomyolipomas, lymp-
hangiomyomas, and enlarged retroperitoneal
lymph nodes [86, 87].
Cysts are often a salient feature of LIP, dis-
cussed earlier. The predominantly perilymphatic
distribution of these cysts usually helps distin-
guish them from LAM and PLCH.
Small Airways Disease
Computed tomography has contributed substan-
tiallytoourunderstandingofsmallairwaysdiseases
and offers a convenient method for classification
of these diverse entities. A current CT-based
classification of small airways disease is pre-
sented in Table 2.5.
In patients with constrictive bronchiolitis (see
Fig. 2.13), the primary CT finding is dramatic
decrease in lung density in affected lobules or
subsegments, associated with narrowing of the
pulmonary vessels. Such findings are identified
in individuals with obliterative bronchiolitis
related to prior infection, connective tissue dis-
ease, toxic fume inhalation, and transplantation
[88–92]. Expiratory images are usually helpful in
confirming air trapping.
Cellular bronchiolitis is characterized on CT
by centrilobular nodularity with a tree-in-bud
pattern (see Fig. 2.5). It is most commonly seen
in patients with acute or chronic pulmonary infec-
tion. In the acute context, it is usually seen in
patients with atypical pneumonia due to myco-
plasma [93] or viruses. In those who are not
acutely ill, the most common causes are myco-
bacterial infection and aspiration.
Fig. 2.20 Pulmonary Langerhans cell histiocytosis in a
young cigarette smoker. Coronal CT shows poorly defined
centrilobular nodules in the upper lungs associated with a
few small cysts. The associated ground-glass attenuation
may represent a component of respiratory bronchiolitis
interstitial lung disease

Panbronchiolitis, typically seen in Asian
patients, is associated with tree-in-bud pattern
associated with bronchiolar dilation, bronchiectasis,
and patchy consolidation [94]. The abnormality is
usually most marked in the lower lobes bilaterally.
A similar pattern may be seen in individuals with
inflammatory bowel disease (see Fig. 2.21).
CT-Based Strategy for Diagnosis
of Diffuse Lung Disease
HRCT is now a pivotal modality in establishing
the diagnosis of diffuse lung disease. Table 2.6
presents a proposed strategy for this purpose. A few
points are important with regard to this table:
The level of diagnostic confidence of the•
radiologic diagnosis is very important and
should be specifically stated. A high-confidence
diagnosis, based on typical features, is much
more likely to be correct than a lower confidence
diagnosis, particularly with IPF.
Certain radiologic findings, particularly ground-•
glass abnormality, consolidation, and reticular
abnormality are relatively nonspecific and will
usually require further diagnostic evaluation.
Table 2.5 CT-based classification of small airways diseases
Radiologic pattern Characteristic radiologic features Causes
Cellular bronchiolitis Centrilobular nodularity Acute or chronic infection
(mycobacterial, fungal)
Tree-in-bud pattern Aspiration
Constrictive bronchiolitis Diffuse or geographic air trapping/
mosaic pattern
Rheumatoid disease
Bronchial dilation Chronic rejection
Childhood viral/mycoplasma infection
Prior toxic fume exposure
Cryptogenic bronchiolitis obliterans
Panbronchiolitis Tree-in-bud pattern Diffuse panbronchiolitis
Bronchiolectasis Cystic fibrosis
Bronchiectasis Immune deficiency
Nontuberculous mycobacterial infection
Inflammatory bowel disease
Respiratory bronchiolitis Poorly defined centrilobular nodules Other inhalation exposures
Patchy ground-glass attenuation
Follicular bronchiolitis Centrilobular nodules Sjogren syndrome and other collagen
vascular diseases
Peribronchial nodules Immunodeficiency
Ground-glass opacity
Adapted from Lynch DA. Imaging of diffuse parenchymal lung diseases. In: Schwarz M, King T, editors. Interstitial
Fig. 2.21 Diffuse panbronchiolitis pattern in a patient
with ulcerative colitis. CT through the lower lungs shows
widespread cylindric bronchiectasis and multifocal tree-
in-bud pattern. Differential diagnosis would include
chronic infection

32 D.A. Lynch
CT may be helpful in identifying optimal sites•
for transbronchial or surgical biopsy.
If clinical or imaging features are atypical,•
biopsy is still indicated.
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