PATTERN APPROACH TO

CT OF DIFFUSE LUNG
DISEASE

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• Predominant patterns of DLD on CT are as follows:
• Linear

• Nodular

• Increased attenuation

• Decreased attenuation

• Cystic

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 1.LINEAR PATTERN
• A linear pattern can be subcategorized into septal and reticular
patterns.

• A septal pattern is characterized by thickening, and thus visibility, of

the interlobular septa.

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 1.LINEAR PATTERN….cont’d
• Common causes of a septal pattern include
• Lung oedema (symmetrical , basal, bilateral , lower lobe)
• Lymphangitic carcinomatosis(random, nodular/beaded)

• Uncommon causes of a septal pattern include

• Pulmonary veno-occlusive disease
• Storage diseases such as Niemann–Pick disease
• Lymphangiectasia

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1.LINEAR PATTERN….cont’d

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 1.LINEAR PATTERN….cont’d
• A reticular pattern usually is the result of interstitial fibrosis, most commonly the usual
interstitial pneumonia (UIP).

• Common causes of a reticular pattern include

• Usual interstitial pneumonia
• Nonspecific interstitial pneumonia
• Fibrotic hypersensitivity pneumonitis

• Uncommon causes of a reticular pattern include

• Sarcoidosis
• Hard metal pneumoconiosis
• Asbestosis
• Familial interstitial pneumonia

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1.LINEAR PATTERN….cont’d

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 2. NODULAR PATTERN
• A nodular pattern can be subcategorized into centrilobular, perilymphatic and
random distributions.

• Centrilobular nodules are fairly evenly spaced, do not abut pleural surfaces and do
not contact large vessels and airways.

• A pattern of well-defined centrilobular nodules with or without branching

centrilobular opacities (tree-in-bud) is most often the result of cellular
bronchiolitis, usually due to infection or aspiration.

• Because the lobular pulmonary artery is located adjacent to the terminal

bronchiole, pulmonary arteriolar disease, albeit rarely, can also manifest as a
centrilobular pattern. 9
 2. NODULAR PATTERN
• Common causes of a centrilobular pattern are

• Well defined (with or without tree-in-bud opacities)

• Infectious bronchiolitis
• Aspiration

• Ground-glass attenuation
• Hypersensitivity pneumonitis
• Respiratory bronchiolitis

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 2. NODULAR PATTERN
• Uncommon causes of a centrilobular pattern are
• Well defined
• Follicular bronchiolitis
• IV drug use (excipient lung disease)
• Endovascular metastases

• Ground-glass attenuation
• Pulmonary capillary haemangiomatosis
• Severe pulmonary hypertension

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2. NODULAR PATTERN

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 2. NODULAR PATTERN
• A perilymphatic pattern is characterized by nodules located primarily
along the pulmonary lymphatics, particularly along the pleural
surfaces, interlobular septa, centrilobular core and large
bronchovascular structures.

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 2. NODULAR PATTERN
• Common causes of a perilymphatic pattern include
• Sarcoidosis
• Lymphangitic carcinomatosis

• Uncommon causes of a perilymphatic pattern include

• Silicosis
• Coal worker’s pneumoconiosis
• Berylliosis

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2. NODULAR PATTERN

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 2. NODULAR PATTERN
• A random pattern of diffuse lung nodules reflects haematogenous
spread of infection or tumour.

• Miliary pattern is a term used to describe diffuse, randomly

distributed tiny (<4 mm) nodules.

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 2. NODULAR PATTERN
• Common causes of a random pattern include

• Disseminated infection
• Tuberculosis
• Endemic fungus
• Histoplasmosis
• Coccidioidomycosis
• Blastomycosis

• Varicella-zoster virus

• Metastases

• A rare cause of a random pattern is

• Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)
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2. NODULAR PATTERN

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 3. INCREASED ATTENUATION

• Increased attenuation of the lung parenchyma can be divided into

ground-glass opacity (GGO) and consolidation.

• It is not uncommon for GGO and consolidation to coexist, as they

represent a continuum of altered lung attenuation.

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 3. INCREASED ATTENUATION
• GGO describes a subtle or hazy increase in lung attenuation with
preservation of the underlying structures including vessels, airways and
interlobular septa.

• GGO is the result of volume averaging of a process below the spatial

resolution of CT, whether it be primarily affecting the airspaces or the
pulmonary interstitium.

• Any process that fills the alveoli with fluid or cells in its early stage can
result in GGO.
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 3. INCREASED ATTENUATION
• Similarly, infiltration of the interstitium such as with an inflammatory
or fibrotic process, can also cause GGO.

• Increased capillary blood volume can also lead to increased

attenuation of the lung, which is referred to as mosaic perfusion.

• GGO can be the manifestation of acute or chronic processes and may

be subtle or occult on CXR

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 3. INCREASED ATTENUATION
• Common causes of GGO include
• Acute
• Oedema
• Aspiration
• Infection (especially Pneumocystis, viral, Mycoplasma)
• Haemorrhage

• Subacute or chronic
• Organizing pneumonia (related to infection, drug toxicity, etc.)

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 3. INCREASED ATTENUATION
• Uncommon causes of GGO include

• Acute
• Diffuse alveolar damage
• Acute exacerbation of DLD
• Acute eosinophilic pneumonia
• Hypersensitivity pneumonitis
• Radiation pneumonitis

• Subacute or chronic
• Nonspecific interstitial pneumonia
• Hypersensitivity pneumonitis
• Lymphoid interstitial pneumonia
• Smoking-related diffuse lung disease
• Chronic eosinophilic pneumonia
• Sarcoidosis
• Pulmonary alveolar proteinosis
• Vasculitis
• Lung adenocarcinoma
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3. INCREASED ATTENUATION

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 3. INCREASED ATTENUATION
• Crazy-Paving
• Crazy-paving describes an area of GGO with superimposed septal lines.

• This pattern was described originally in cases of pulmonary alveolar

proteinosis (PAP) ; however, many other diseases can cause a crazy-paving
pattern .

• Crazy-paving can be the only finding (typical of PAP) or more commonly

coexists with ground-glass opacity, consolidation, or both.

• The differential diagnosis for crazy-paving is similar to that of GGO.

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3. INCREASED ATTENUATION

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 3. INCREASED ATTENUATION
• Consolidation
• Consolidation represents an area of homogeneous increased lung
attenuation that obscures the underlying structures, with the possible
exception of airways (air bronchograms).

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 3. INCREASED ATTENUATION
• Acute

• Common
• Infection
• Aspiration
• Oedema

• Uncommon
• Diffuse alveolar damage
• Haemorrhage
• Acute eosinophilic pneumonia

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 3. INCREASED ATTENUATION
• Chronic

• Common
• Organizing pneumonia
• Cancer (especially invasive mucinous adenocarcinoma)

• Uncommon
• Sarcoidosis
• Lipoid pneumonia
• Lymphoma and other lymphoproliferative diseases
• Chronic eosinophilic pneumonia
• Hypersensitivity pneumonitis
• Radiation-induced injury
• Vasculitis 29
3. INCREASED ATTENUATION

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4. DECREASED ATTENUATION
• Decreased attenuation occurs when the lung parenchyma is darker or
more lucent than normal, usually from reduced perfusion or gas
trapping.

• Comparing it to the trachea, the lung should always have higher

attenuation.

• Diseases that cause low attenuation include those that destroy the lung
parenchyma such as emphysema, those causing mosaic perfusion
including chronic pulmonary embolism, and cystic lung disease
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4. DECREASED ATTENUATION
• Destruction of the lung parenchyma
• Common:
• Smoking-related emphysema (centrilobular, paraseptal)
• Emphysema related to α-1-antitripsin deficiency (panlobular)

• Uncommon:
• Pulmonary laceration
• Inflammatory pneumatoceles

• If advanced, distinguishing emphysema from lung cysts can be challenging.

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 4. DECREASED ATTENUATION
Emphysema Cysts

No clear walls Well-defined walls that are usually thin

(if thick it is bullae)

Destroys pulmonary architecture Displaces adjacent structures (vessels and airways)

without destroying them

Often has a central dot, which represents the remaining No central structures
lobular pulmonary artery

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4. DECREASED ATTENUATION

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 4. DECREASED ATTENUATION
• Mosaic perfusion (mosaic oligemia)
• Mosaic perfusion refers to the heterogeneous appearance of the lung with
alternating areas of different attenuation caused by a shift in lung
perfusion by a disease.

• Both airway and vascular diseases can cause mosaic perfusion, although
airway causes are by far more common.

• The areas of different attenuation can be lobular, segmental or larger. In

mosaic perfusion, the dark lung is abnormal and underperfused.
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 4. DECREASED ATTENUATION
• Expiratory images are extremely useful in distinguishing airways from
vascular disease.

• Small airways disease will show air trapping on expiratory images,

which means that the lucent areas will stay lucent on expiratory
images and the remaining lung will become denser.

• If all of the lung parenchyma (including the lucent areas) increase in

attenuation and decrease in volume on expiratory images, then the
aetiology is vascular.

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 4. DECREASED ATTENUATION
• Common airways causes of mosaic perfusion include
• Asthma
• Bronchiectasis
• Constrictive bronchiolitis

• Uncommon airways causes of mosaic perfusion include

• Cystic fibrosis
• Hypersensitivity pneumonitis
• DIPNECH

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 4. DECREASED ATTENUATION
• Common vascular causes of mosaic perfusion include
• Acute or chronic pulmonary thromboembolism

• Uncommon vascular causes of mosaic perfusion include

• Pulmonary hypertension (especially chronic PTE)
• Large vessel vasculitis

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4. DECREASED ATTENUATION

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4. DECREASED ATTENUATION

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 5. CYSTIC PATTERN
• A lung cyst is defined as any round circumscribed space that is surrounded
by an epithelial or fibrous wall of variable thickness, usually <3 mm.

• Cysts usually contain air but can be filled with liquid or solid material.

• Diseases mimicking lung cysts include emphysema and cystic

bronchiectasis.

• Many cystic lung diseases are seen in younger people.

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• Common causes of cystic lung disease are
• Incidental (usually elderly patients; usually not a negligible finding if
patient is <50 years old)
• Pulmonary Langerhans cell histiocytosis (PLCH)

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• Uncommon causes of cystic lung disease are
• Lymphangioleiomyomatosis (LAM)
• Tuberous sclerosis complex (TSC)
• Birt–Hogg–Dubé syndrome (BHD)
• Lymphoid interstitial pneumonia (LIP)
• Amyloidosis and light-chain deposition disease (LCDD)
• Pneumatoceles (such as in Pneumocystis infection)
• Barotrauma
• Cystic metastasis
• Tracheobronchial papillomatosis
• Neurofibromatosis
• Proteus syndrome
• Honeycombing (UIP)
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• END

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