Constrictive Bronchiolitis (Bronchiolitis Oblite rans)

Postinfectious Bronchiolitis Toxic Fume Exposure Transplant- related Bronchiolitis Cryptogenic Bronchiolitis Obliterans

Bronchiolitis Obliterans with Organizing Pneumonia

Defined histologically as concentric luminal narrowing of the membranous and respiratory bronchioles secondary to submucosal and peribronchiolar inflammation and fibrosis without any intraluminal granulation tissue or polyps Can be cryptogenic; postinfectious, or secondary to noxious fume inhalation, graft-versus-host disease, lung transplantation, rheumatoid arthritis, inflammatory bowel disease, and penicillamine therapy; histology varies according to the cause.

Direct CT signs of bronchiolitis are usually absent because the amount of abnormal soft tissue in and around the bronchioles is relatively small Characteristics:
Mosaic attenuation Bronchial dilation Air trapping - can be lobular, segmental, or lobar or present as larger areas of confluent decreased lung attenuation that are accentuated on expiratory imaging (expiratory high- resolution CT) Areas of low attenuation - reduction in the size of the pulmonary vessels

Most cases of are secondary to an infection with adenovirus type 7 during childhood or infancy May also develop with measles, pertussis, tuberculosis, and Mycoplasma infection. Alveolar maturation occurs in children by the age of 8 years. If bronchiolitis occurs before this age, it affects the division of alveoli, with a resultant decrease in the number of alveoli and pulmonary vessels. Patchy distribution of bronchiolitis and air trapping (mosaic attenuation) Focal areas of decreased lung opacity with sharp margins, reduced-size pulmonary vessels, bronchial wall thickening, and bronchiectasis

35-year-old man with cellular bronchiolitis secondary to Mycoplasma infect ion. Multiple poorly defined centrilobular nodules, many of which connect to branching linear structures (arrows), tree-in-bud pattern.

Reactive airways dysfunction syndrome appears to be more common than bronchiolitis as a sequel of toxic fume exposure and is usually not associated with any CT manifestations. Silo filler's lung is a classic cause of constrictive bronchiolitis, although its incidence may have decreased with aggressive corticosteroid treatment Work-related inhalation of flavoring agents (used in making popcorn) has been found to result in a clinical presentation and imaging pattern typical of constrictive bronchiolitis.

Constrictive bronchiolitis pattern in a patient who had severe obstructive lung disease Shows diffuse decrease in lung attenuation, with mild cylindric bronchiectasis.

Constrictive bronchiolitis remains the most common form of chronic rejection in patients with lung transplants, occurring in up to 50% of patients. The diagnosis of bronchiolitis obliterans syndrome in these patients is based on reduction baseline value Risk factors:

in the forced expiratory flow volume in 1sec (FEV1) to less than 80% of the posttransplantation

acute rejection lymphocytic bronchiolitis medication noncompliance cytomegalovirus infection

CT findings

The bronchial dilation found in patients with posttransplantation bronchiolitis obliterans usually has lower lung predominance. Constrictive bronchiolitis is seen as a manifestation of graft-versus-host disease in 10% of people who have received allogeneic bone marrow transplants. CT findings are the same with bronchiolitis obliterans.

bronchial dilation bronchial wall thickening mosaic perfusion air trapping on expiratory images (most sensitive indicator)

Constrictive bronchiolitis pattern in 41-year-old male double lung transplant recipient with bronchiolitis obliterans syndrome. Shows bilateral diffuse cylindric bronchiectasis, with diffuse decrease in vascularity, and decrease in lung attenuation

Uncommon entity that is most common in older women; characterized by airway obstruction that other forms of constrictive bronchiolitis mosaic attenuation, air trapping, and cylindrical bronchiectasis

progresses to respiratory failure Imaging findings similar to those of patients with

Must be differentiated from refractory asthma.

A mosaic pattern of lung attenuation was the most reliable distinguishing feature, being found in one (3%) of 30 patients with asthma and in seven (50%) of 14 patients with bronchiolitis obliterans.

Distinction between bronchiolitis obliterans and panlobular emphysema

recognition of parenchymal destruction, vascular distortion, and linear scars or thickened septa at the lung bases in most patients with panlobular emphysema

Neuroendocrine hyperplasia, a rare entity, can cause a pattern of mosaic attenuation identical to that of bronchiolitis obliterans, but it is usually associated with small scattered pulmonary nodules.

Constrictive bronchiolitis pattern in patient with pulmonary neuroendocrine cell hyperplasia. Shows mosaic attenuation, which is more marked on right than on left.

An idiopathic interstitial pneumonia (cryptogenic organizing pneumonia) rather than a small airways disease because its radiologic, clinical, and physiologic features are more similar to those of a restrictive parenchymal process than a small airways disease.

Bronchiolitis may be classified into inflammatory and fibrotic subtypes Direct signs of bronchiolitis include

centrilobular nodules and tree-in-bud pattern Indirect signs include mosaic attenuation and air trapping

High-resolution CT findings correlate with the histology of different forms of bronchiolitis. Classic examples of each entity exist, but there can be substantial overlap in the appearances, and distinguishing among these entities is not always possible. Clinical details will usually help to narrow the differential diagnosis.

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