Case 2


Section 1

Image 1

1. What is the major abnormality in this case?

a) Linear opacities
b) Nodules
c) Consolidation
d) Ground-glass opacity

2. What is the distribution of the abnormalities?

a) Bronchial/bronchiolar
b) Interlobular septal
c) Centrilobular
d) Pleural

Answers


Section 2

Image 1

See diagrams and definitions below.

Find a row of centrilobular nodules within 5 mm of the pleura in the right lung.

Find 2 rosettes in the right lung.

Find a tree-in-bud pattern in the right lung.

Find bronchial wall thickening in longitudinal or cross-section in the right lung (one of each is marked).

 

clnodrosette1rosette2tibbrwallthbrwallth1brwallth2


Section 3: Diagrams Illustrating Centrilobular Nodules

This diagram illustrates lymphangitic tumor highlighting anatomic structures--interlobular septa and centrilobular nodules.

Here, the regularly-spaced centrilobular nodules remain when the linear structures are taken away.

Definitions

Centrilobular nodules are nodules in the centrilobular area, sublobular in size. At the periphery, these nodules usually occur within 5 mm of the pleura (half the distance of a 1 cm lobule).

Rosettes are clustered nodules often within a lobule. These represent involvement of several centriacinar airways (see definition of acinus (click the back button in the menu bar to return)). Find two rosettes in the diagram.

Tree-in-bud pattern represents several centrilobular nodules connected by thin, branching, linear structures. These often represent connected nodules of a rosette. Find two examples in the diagram.

tibtib2rosetterosette2


Section 4: Gross Appearance

This slice of lung with bronchopneumonia shows a pattern similar to that shown in the HRCT image above.

Find a row of subpleural centrilobular nodules.

Find rosettes (2 are marked).

Find tree-in-bud patterns (1 is marked).

subpleuralnodrosette1rosette2treebud


Section 5: Follow-up HRCT

Compare HRCT image 1 above with image 2 taken after treatment.

Image 2

What changes have occurred after therapy?

Answer


Section 6: Histologic Changes

1. What type of airway is this?

a) Bronchus
b) Bronchiole

2. What are the collections of cells in the thickened airway interstitium?

a) Lymphoid infiltrates
b) Lymphoid follicles
c) Infiltrates of PMNs

What is the histologic diagnosis?

Answers

     

     

Differential diagnosis of centrilobular nodules on HRCT: Centrilobular nodules usually result from acute or chronic bronchiolar infections--bacterial, viral, or fungal--especially those associated with bronchiectasis or cystic fibrosis. They also occur in inflammatory conditions such as hypersensitivity pneumonia, respiratory bronchiolitis, bronchiolitis obliterans organizing pneumonia, pneumoconioses, sarcoidosis, asthma, autoimmune and immunodeficiency diseases, and bronchiolitis obliterans.

Histologic differential diagnosis: Immunodeficiency diseases including AIDS, collagen vascular diseases, hypersensitivity pneumonia, chronic infections

Diagnosis: Diffuse bronchitis and bronchiolitis

Summary of diagnostic features of diffuse bronchitis/bronchiolitis on HRCT

Comment: This adult patient has common variable immunodeficiency disease, which predisposes to bronchitis and bronchiolitis.

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1. b. Nodules

2. a. & c. Bronchial/bronchiolar and centrilobular

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Centrilobular nodules within 5 mm of pleura

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Rosette

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Centrilobular nodules within 5 mm of pleura

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Tree-in-bud pattern

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Rosette

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Bronchial wall thickening in longitudinal or cross-section

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Post therapy changes: Marked resolution of diffuse centrilobular nodules, tree-in-bud changes, and bronchial/bronchiolar wall thickening

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Rosette

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Tree-in-bud pattern

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Tree-in-bud pattern

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1. What type of airway is this?

b. This airway is a bronchiole because it lacks cartilage.

2. What are the collections of cells in airway interstitium?

a. & b. The inflammatory cells are lymphoid cells, some in aggregates. The aggregate with a germinal center at the lower aspect of the airway qualifies as a lymphoid follicle. Even though you cannot see much detail, the cells are not PMNs, which usually occur as an exudate in air spaces.

3. What is the histologic diagnosis?

Chronic follicular bronchiolitis

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