Case 11


Section 1

Image 1

Give the distribution and pattern of the nodules in the right lower lobe?

Answer

The right middle lobe and portions of the lingula are collapsed.

Find the collapsed right middle lobe. The lucencies extending from the hilus into the right middle lobe represent varicose bronchiectasis.

Find the collapsed lingula.

 

collrmlcolllintib1tib2bwtcln

Image 1

 

Find a row of 3 centrilobular nodules in the right lung.

Find 2 examples of tree-in-bud pattern in the right lung.

Find a thickened bronchus, consistent with bronchitis in the right lung.

collrmlcolllintib1tib2bwtcln

The lung adjacent to regions of bronchiectasis frequently shows centrilobular nodules and a tree-in-bud pattern, which result from recurrent bronchitis/bronchiolitis. Bronchiectasis commonly results from infections and is associated with volume loss in the involved lung.


Section 2

Gross Appearance

This lung from a young child with cystic fibrosis shows the volume loss and atelectasis (red areas) associated with bronchiectasis. The paler, aerated lung bulges above the areas of collapse.

This lung did not collapse when it was removed postmortem as a normal lung would.

Why would the aerated portions of lung remain expanded?

Answer

 

Bronchiectasis

Here, the posterior mid lung shows extensive varicose bronchiectasis, which is similar to that seen in the HRCT image in the right middle lobe. The term varicose denotes dilation as seen in venous varices. When greater dilation occurs, it is referred to descriptively as cystic bronchiectasis (see Cysts (use the "back" button in the menu bar to return)).

Note the loss of parenchyma between the crowded airways, and the large caliber of the lumen near the pleural surface, compared to airways in the lower lung.

Find a bronchiectatic airway.

Find a normal airway in the lower lung.

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Section 3: Histologic Changes

This is a subsegmental bronchus from a patient with bronchiectasis.

Describe the structures in the wall.

Describe the contents of the lumen.

How does alveolar parenchymal loss occur?

How does airway obstruction occur?

Answers

Differential diagnosis of bronchiectasis, bronchitis, and bronchiolitis on HRCT: Bronchiectasis of any cause listed under histologic differential diagnosis

Histologic differential diagnosis: Causes include chronic bacterial or mycobacterial infections, cystic fibrosis, allergic bronchopulmonary aspergillosis, middle lobe syndrome, chronic bronchiolitis, and proximal bronchial obstruction by tumor or foreign body.

Diagnosis: Bronchiectasis with associated adjacent bronchitis and bronchiolitis.

Diagnostic features of bronchiectasis, bronchitis, and bronchiolitis on HRCT

Comment: This case illustrates another cause of centrilobular nodules and tree-in-bud pattern. It introduces bronchiectasis, which, when suspected clinically, is best diagnosed by HRCT.

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Centrilobular nodules with tree-in-bud pattern

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Collapsed right middle lobe

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Collapsed lingula

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Tree-in-bud pattern

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Bronchial wall thickening of bronchitis

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Centrilobular nodule

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The widespread bronchitis and bronchiolitis produce variable obstruction of small airways with mucus and exudate, which trap air.

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Bronchiectatic airway

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Normal airway in lower lung

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Describe the structures in the wall.

Fibrous tissue and inflammation. The cartilage and smooth muscle have been destroyed.

Describe the contents of the lumen.

Purulent exudate

How does alveolar parenchymal loss occur?

Chronic peribronchial inflammation gradually replaces alveoli with scar.

How does airway obstruction occur?

1) Mucus and exudate in large airways and 2) stenosing mural fibrosis and luminal inflammation of small airways.

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