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L. Renata Thronson, HMS IIIGillian Lieberman, MD
Radiologic Findings in Radiologic Findings in BronchiectasisBronchiectasis
L. Renata Thronson, Harvard Medical School Year IIIGillian Lieberman, MD
Oct/Nov 2003
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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BronchiectasisBronchiectasis
Bronchiectasis is an irreversible, chronic dilatation of diseased airways.
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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A 64 yearA 64 year--old male old male with recurrent with recurrent
pneumoniapneumoniaandand
A 44 yearA 44 year--old old woman with woman with
cough and cough and ralesrales
PACS, BIDMC PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Pathogenesis of Pathogenesis of BronchiectasisBronchiectasis
Colonization
Tissue damage
Defective mucociliaryclearance
Microbes persist inbronchi
Environmentalinsult
Geneticsusceptibility
ChronicinflammationProgressive
lung damage
Adapted from Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Menu of testsMenu of tests
• Bronchography– The “gold standard”
• High-resolution CT– 1-2 mm collimation– Grenier et al: Se 96%; Sp 93%– Young et al: Se 98%; Sp 99%
• Chest x-ray– Inferior sensitivity and specificity
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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BronchographyBronchography
• Requires local anesthetic and bronchographic medium potential for allergic reaction
• Exam limited to airways http://radiology.rsnajnls.org
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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CXR: FindingsCXR: Findings
• Indistinct vessel margins
• Tram lines• Ring shadows• Volume loss
– Elevated left hemidiaphragm
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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HRCT: FindingsHRCT: Findings
• Dilatation– Signet ring sign– Non-tapering airways
• Indirect signs– Mucous plugging– Lobar volume loss– Wall thickening
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Signet Ring SignSignet Ring Sign
PACS, BIDMC
Airway
Pulmonary artery
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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NonNon--tapering airwaystapering airways
• Airways visible within 1 cm of the visceral pleura
• Tram lines• Flaring
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Mucous pluggingMucous plugging
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Morphologies of Morphologies of BronchiectasisBronchiectasis
• Cylindrical• Cystic• Varicoid
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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DDX of DDX of BronchiectasisBronchiectasis• Postinfectious
– Bacterial– Mycobacterial– Viral– Fungal
• Post-transplantation– Chronic rejection– GVHD
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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DDX of Bronchiectasis
• Postinflammatory– Aspiration– Toxic inhalation
• Postobstructive– Tumor– Foreign body– Stricture
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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DDX of DDX of BronchiectasisBronchiectasis
• Impaired mucociliary clearance– Dyskinetic cilia syndromes– Cystic Fibrosis
• Inherited cellular or molecular defects– Alpha-1-antitrypsin deficiency– Cystic Fibrosis
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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DDX of DDX of BronchiectasisBronchiectasis• Immune deficiency
– Inherited– Acquired
• Collagen Vascular Disease– Rheumatoid arthritis– Sjogren’s syndrome– Ankylosing spondylitis– Marfan syndrome– IBD
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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DDX of DDX of BronchiectasisBronchiectasis
• Congenital bronchial abnormalities– Mounier-Kuhn syndrome– Williams-Campbell syndrome– Bronchopulmonary sequestration
• Miscellaneous– Asthma– Yellow-nail syndrome– Sarcoidosis
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Diagnostic PitfallsDiagnostic Pitfalls
PACS, BIDMC http://www.hospitalist.net/case1.html
Bronchiectasis Interstitial disease
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Diagnostic PitfallsDiagnostic Pitfalls
Signet ring? Tram lines?
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Diagnostic PitfallsDiagnostic Pitfalls
Branching airway
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126
Double shadow: heart and vessels
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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64 year64 year--old man with recurrent old man with recurrent pneumoniapneumonia
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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64 year64 year--old man with recurrent old man with recurrent pneumoniapneumonia
PACS, BIDMC
Ring shadow Tram lines
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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64 year64 year--old man with recurrent old man with recurrent pneumoniapneumonia
Varicoiddilatation
Airways visible at pleural margin
PACS, BIDMC
Mucous plugging
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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44 year44 year--old woman with coughold woman with cough
Varicoid dilatation Cystic dilatation
PACS, BIDMC PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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44 year44 year--old woman with coughold woman with cough
Tracheal margins
Tracheal margins
PACS, BIDMC
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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MounierMounier--Kuhn syndromeKuhn syndrome
• Congenital bronchial abnormality
• ?Autosomal recessive• Findings
– Tracheomegaly– Bronchomegaly
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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BronchiectasisBronchiectasis and and SitusSitus InversusInversus
Courtesy of Phillip Boiselle, MD
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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KartagenerKartagener syndromesyndrome
• Primary ciliary dismotility– Recurrent respiratory
infections– Decreased fertility
• Findings on CXR– Bronchiectasis– Situs inversus Courtesy of Phillip Boiselle, MD
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Cystic FibrosisCystic Fibrosis
• Upper lobe predilection
• Panlobar disease• Marked cystic
dilatation– Air-fluid levels
may be seen within cysts Courtesy of Phillip Boiselle, MD
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Cystic FibrosisCystic Fibrosis
• Upper lobe predilection
• Panlobar disease• Marked cystic
dilatation– Air-fluid levels
may be seen within cysts Courtesy of Phillip Boiselle, MD
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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PostinfectiousPostinfectious VaricoidVaricoid BronchiectasisBronchiectasis
Focal bronchiectasis
PACS, BIDMC
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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SummarySummary• DDX of bronchiectasis is broad, but the diseases
share a common pathogenesis• Morphologies reflect degrees of severity
– Cylindrical– Cystic– Varicoid
• Tests available– Bronchography– CXR– HRCT
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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SummarySummary
• Radiologic findings– CXR
• Volume loss• Mucous plugging
– “gloved finger”
• Inflammation– Indistinct vessel margins– Tram lines– Ring shadows
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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SummarySummary
• Radiologic findings– HRCT
• Wall thickening• Mucous plugging• Crowded bronchilobar volume loss• Airway dilatation
– Signet ring sign– Non-tapering small airways
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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ReferencesReferences• Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.• McGuinness G, Naidich DP. CT of Airways Disease and Bronchiectasis. Radiologic Clinics of
North America 2002; 40:1-19.• Friedman, PJ. Chest Radiographic Findings in Adults with Cystic Fibrosis. Seminars in
Roentgenology 1987; 22:114-124.• Grenier P, Maurice R, Musset D, et al. Bronchiectasis: Assessment by thin-section CT.
Radiology 1986; 161:95-99.• Young K, Aspestrand F, Kolbenstvedt. High resolution CT and bronchography in the
assessment of bronchiectasis. Acta Radiology 1991; 32:439-441.
L. Renata Thronson, HMS IIIGillian Lieberman, MD
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Acknowledgements
• Andru Bageac, MD• Eric Niendorf, MD• Phillip Boiselle, MD• Gillian Lieberman, MD• Larry Barbaras• Pamela Lepkowski
