Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs

Head Cheese Sign

Brett W. Carter, MD, CPPS

Selected Images Hide Images

Axial NECT of a patient with Axial NECT of a patient with Axial expiratory HRCT of a patient Axial expiratory HRCT of the same
hypersensitivity pneumonitis hypersensitivity pneumonitis shows with hypersensitivity pneumonitis patient demonstrates 3 distinct CT
demonstrates well-demarcated alternating regions of increased demonstrates heterogeneous lung attenuations including, normal lung
regions of normal and and decreased lung attenuation with areas of increased attenuation , air-trapping
increased lung attenuation attenuation and consolidation , decreased , and normal (decreased attenuation) , and
resulting in the head cheese sign. with at least 3 different CT lung attenuation. ground-glass opacity .
Note the background of attenuations identified. Transitions between different lung
centrilobular ground-glass nodules attenuations reflect the margins of
. the secondary pulmonary lobules.

Additional Images
KEY FACTS

Terminology
Juxtaposition of lobular regions of low, normal, and high attenuation on CT
Results in 3 or more different sharply demarcated CT attenuations
Transitions between different CT attenuations reflect margins of secondary pulmonary lobules
Reminiscent of variegated appearance of head cheese cold cut meat
Indicates mixed infiltrative and obstructive process
Initially considered highly specific if not pathognomonic for cluster 1 (subacute) hypersensitivity pneumonitis
Imaging
CT
Combination of imaging findings
Normal lung
Consolidation
Ground-glass opacity
Low-attenuation lobules
Obstructive small airways disease
Air-trapping
Can be confirmed with expiratory CT
Contributes to mosaic attenuation pattern
Vasoconstriction from localized hypoxia
Top Differential Diagnoses
Hypersensitivity pneumonitis (cluster 1, subacute)
Sarcoidosis
Atypical infections associated with bronchiolitis (mycoplasma pneumonia, pneumocystis pneumonia)
Respiratory bronchiolitis
Respiratory bronchiolitis interstitial lung disease
Desquamative interstitial pneumonia
Diagnostic Checklist
Consider hypersensitivity pneumonitis in patients with unexplained dyspnea and head cheese sign on CT

SELECTED REFERENCES

1. Chong BJ et al: Headcheese sign. J Thorac Imaging. 29(1):W13, 2014

 2. Webb WR: Thin-section CT of the secondary pulmonary lobule: anatomy and the image--the 2004 Fleischner lecture. Radiology.
239(2):322-38, 2006
© 2022, Elsevier, Inc. AmirsysSupport@Elsevier.com