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Plain Film Evaluation of

Interstitial Lung Disease

Laura E. Heyneman, MD
Duke University Medical Center
Approach to ILD
• What is the pattern?
• Acute vs chronic?
• Any clues?
– distribution, lung volumes
– associated findings
Patterns of ILD
• Nodular

• Reticular
• Cystic
• Septal lines
Nodular
• Acute
– atypical infection
Nodular
• Chronic
– Mets
– Sarcoid
– Silicosis / Coal worker’s
– Eosinophilic granuloma
– Hypersensitivity: subacute
Nodular: Clues
Diffuse / lower distribution
– Miliary infection
– Metastases
Nodular: Clues
Upper lung distribution
– Sarcoid
– Silicosis / Coal worker’s
– Eosinophilic granuloma
– Hypersensitivity: subacute
Acute

1 month earlier
Miliary TB
Upper lobe predominant
Clues to etiology?
nodules: central lucencies
Eosinophilic Granuloma
Upper lobe predominant
Clues to etiology?
lymphadenopathy
Sarcoid
Clues to etiology?
calcified nodes (“egg shell”)
Clues to etiology?
silicosis vs sarcoid
Sarcoid
Clues to etiology?
calcified nodules
Silicosis
Reticular
• Acute
– atypical infection
• Pneumocystis
• viral infection
Reticular
• Chronic
– fibrosis (UIP, NSIP)
– emphysema
– cystic lung disease
– bronchiectasis
Reticular: Clues
Normal to ↑ lung volumes
– infection
– emphysema
– cystic lung disease
– bronchiectasis
Reticular: Clues
Decreased lung volumes
– fibrosis (*)
Reticular: Clues
Upper lobe distribution
– sarcoid
– chronic hypersensitivity
– cystic fibrosis
– ankylosing spondylitis
Reticular: Clues
Lower lobe distribution
– UIP, NSIP
– chronic aspiration
Acute perihilar reticulation

2 months earlier
Pneumocystis jirovecii
Low volumes,
upper lobe fibrosis
Clues to etiology?
Osseous findings
Ankylosing spondylitis
Low volumes,
upper lobe fibrosis
Clues to etiology?
lymphadenopathy
Sarcoid
Upper lobe fibrosis,
perihilar confluent masses
Progressive massive fibrosis
silicosis vs sarcoid
PMF: Clues to etiology?
parallel chest wall: silicosis
PMF: Clues to etiology?
noncalcified LAN: sarcoid
Low volumes, lower lobe
Fibrosis: UIP or NSIP
Clues to etiology?
pleural plaques
Clues to etiology?
Asbestosis
Clues to etiology?
osseous changes?
Clues to etiology?
Rheumatoid Arthritis
Clues to etiology?
soft tissue calcification?

Courtesy of Charles White, MD


Clues to etiology?
soft tissue calcification?

Courtesy of Charles White, MD


Clues to etiology?
Connective Tissue Disease

Courtesy of Charles White, MD


Clues to etiology?
esophageal dilation
Clues to etiology?
esophageal dilation
Clues to etiology?
Scleroderma
Cysts/ Ring Lucencies
• Acute
– Pneumocystis pneumonia
– (necrotizing pneumonia)
Cysts/ Ring Lucencies
• Chronic
– honeycombing
– bronchiectasis
– eosinophilic granuloma
– lymphangioleiomyomatosis
– emphysema
Normal lung volumes,
upper lobe cystic change
Acute

2 months earlier
Pneumocystis jirovecii
Low volumes
Cysts stacked upon cysts
Honeycombing
Lower lobe: UIP
Upper: sarcoid, chronic HP
Normal volumes,
cysts stacked on cysts
cysts stacked on cysts
tubular, converge toward hila
Bronchiectasis
Clues to etiology?
lower lobe: chronic aspiration
Clues to etiology?
upper lobe, ↑volumes, young pt
Cystic Fibrosis
Increased volumes,
upper lobe cysts
Increased volumes,
upper lobe cysts, spares lower
Eosinophilic granuloma
Increased volumes,
diffuse thin walled cysts
Lymphangioleiomyomatosis
Increased volumes,
lower lobe lucencies
Alpha-1 antitrypsin dz
Septal Lines
• Acute
– edema
– (atypical infection)
Septal Lines
• Chronic
– lymphangitic ca
– (amyloid)
– (Kaposi’s sarcoma)
Acute

6 weeks earlier
Clues to etiology?
signs cardiac, renal disease
chronic septal thickening

follow-up film 2 weeks


Lymphangitic carcinomatosis
Clues to etiology?
mastectomy, lung mass,
surgical clips, biliary stent
Clues to etiology?
mastectomy, lung mass,
surgical clips, biliary stent
Clues to etiology?
linitis plastica
Patterns may overlap
septal lines + nodules
Septal Lines + Nodules
• Acute
– atypical infection
• Chronic
– lymphangitic carcinoma
Lymphangitic carcinomatosis
Abnormal CXR

Pattern

Septal Lines Reticular Nodular Cystic


acute chronic

Infection upper lower ↑ volumes

Sarcoid UIP, NSIP Emphysema


EAA aspiration EG, LAM
Abnormal CXR

Pattern

Septal Lines Reticular Nodular Cystic


acute chronic
EG
PCP
LAM
(LIP)
Abnormal CXR

Pattern

Septal Lines Reticular Nodular Cystic


acute chronic

Edema Lymphangitic
Infection Amyloid
Abnormal CXR

Pattern

Septal Lines Reticular Nodular Cystic


acute chronic

Infection Mets
Sarcoid
Silicosis
EAA

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