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