By:

Nour-Eldin A. Nour-Eldin
The Lung Interstitium
The interstitium of the lung is not normally visible radiographic-
ally; it becomes visible only when disease (e.g., edema,
fibrosis, tumor) increases its volume and attenuation.
The interstitial space is defined as continuum of loose
connective tissue throughout the lung composed of three
subdivisions:
(i) the bronchovascular (axial), surrounding the bronchi,
arteries, and veins from the lung root to the level of the
respiratory bronchiole
(ii) the parenchymal (acinar), situated between the alveolar
and capillary basement membranes
(iii) the subpleural, situated beneath the pleura, as well as in
the interlobular septae.
Patterns of Interstitial Lung Disease
 Interstitial lung disease may result in
four patterns of abnormal opacity on
chest radiographs and CT scans: linear,
reticular, nodular, and reticulonodular
 These patterns are more accurately and
specifically defined on CT
Patterns of Interstitial Lung Disease
 Linear Pattern
A linear pattern is seen when there is
thickening of the interlobular septa,
producing Kerley lines.
Kerley A lines
Kerley B lines

Kerley A lines

The interlobular septa contain

pulmonary veins and lymphatics.

The most common cause of interlobular

septal thickening, producing Kerley A
and B lines, is pulmonary edema, as a
result of pulmonary venous
Kerley B lines
hypertension and distension of the
lymphatics.
DD of Kerly Lines:
Pulmonary edema is the most common cause
Mitral stenosis
Lymphangitic carcinomatosis
Malignant lymphoma
Congenital lymphangiectasia
Idiopathic pulmonary fibrosis
Pneumoconiosis
Sarcoidosis
b. Reticular Pattern
A reticular pattern results from the summation
or superimposition of irregular linear
opacities.
The term reticular is defined as meshed, or in
the form of a network. Reticular opacities can be
described as fine, medium, or coarse, as the
width of the opacities increases.
A classic reticular pattern is seen with pulmonary fibrosis,
in which multiple curvilinear opacities form small
cystic spaces along the pleural margins and lung
bases (honeycomb lung)
This 50-year-old man presented with end-stage lung fibrosis
PA chest radiograph shows medium to coarse reticular
B: CT scan shows multiple small cysts (honeycombing) involving
predominantly the subpleural peripheral regions of lung. Traction
bronchiectasis, another sign of end-stage lung fibrosis.
c. Nodular pattern
 A nodular pattern consists of multiple round opacities,
generally ranging in diameter from 1 mm to 1 cm

 Nodular opacities may be described as miliary (1 to 2 mm,

the size of millet seeds), small, medium, or large, as the
diameter of the opacities increases

 A nodular pattern, especially with predominant

distribution, suggests a specific differential diagnosis
Disseminated histoplasmosis and nodular ILD.
CT scan shows multiple bilateral round circumscribed
pulmonary nodules.
Hematogenous metastases and nodular ILD. This 45-year-
old woman presented with metastatic gastric carcinoma.
The PA chest radiograph shows a diffuse pattern of
nodules, 6 to 10 mm in diameter.
 Differential diagnosis of a nodular pattern of
interstitial lung disease

SHRIMP
Sarcoidosis
Histiocytosis (Langerhan cell
histiocytosis)
Hypersensitivity pneumonitis
Rheumatoid nodules
Infection (mycobacterial, fungal, viral)
Metastases
Microlithiasis, alveolar
Pneumoconioses (silicosis, coal
worker's, berylliosis)
d. Reticulonodular pattern results
A reticulonodular pattern results from a
combination of reticular and nodular opacities.

This pattern is often difficult to distinguish from a

purely reticular or nodular pattern, and in such a
case a differential diagnosis should be developed
based on the predominant pattern.

If there is no predominant pattern, causes of both

nodular and reticular patterns should be
considered.
How To Approach a
Practical Diagnosis?
Rule no. 1

An acute appearance suggests pulmonary

edema or pneumonia
Disseminated histoplasmosis and reticulonodular ILD.
A: PA chest radiograph, close-up of right upper lung, shows
reticulonodular ILD.
B: CT scan shows multiple circumscribed round pulmonary nodules, 2 to 3
mm in diameter.
 Rule no. 2

Reticulonodular lower lung predominant distribution

with decreased lung volumes suggests: (APC)

1. Asbestosis

2. Aspiration (chronic)

3. Pulmonary fibrosis (idiopathic)

4.Collagen vascular disease

Asbestos-related
pleural disease and
asbestosis
Pulmonary fibrosis and rheumatoid arthritis.
Systemic sclerosis.
A: PA chest radiograph shows a bibasilar and subpleural distribution of fine
reticular ILD. The presence of a dilated esophagus (arrows) provides a clue
to the correct diagnosis.
B: CT scan shows peripheral ILD and a dilated esophagus (arrow).
Rule no. 3

A middle or upper lung predominant distribution

suggests: (Mycobacterium Settle Superiorly in
Lung)
1.Mycobacterial or fungal disease
2.Silicosis
3.Sarcoidosis
4.Langerhans Cell Histiocytosis
Complicated silicosis. PA chest radiograph shows multiple
nodules involving the upper and middle lungs, with coalescence
of nodules in the left upper lobe resulting in early progressive
massive fibrosis
Sarcoidosis. CT scan shows nodular thickening of the bronchovascular
bundles (solid arrow) and subpleural nodules (dashed arrow), illustrating the
typical perilymphatic distribution of sarcoidosis.
Langerhan cell histiocytosis.
This 50-year-old man had a
30 pack-year history of
cigarette smoking.
A: PA chest radiograph
shows hyperinflation of the
lungs and fine bilateral
reticular ILD.

B: CT scan shows multiple

cysts (solid arrow) and
nodules (dashed arrow).
 Rule no. 4

Associated lymphadenopathy suggests :

1.Sarcoidosis
2.neoplasm (lymphangitic carcinomatosis,
lymphoma, metastases)
3. infection (viral, mycobacterial, or fungal)
4. silicosis
Simple silicosis.
A: CT scan with lung windowing shows numerous
circumscribed pulmonary nodules, 2 to 3 mm in diameter
(arrows).
B: CT scan with mediastinal windowing shows densely
calcified hilar (solid arrows) and subcarinal (dashed arrow)
nodes.
 Rule no. 5

Associated pleural thickening and/or

calcification suggest asbestosis.
 Rule no. 6

Associated pleural effusion suggests :

1.pulmonary edema
2.lymphangitic carcinomatosis
3.lymphoma
4.collagen vascular disease
Cardiogenic pulmonary edema.
PA chest radiograph shows enlargement of the cardiac
silhouette, bilateral ILD, enlargement of the azygos vein
(solid arrow), and peribronchial cuffing (dashed arrow).
Lymphangitic carcinomatosis. This 53-year-old man
presented with chronic obstructive pulmonary disease and
large-cell bronchogenic carcinoma of the right lung.
CT scan shows unilateral nodular thickening (arrows) and a
malignant right pleural effusion.
 Rule no. 7

Associated pneumothorax suggests

lymphangioleiomyomatosis or LCH.
Lymphangioleiomyomatosis
(LAM).

A: PA chest radiograph shows a

right basilar pneumothorax and
two right pleural drainage
catheters. The lung volumes are
increased, which is
characteristic of LAM, and there
is diffuse reticular ILD.

B: CT scan shows bilateral thin-

walled cysts and a loculated
right pneumothorax (P).
Tell me the rules
again?
 1. Acute 2. Pleural effusion
•P.Edema •1.pulmonary edema
•Pneumonia •2.lymphangitic carcinomatosis
•3.lymphoma
•4.collagen vascular disease
3.Pneumothorax
•lymphangioleiomyom
atosis 4.Predominantly Below with
•LCH reduced volume

1.Asbestosis

2. Aspiration (chronic)

3. Pulmonary fibrosis (idiopathic)

4.Collagen vascular disease

 5. A middle or upper lung predominant
1. Mycobacterial or fungal disease
2. Silicosis
3. Sarcoidosis
4. Langerhans Cell Histiocytosis

6. Associated lymphadenopathy
7. Pleural Thickening
and or Calcification 1.Sarcoidosis
2.neoplasm (lymphangitic
•Asbestosis
carcinomatosis, lymphoma,
metastases)
3. infection (viral, mycobacterial, or
fungal)
4. silicosis
Thank You