Parenchymal Micronodules Research Articles

Multifocal choroïditis: is it a granulomatosis close to sarcoidosis?

AbstractPurpose Multifocal choroiditis is an idiopathic posterior uveitis. It combines small white spots in fundus of eye and recurrent intraocular inflammation. Some biological or radiological manifestations of sarcoidosis may be found in these patients.Methods We report a case of severe multifocal choroiditis associated with systemic granulomatosis. The aim of our study was to describe the clinical and therapeutic aspects, and discuss the etiopathogenic approach of this rare entity.Results A 45 years old women who consults for blurred vision. Visual acuity is reduced at 1/20 P8 in right eye and 3/10 P5 in the left. There is a hyalite + bilaterally. Peri papillary atrophy, hemorrhage around the macula, multiple white and pigmentis small spots was found in fundus of eyes. Retinal thickening and involvements of the pigment epithelium and choroid are revealed by macular OCT in the right eye. The fluorescein angiography show hypofluorescence of chorioretinal spots in early time, a window effect scarring and bilateral papillitis. The ECA is 74 UECA. Chest scan reveal a non specific parenchymal micronodules. The patient received systemic corticosteroids. Control OCT show a subretinal fibrosis explaining the introduction of immunosuppressant treatment. The final visual acuity is 1/10 right and 12/10 left with a decline of 3 years.Conclusion Although intraocular manifestations of multifocal choroiditis, it most correspond to a systemic granulomatosis near sarcoidosis.

Lung parenchymal changes in patients with ankylosing spondylitis

To assess lung parenchymal changes in ankylosing spondylitis (AS) using high resolution computed tomography (HRCT). We included 78 AS patients whose average age was 33.87 (18-56) years with a ratio of 53 males to 25 females who were followed up for 3.88 (1-22) years on average. Pneumonia and tuberculosis were excluded. In a detailed examination of lung HRCT findings, we investigated the presence of parenchymal micronodules, parenchymal bands, subpleural bands, interlobular and intralobular septal thickening, irregularity of interfaces, ground-glass opacity, consolidation, mosaic pattern, bronchial wall thickening, bronchial dilatation, tracheal dilatation, pleural thickening, emphysema, thoracic cage asymmetry, honeycomb appearance, structural distortion, apical fibrosis and other additional findings. In detailed HRCT evaluations, lung parenchymal changes were found in 46 (59%) of all patients. We found parenchymal bands in 21 (27%) cases, interlobular septal thickening in 9 (12%), emphysema in 9 (12%), apical fibrosis in 8 (10%), ground-glass opacities in 7 (9%), parenchymal micronodules in 5 (6%), irregularity in interfaces in 3 (4%), bronchial dilatation in 3 (4%), mosaic pattern in 2 (3%), pleural thickening in 2 (3%), consolidation in 1 (1%), bronchial wall thickening in 1 (1%) and a subpleural band in 1 (1%) case. Furthermore, we detected subsegmental atelectasis in 2 patients and a cavitary lesion in 1 patient. Our study had the highest number of AS cases of all previous studies in evaluating lung parenchymal changes. The rate of lung parenchymal changes was slightly lower than that reported in recent literature.

Gradual Progression of Intrapulmonary Lymph Nodes Associated with Usual Interstitial Pneumonia in Progressive Systemic Sclerosis on Chest Radiographs and CT

Progressive systemic sclerosis (PSS) is a chronic, multisystemic disease, which is characterized by vascular changes, fibrosis, and inflammation of the skin and visceral organs. Pulmonary involvement occurs frequently in patients with PSS and is now considered as the main cause of death among these patients (1). Lung abnormalities are often subtle, most frequently occurring at the lung bases, and progressively expanding to involve the lower two-thirds of the lungs (2). High resolution CT (HRCT) findings of interstitial fibrosis in PSS include fine reticular opacities, ground-glass opacity, consolidation, traction bronchiectasis, honeycombing, and coarse or irregular reticulations. The presence of faint parenchymal micronodules on CT scans is not unexpected, as focal lymphoid hyperplasia (follicular bronchiolitis) has been reported as a frequent histologic feature. Subpleural micronodules may reflect lung involvement at the pleural parenchymal interface, as small lymphoid aggregates adjacent to the pleura have been observed in lower lobe biopsies of patients with PSS (3). However, the radiologic detection of progressive intrapulmonary lymph nodes (IPLNs) with PSS has not yet been reported. In this review, we report the serial chest radiologic findings in one case of PSS with multiple growing lung nodules, which turned out to be IPLNs on video-assisted thoracoscopic lung biopsy (VATS).

First isolation of Tropheryma whipplei from bronchoalveolar fluid and clinical implications

A patient presented diffuse pulmonary parenchymal micronodules. Tropheryma whipplei was detected in the saliva, a bronchial biopsy and bronchoalveolar fluid. PAS staining, immunohistochemistry and PCR for T. whipplei were negative in the duodenal biopsies. T.whipplei was isolated from the bronchoalveolar fluid, reinforcing its role as a respiratory pathogen.

Small airway obstruction in patients with rheumatoid arthritis

This work was intended to evaluate the prevalence of obstructive small-airway disease in patients with rheumatoid arthritis (RA) and its association with clinical characteristics. Pulmonary function testing (PFT) and high-resolution computed tomography (HRCT) were performed on 189 consecutive RA patients. Each case was diagnosed based on abnormal HRCT findings. We defined obstructive dysfunction of small airways as a forced expiratory flow from 25% to 75% of vital capacity (FEF25–75) value >1.96 residual standard deviation (RSD) below predicted values. We found 19 patients (10.1%) with an interstitial pneumonia (IP) pattern and 15 (7.9%) with a bronchiolitis pattern; the other 155 (82.0%) had no abnormal HRCT patterns. In patients with neither abnormal pattern, median values of percentage predicted for carbon monoxide diffusing capacity (DLCO) and ratio of DLCO to alveolar ventilation (DLco/VA) were within the normal range, but median FEF25–75, forced expiratory flow at 25% of vital capacity (V25), and V25/height were <70% of predicted values. Forty-seven patients (30.3%) in this group had obstructive small-airway dysfunction. Multivariate logistic regression analysis indicated that this type of abnormality is strongly associated with respiratory symptoms [odds ratio (OR) 5.18; 95% confidence interval (CI) 1.70–15.75; p = 0.012), smoking history (OR 2.78; 95% CI 1.10–6.99; p = 0.03), and disease duration >10 years (OR 2.86; 95% CI 1.27–6.48; p = 0.012). Parenchymal micronodules, bronchial-wall thickening, and bronchial dilatation on HRCT scans were also predictive factors for abnormal FEF25–75, although these morphological changes were too limited for us to diagnose these patients with the bronchiolitis pattern. Obstructive dysfunction of small airways is apparently common among RA patients, even among those with neither the IP nor the bronchiolitis pattern on HRCT scans. Factors significantly associated with abnormal FEF25–75 are respiratory symptoms, smoking history, and RA duration.

Small airway obstruction in patients with rheumatoid arthritis.

This work was intended to evaluate the prevalence of obstructive small-airway disease in patients with rheumatoid arthritis (RA) and its association with clinical characteristics. Pulmonary function testing (PFT) and high-resolution computed tomography (HRCT) were performed on 189 consecutive RA patients. Each case was diagnosed based on abnormal HRCT findings. We defined obstructive dysfunction of small airways as a forced expiratory flow from 25% to 75% of vital capacity (FEF25–75) value >1.96 residual standard deviation (RSD) below predicted values. We found 19 patients (10.1%) with an interstitial pneumonia (IP) pattern and 15 (7.9%) with a bronchiolitis pattern; the other 155 (82.0%) had no abnormal HRCT patterns. In patients with neither abnormal pattern, median values of percentage predicted for carbon monoxide diffusing capacity (DLCO) and ratio of DLCO to alveolar ventilation (DLco/VA) were within the normal range, but median FEF25–75, forced expiratory flow at 25% of vital capacity (V25), and V25/height were <70% of predicted values. Forty-seven patients (30.3%) in this group had obstructive small-airway dysfunction. Multivariate logistic regression analysis indicated that this type of abnormality is strongly associated with respiratory symptoms [odds ratio (OR) 5.18; 95% confidence interval (CI) 1.70–15.75; p = 0.012), smoking history (OR 2.78; 95% CI 1.10–6.99; p = 0.03), and disease duration >10 years (OR 2.86; 95% CI 1.27–6.48; p = 0.012). Parenchymal micronodules, bronchial-wall thickening, and bronchial dilatation on HRCT scans were also predictive factors for abnormal FEF25–75, although these morphological changes were too limited for us to diagnose these patients with the bronchiolitis pattern. Obstructive dysfunction of small airways is apparently common among RA patients, even among those with neither the IP nor the bronchiolitis pattern on HRCT scans. Factors significantly associated with abnormal FEF25–75 are respiratory symptoms, smoking history, and RA duration.

Drs. Mori and Cho reply

We thank Dr. Georgiadis and colleagues for their comments on our study1. We are pleased that our findings have attracted the interest of readers, and we offer the following response. First, Georgiadis, et al state that we reported no significant differences in HRCT findings between patients with early RA and those with longstanding RA, but we think that this is a misinterpretation. We performed HRCT on a total of 126 patients with either early RA (n = 65) or longstanding RA (n = 61). Abnormalities on HRCT imaging were categorized, and the frequency of each finding and its extent in the lungs were compared between the 2 patient populations. We found that the frequency of interstitial abnormalities such as ground-glass attenuation, reticulation, honeycombing, and consolidation was not significantly different between the 2 groups. Yet it is important to recall that, in contrast, there were significant differences in the frequencies of parenchymal micronodules and bronchial wall thickening, both of which are indicative of small-airway diseases; specifically, these conditions were more prominently observed in the patients with longstanding RA, which tendency apparently contributed to the higher incidence of the bronchiolitis pattern in this group. We therefore concluded that the incidence of bronchiolar abnormalities is associated with the duration of RA. The longstanding RA group appeared to be predisposed to complications … Address reprint requests to Dr. S. Mori, Clinical Research Center for Rheumatic Disease and Department of Rheumatology, Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto 861-1196, Japan. E-mail: moris{at}saisyunsou1.hosp.go.jp

Pulmonary Involvement in Systemic Sclerosis

Scleroderma, also known as progressive systemic sclerosis (SSc), is a multisystem autoimmune disorder characterized by inflammation and fibrosis involving the skin as well as internal organs such as the vasculature, esophagus, and the respiratory tract. Pulmonary involvement consists most often of interstitial fibrosis and pulmonary vascular disease leading to pulmonary arterial hypertension (PAH). Bronchiectasis is an uncommon pulmonary manifestation of systemic sclerosis. Pulmonary hemorrhage with acute renal failure and diffuse alveolar hemorrhage in the absence of a history of renal involvement or penicillamine intake have rarely been reported in patients with systemic sclerosis.On high resolution CT, evidence of interstitial disease is seen in approximately 90% of patients, the main findings being a fine reticular pattern involving the subpleural regions of the lower lobe. Other common findings include ground-glass opacities, honeycombing, and parenchymal micronodules. The most distinctive pulmonary histologic findings in patients with scleroderma are the vascular changes found in PAH in the absence of significant interstitial fibrosis.There is no strong evidence that any drug alters the course of the two main types of lung disease in systemic sclerosis. This apparent failure of therapy may reflect the fact that pulmonary involvement is usually identified at an established or late stage. It has been suggested that, for fibrosing alveolitis, corticosteroids are most effective if given in combination with cyclophosphamide. In some patients with SSc, PAH has been considered as a major cause of morbidity and mortality. Centrally infused prostacyclin (epoprostenol) and its subcutaneously infused analog treprostinil improve hemodynamics, as well as the quality of life and survival in these patients. Iloprost has also shown a positive effect on PAH in SSc patients. More recently, bosentan, an endothelin receptor antagonist, has proved effective in controlling PAH after 6 months' treatment. Sildenafil has been used as a selective pulmonary vasodilator in SSc patients with isolated PAH. This drug decreased mean pulmonary artery pressure and pulmonary vascular resistance, and increased cardiac output, with much improvement of the physical condition of the patients. Lung transplant can be considered as a last option.Clinicians must be aware of the possibility of lung disease in patients with SSc so that it can be treated as early as possible.

Comparison of early and late pleuropulmonary findings of ankylosing spondylitis by high-resolution computed tomography and effects on patients’ daily life

Ankylosing spondylitis (AS) is a multisystemic disease and extra-articular features may develop as pleuropulmonary involvement. We aimed to show and compare the early and late pleuropulmonary findings of AS and its effects on patients' daily life by causing dyspnea. The study consisted of 38 patients (33 male, 5 female). All patients met the New York criteria for AS. Patients were divided into two groups for comparison of early (disease duration <10 years and normal chest X-ray, 18 patients) and late (disease duration >/=10 years and normal or abnormal chest X-ray, 20 patients) manifestations. All patients underwent high-resolution computed tomography (HRCT) and pulmonary function tests. A questionnaire was completed to measure perceived shortness of breath (dyspnea score) with activities of daily living such as dressing, shaving or walking. HRCT findings were abnormal in 27 of the 38 patients (73%). Pulmonary involvement was high in early AS (61.1%). The number of findings in early and late AS found were as follows: mosaic pattern (9/10), parenchymal micronodules (2/3), parenchymal bands (5/9), bronchial wall thickening (2/10), ground-glass opacity (7/7), and interlobular septal thickening (6/10). A moderate correlation was obtained between presence of mosaic pattern and forced midexpiratory flow rate (FEF(25-75)) values indicating small airway obstruction (r=0.346, p=0.019). The dyspnea score was statistically higher in patients with AS having pulmonary involvement than those without involvement. Pulmonary involvement is common in early AS compared to late AS. The involvement of small airways was found frequently as interstitial lung disease in early and late AS. This study also suggests that AS with pulmonary involvement may affect patients' daily life by causing dyspnea, which is why early detection of pulmonary lesions may have clinical importance and should be studied in a large cohort.

High-resolution CT findings of lung disease in patients with polymyositis and dermatomyositis.

The purpose of this study was to determine the type and distribution of interstitial lung disease seen in patients with polymyositis and dermatomyositis, using high-resolution computed tomography (HRCT). The presence and distribution of high-resolution CT findings were retrospectively evaluated in 25 patients with polymyositis/dermatiomyositis. In 14 patients, a pathological diagnosis of pulmonary disease was obtained. Three lung specimens were also studied. Results showed that 23 patients had abnormal HRCT showing the following abnormalities: ground glass opacities (92%), linear opacities (92%), irregular interfaces (88%), airspace consolidation (52%), parenchymal micronodules (28%), and honeycombing (16%). A relatively high prevalence of airspace consolidation (52%) and a low prevalence of honeycombing (16%) were observed. Two patients with extensive consolidation proved to have diffuse alveolar damage; eight patients with either subpleural band-like opacities (n = 5) and/or airspace consolidation (n = 7) had bronchiolitis obliterans organizing pneumonia; four patients with honeycombing had usual interstitial pneumonitis. We conclude that HRCT findings in patients with polymyositis/dermatomyositis are nonspecific. However, a high prevalence of airspace consolidation and a low prevalence of honeycombing were observed. Predominant HRCT patterns are suggestive of the pathologic processes occurring in polymyositis/dermatomyositis.

Lung parenchymal changes secondary to cigarette smoking: pathologic-CT correlations.

To determine the histopathologic basis for computed tomographic (CT) interpretation of smokers' lung and the accuracy of CT in the detection of alterations related to cigarette smoking, parenchymal lung lesions were studied from 41 heavy smokers who underwent thoracotomy for removal of a solitary pulmonary nodule. CT scanning of the resected lungs, corresponding exactly to the sections seen on preoperative CT scans, resulted in the following pathologic-CT correlations. Areas of ground-glass attenuation seen on preoperative CT scans (n = 11 [27%]) were related to three main histologic features: (a) accumulation of pigmented macrophages and mucus in the alveolar spaces, associated with mild interstitial inflammation and/or fibrosis (n = 7); (b) thickening of the alveolar walls with inflammatory cells with normal alveolar spaces (n = 3); and (c) presence of organizing alveolitis (n = 1). Parenchymal micronodules depicted presurgically (n = 4 [10%]) corresponded to bronchiolectases with peribronchiolar fibrosis (n = 4) associated with obliterative bronchiolitis in one patient. When emphysema was detected presurgically (n = 21 [51%]), it was always present at pathologic study to a higher extent than initially suspected.

Morphologic effects of cigarette smoking on airways and pulmonary parenchyma in healthy adult volunteers: CT evaluation and correlation with pulmonary function tests.

A prospective computed tomographic (CT) study was performed to determine the prevalence of lung changes in smokers. The study group comprised 175 healthy adult volunteers (current smokers, n = 98; ex-smokers, n = 26; nonsmokers, n = 51). The subjects underwent clinical examination, pulmonary function tests, chest radiography, and conventional and high-resolution CT (HRCT). Significant differences between current smokers, ex-smokers, and nonsmokers were observed with HRCT in the identification of subpleural (P = .11) and parenchymal (P < .001) micronodules, emphysema (P < .001), and areas of ground-glass attenuation (P = .0001). All subjects had normal pulmonary function. Parenchymal micronodules, areas of ground-glass attenuation, and emphysema were observed with a significant predominance in the upper lung zones (P < .01). Presence of emphysema and abnormal bronchial wall thickening were the only HRCT signs associated with significantly lower values of functional parameters. These data support the concept that parenchymal abnormalities can be detected in healthy smokers with normal findings at chest radiography and pulmonary function tests.

Subpleural micronodules in diffuse infiltrative lung diseases: evaluation with thin-section CT scans.

Thin-section computed tomography (CT) was performed in 244 patients with infiltrative lung diseases and 29 healthy control subjects to evaluate the frequency, profusion, and diagnostic value of subpleural parenchymal micronodules. These areas of increased attenuation (less than 7 mm in diameter) were analyzed in four groups: coal miners with chest radiographic findings of coal worker's pneumoconiosis (n = 61), coal miners with no radiographic evidence of pneumoconiosis (n = 73), patients with nonoccupational chronic infiltrative lung disease (n = 110), and healthy adults (n = 29). Subpleural parenchymal micronodules were observed with high frequency in pulmonary lymphangitic carcinomatosis, coal worker's pneumoconiosis, and sarcoidosis but were also seen in 14% of control subjects. Predominant sites of lesions were the posterior subpleural areas in the upper lobes. Subpleural parenchymal micronodules have no diagnostic value when observed as an isolated CT finding but may suggest that diagnosis of pneumoconiosis, sarcoidosis, or pulmonary lymphangitic carcinomatosis when observed in association with mild parenchymal lesions.