what is linear opacities in lungs

Coronavirus: patient assessment. Vicky T. Nguyen, Elaine S. Chan, Shinn-Huey S. Chou, J. David Godwin, Corinne L. Fligner, Rodney A. Schmidt, Sudhakar N. J. Pipavath. They are short, fine lines throughout the lungs, with a reticular appearance. In cases of ICI therapyrelated pneumonitis, the most common finding at bronchoalveolar lavage is T-lymphocytic alveolitis (25). Hence, the reason for being previously termed bronchiolitis obliterans organizing pneumonia (BOOP). Radiation, used to treat cancer, can cause pneumonitis when applied to the chest or full body. Some degree of pulmonary fibrosis may be evident in a CT which is indicative of chronic pulmonary inflammatory processes. When lung markings are partially obscured by the increased whiteness, a ground glass pattern (ground glass opacity, fig 1) occurs. [citation needed] In the case of pneumonitis, it is more difficult for this exchange of oxygen to occur since irritants have caused inflammation of the alveoli. [7], Histological samples of lung tissue with pneumonitis include the presence of poorly formed granulomas or mononuclear cell infiltrates. National Institute for Health and Care Excellence. 10, No. (d) Axial CT image obtained after completing steroid therapy and restarting nivolumab therapy shows recurrence of an OP pneumonitis pattern with new areas of involvement (arrows). 2003;180 (5): 1251-4. 43, No. 1998;171 (3): 835, 838-9. (b) Axial CT image obtained 2 weeks after starting nivolumab therapy shows a region of centrilobular solid and ground-glass nodularity (black arrows) in the right lower lobe. People affected by this type of lung We searched PUBMED on the 26 March 2020 using the search terms COVID-19, and chest radiography. We identified 20 articles. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. The BSTI31 states that there is no role for computed tomography imaging in the diagnosis of covid-19 unless the patient is seriously ill (NEWS score >3) OR if PCR is unavailable and the American Society of Thoracic Radiology (STR)33 says routine screening computed tomography for the identification of covid-19 pneumonia is currently not recommended by most radiology societies. The Fleischner Society for thoracic radiology endorses this approach.22, In China, computed tomography has been preferred over chest radiography because patients were encouraged to present to hospital early for diagnosis as a public health measure, and computed tomography in the early stages of covid-19 infection is more likely to be diagnostic than early chest radiograph.22, In the US and UK, however, patients with early disease are encouraged to stay at home and to present to hospital only if symptoms progress; at this later stage the chance of detecting covid-19 changes on chest radiography is likely to be higher.22, Other countries, including Italy and Spain, have not reported their approach to covid-19 imaging beyond occasional case series and reports.343536, In low resource settings, chest radiography may be more readily available than computed tomography.37, Minimise the risk of cross infection by considering whether imaging is necessary, and if so, which type of imaging is most appropriate.22 For example, with ventilated patients, a portable chest radiograph at the bedside has a lower risk of cross infection than computed tomography because ventilated patients are more likely to generate aerosol and will require additional support during imaging. This immune overreaction leads to the autoimmune-type reactions observed with irAEs. Figure 9b. Despite treatment of pneumonitis, approximately one-fourth of patients will develop recurrence (21) (Fig 10). Make a note of known comorbidities and smoking history on paperwork requesting investigations; this will help radiologists to consider other pathologies that may be causing patients symptoms. Radiology. This may be seen as whiteness in the lungs on radiography which, depending on the severity of the pneumonia, obscures the lung markings that are normally seen; however, this may be delayed in appearing or absent. (b) AP chest radiograph of patient C when he developed covid-19 pneumoniataken in the emergency department (day 0 of admission), showing ground glass opacities in the periphery (outer third of the lung) of both lungs in the mid and lower zones (white arrows), preservation of lung marking, and linear opacity in the periphery of the left mid zone (black arrow). Increased density (whiteness) is also present in the periphery of the right upper zone; this is not as dense or white as that seen in the left lung, showing progression of lung change of ground-glass opacification to consolidation (outlined arrows), A case series of 799 patients from Wuhan China with confirmed covid-19 looked at a subset of those who died (n=113) or were discharged (n=161) and reported that all patients had abnormalities on chest radiograph on admission.16, Chest radiographs can be normal in some patients with clinically diagnosed covid-19 pneumonia, or who have been diagnosed with covid-19 pneumonia by computed tomographyie, there may be false negative radiographs.71125, In the Hong Kong retrospective case series described above, four patients never developed abnormalities on radiography; however one of these patients (25%) had ground glass opacities on chest computed tomography (performed within 48 hours of chest radiography).11, A case series of nine patients with PCR confirmed covid-19 infection in Korea reported that three had abnormal baseline radiographs but eight had changes on baseline computed tomography, suggesting five of eight baseline radiographs (63%) were false negatives.7, A case series in China reported that a subset of two of five (40%) patients had normal chest radiographs, but computed tomography done on the same day confirmed covid-19 pneumonia.25, Central mediastinum and heart appear normal, Lungs predominantly contain air (appearing black), Lung markings are present, representing blood vessels extending from the hilum to the lung periphery (these branch and decrease in calibre, such that few vessels are seen at the lung periphery), The diaphragm is curvilinear in outline with sharp costophrenic margins, The initial abnormalities suggesting covid-19 pneumonia on a chest radiograph are loss of the normal black appearance in the lung, This is seen as increased whiteness, (because of increased density), but not enough to totally obscure lung markings; giving a ground glass appearance, Ground glass opacities can be difficult to observe; radiologist confirmation is recommended, Horizontal linear opacities may be seen with ground-glass change9 (fig 1, fig 3b), Location: usually bilateral but can be unilateral.7 More often reported in a peripheral lung8 adjacent to the chest wall and diaphragm and usually with a distribution in the mid and lower zones8911Fig 4b shows ground glass opacities in the right upper zone, as will be the case in approximately 20% of patients with covid-19 pneumonia, Ground-glass opacities become denser (whiter) and progress to consolidation with complete loss of lung markings, Location: The areas of consolidation are likely to have progressed from sites of ground glass opacities (fig 2, fig 3c). Farmers lung and hot tub lung are common names for types of hypersensitivity pneumonitis that result from exposure to some types of thermophilic actinomyces, mycobacteria and molds. Spectrum of treatment-related pneumonitis among various therapy types. 30, No. Diagnosis and staging working group report, Bronchiolitis obliterans syndrome after allogeneic hematopoietic stem cell transplantation-an increasingly recognized manifestation of chronic graft-, Bronchiolitis obliterans syndrome epidemiology after allogeneic hematopoietic cell transplantation, The histological spectrum of pulmonary graft-, Lung histology predicts outcome of bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation, [In press DOI 10.1016/J.BBMT.2013.03.017], Small-airways disease in recipients of allogeneic bone marrow transplants. An abnormality of the respiratory system, which include the airways, lungs, and the respiratory muscles. Normally, an important function of T cells is in the cell-mediated clearance of tumor cells. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. Azathioprine and mycophenolate are two particular treatments that have been associated with an improvement of gas exchange. Infection, including atypical and fungal causes such as invasive aspergillosis, should also be considered and often can be distinguished by clinical and laboratory findings. 4, Journal for ImmunoTherapy of Cancer, Vol. Patient consent: We considered seeking individual consent to use radiological images. Furthermore, the use of serum markers for the prediction and monitoring of ICI therapyrelated pneumonitis is also an active area of investigation. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA, 2019-novel Coronavirus severe adult respiratory distress syndrome in two cases in Italy: An uncommon radiological presentation, COVID-19 outbreak in Italy: experimental chest X-ray scoring system for quantifying and monitoring disease progression, Adoption of COVID-19 triage strategies for low-income settings, Coronavirus (COVID-19) Outbreak: what the department of radiology should know, senior clinical teaching fellow (acute medicine), general practitioner and clinical associate professor, The role of chest radiography in confirming covid-19 pneumonia, https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests, https://www.england.nhs.uk/coronavirus/secondary-care/assessment-diagnosis/patient-assessment/, https://www.nice.org.uk/guidance/ng165/chapter/3-Diagnosis-and-assessment, https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection, https://bestpractice.bmj.com/topics/en-gb/18, https://www.bsti.org.uk/media/resources/files/NHSE_BSTI_APPROVED_Radiology_on_CoVid19_v6_modified1__-_Read-Only.pdf, https://bestpractice.bmj.com/topics/en-gb/3000168/epidemiology, https://cks.nice.org.uk/coronavirus-covid-19#!scenario, https://www.bsti.org.uk/standards-clinical-guidelines/clinical-guidelines/bsti-covid-19-guidance-for-the-reporting-radiologist/2020, https://healthcare-in-europe.com/en/news/imaging-the-coronavirus-disease-covid-19.html, https://blogs.bmj.com/bmj/2020/03/12/covid-19-is-ct-scanning-ready-to-answer-a-diagnostic-call/, https://www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/resp-follow-up-guidance-post-covid-pneumonia/, North Petherton Surgery: GP Opportunity (up to 8 sessions) - North Petherton Surgery, Meadows Surgery: GP Opportunity (up to 8 sessions) - The Meadows Surgery, Ilminster, Bruton Surgery: GP Opportunity (8 sessions) - Bruton Surgery, Government of Jersey: Staff Grade in Trauma & Orthopaedics, Womens, childrens & adolescents health. 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NSIP pattern in a 67-year-old man undergoing pembrolizumab therapy for stage IV lung adenocarcinoma. Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review. Minimal subpleural ground-glass opacities in the right lower lobe were thought to be dependent atelectasis. It may occur when an injury to the lungs triggers an Minimal subpleural ground-glass opacities in the right lower lobe were thought to be dependent atelectasis. Isr. The Golden S-sign is seen on both PA chest radiographs and on CT scans. Figure 3a. Provenance and peer review: commissioned; externally peer reviewed. 217, No. Pneumonitis is often difficult to recognize and discern from other interstitial lung diseases.[7]. They agreed this was acceptable. Limitations of AP chest radiograph include reduced inspiratory effort because of the patients positioning (potentially exacerbated by their illness), resulting in sub-optimal imaging; lung changes may therefore appear more marked or localised infection may be missed; the heart can also appear magnified. 94, No. Although the disruption of the immune checkpoint pathway is the principle mechanism behind stimulating immune response against tumor cells, this same pathway is also responsible for various irAEs. Churchill Livingstone. This page was last edited on 16 October 2022, at 13:44. 8. If you are unable to import citations, please contact 13. A quantitative meta-analysis covering 2847 patients in China and Australia, and a multinational descriptive analysis of 39 case report articles summarising 127 patients, found that covid-19 pneumonia changes are mostly bilateral on chest radiographs (72.9%, 95% confidence interval 58.6 to 87.1) and have ground glass opacity in 68.5% of cases (95% CI 51.8 to 85.2) (fig 1, fig 3b); however, these data are pooled so it is not possible to link the radiographic findings to the duration of disease or severity.10. Kerley A lines are never seen without Kerley B or C lines. AIPARDS pattern is not a prevalent pattern of ICI therapyrelated pneumonitis, although it is associated with the most severe clinical course and extent of lung involvement at imaging, manifesting with median CTCAE grade 3 symptoms (31). Despite researchers increasing awareness and experience with ICI therapyrelated pneumonitis, large-scale studies categorizing the various radiologic patterns are somewhat limited. 218, No. Radiographic features CT HRCT chest. 2005;7 (9): 568-70. Respir. Summation of multiple linear opacities can lead to a net-like or reticular pattern. (b) Axial chest CT image shows new multifocal ground-glass opacities (black arrows), with interval enlargement of several pulmonary masses (white arrows). AJR Am J Roentgenol. MJ, JC, and JP drafted and checked the final article. Although generally considered separate from ICI therapyrelated pneumonitis, sarcoidlike reaction is another potential pulmonary irAE reported with ICI therapy. Lippincott Williams & Wilkins. (a) Baseline axial chest CT image obtained before starting immunotherapy shows multiple lung nodules and masses. CT of the chest demonstrates extensive hilar and mediastinal adenopathy; Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities. Rossi SE, Franquet T, Volpacchio M et-al. The connection to opacified or thickened branching structures extends proximally (representing the dilated and opacified bronchioles or inflamed arterioles) 1-3,6. Community acquired pneumonias are predominantly associated with consolidation on chest radiography, not ground glass opacity or linear opacities.20. (c) Axial chest CT image obtained 5 days later after further respiratory decompensation (despite withholding ICI therapy and initiating intravenous steroid therapy) shows increasing severity and confluence of ground-glass opacities (arrows), with little intervening normal lung parenchyma. Eur. 22, No. Figure 8b. 2008;3 (2): 67-75. 2015;89(2):162-5. bunch of grapes sign (botryoid rhabdomyosarcoma), bunch of grapes sign (intracranial tuberculoma), bunch of grapes sign (intraosseous hemangiomas), bunch of grapes sign (multicystic dysplastic kidney). ICI therapy can also be used with nivolumab, a PD-1 inhibitor, and ipilimumab, a combination that has FDA approval for the treatment of colorectal cancer and renal cell carcinoma. It was first described by Davisonand colleagues in 1983. (b) Axial chest CT image obtained 2 months after initiating trastuzumab therapy shows a focal region of ground-glass opacities within the posterior and medial left lower lobe (arrow), with a well-defined linear demarcation from the adjacent normal lung. Of these patients, 35% (n=7) developed radiographical changes on follow-up radiography.1122 This study also suggested that peak radiological severity on chest radiography is seen at days 10-12 of symptom onset.11 (see patient C, fig 3), On the basis of this study, the multinational consensus statement from the Fleischner Society for thoracic radiology stated that chest radiography can be insensitive in mild or early covid-19 infection.2224. Located at a transitional zone between larger airways and lung interstitium, small airways may be affected in a wide variety of pathophysiological conditions. ), and Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (N.H.R., K.R.L., A.G.). 3. (a) Axial chest CT image obtained 5 months after starting nivolumab therapy shows diffuse centrilobular ground-glass nodules (arrows). For example, trimethoprim and sulfamethoxazole may be administered for Pneumocystis jirovecci prophylaxis (47). In an under-exposed image, the whole radiograph appears whiter. (a) Baseline axial chest CT image shows the lungs after completion of radiation therapy. (c) Follow-up axial chest CT image obtained 2 months later after steroid therapy shows resolved right lower lobe pneumonitis. Aspiration pneumonitis is caused by a chemical inhalation of harmful gastric contents which include causes such as: A lung injury after the inhalation of habitual gastric contents. Common Terminology Criteria for Adverse Events, Seminars in Nuclear Medicine, Vol. 28, No. These lines represent interlobular septa, which are usually less than 1 cm in length and parallel to one another at right angles to the pleura. Pneumonitis describes general inflammation of lung tissue. (b) Axial CT image obtained 2 weeks after starting nivolumab therapy shows a region of centrilobular solid and ground-glass nodularity (black arrows) in the right lower lobe. This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. Inhaled corticosteroids such as fluticasone or budesonide may also be effective for reducing inflammation and preventing re-inflammation on a chronic level by suppressing inflammatory processes that may be triggered by environmental exposures such as allergens. "Tree-in-bud sign". (c) Follow-up axial chest CT image obtained 2 months later after steroid therapy shows resolved right lower lobe pneumonitis. HP pattern can often be differentiated from atypical infection on clinical grounds. What differential diagnoses will you consider if consolidation is visible on chest radiography? Cordier JF. [7], Clinical tests include chest radiography or (HRCT) which may show centrilobular nodular and ground-glass opacities with air-trapping in the middle and upper lobes of the lungs. A high index of suspicion and prompt recognition of pneumonitis by the radiologist are critical to initiate prompt treatment and prevent further morbidity and mortality for these patients. Also, tumors may increasingly express PD-L1 receptors causing decreased T-cell activity and tumor proliferation (7). Viewer, https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf, https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2018.197.1_MeetingAbstracts.A4008, Medication-induced Pulmonary Injury: A Scenario- and Pattern-based Approach to a Perplexing Problem, Side Effects of Oncologic Treatment in the Chest: Manifestations at FDG PET/CT, Chest CT Diagnosis and Clinical Management of Drug-related Pneumonitis in Patients Receiving Molecular Targeting Agents and Immune Checkpoint Inhibitors: A Position Paper from the Fleischner Society, Thoracic Complications of Precision Cancer Therapies: A Practical Guide for Radiologists in the New Era of Cancer Care, Bronchiolitis: A Practical Approach for the General Radiologist, Interstitial Lung Abnormalities at CT: Subtypes, Clinical Significance, and Associations with Lung Cancer, Chronic Lung Allograft Dysfunction: Review of CT and Pathologic Findings, Radiologic Patterns of Immune Checkpoint Inhibitor-Associated Pneumonitis and Management According to 2018 ASCO Guidelines: A Primer for the Radiologist, Reversed Halo/Atoll Sign: Nailing the Diagnosis, Pulmonary Manifestations of Immune-related Adverse Events Associated with Cancer Immunotherapy: Guidelines for the Radiologist, COVID-19 pneumonia transmitted in elevator. Check for errors and try again. (c) Axial chest CT image obtained 1 month later after withholding ICI therapy and administering steroid therapy shows residual, although significantly improved, airspace disease (arrows). In chest radiology, reticular and linear opacification refers to a broad subgroup of pulmonary opacification caused by a decrease in the gas to soft tissue ratio due to a pathological process centered in or around the pulmonary interstitium.This includes thickening of any of the interstitial compartments by blood, water, tumor, cells, fibrous disease or any combination thereof. (b) Axial chest CT image shows new multifocal ground-glass opacities (black arrows), with interval enlargement of several pulmonary masses (white arrows). In addition, undergoing combination immunotherapy, concurrent radiation therapy, and previous high-dose chemotherapy are also thought to be risk factors (48). (a) Baseline axial chest CT image obtained before starting immunotherapy shows multiple lung nodules and masses. Linear and band-like opacities: thick radial bands of consolidation containing an air bronchogram or subpleural curvilinear bands, parallel to the pleura High resolution CT scan of the chest showed bilateral patchy ground glass opacities in the lungs. Figure 6b. Interlobular septal thickening and a crazy-paving pattern may also be present (34). Differential diagnosis. In addition, interpreting pathologic and radiographic test results remains a challenge to clinicians. (b) An AP chest radiograph of patient D on day 8, showing ground glass opacification now present at both lung bases (white arrows). [12], Corticosteroids effectively reduce inflammation by switching off several genes activated during an inflammatory reaction. British Thoracic Society. Cryptogenic organizing pneumonia. It is similar to the color comet tail artifact and is seen in similar situations, although is in general less sensitive than the latter.. small renal or ureteric calculi Currently in its fifth version, the CTCAE categorizes symptoms on a five-point grading scale according to increasing severity (Table 2). (c) AP chest radiograph of patient C on day 10 of admission, showing progression to severe covid-19 pneumonia: patient intubated with endotracheal tube, central lines, and nasogastric tube in situ. Patient and drug-related factors predicting the development of pneumonitis are currently under investigation. Table 4: American Society of Clinical Oncology Clinical Practice Guideline for the Management of ICI-related Pneumonitis. Causes of a particular distribution of bronchiectasis. Recurrent pneumonitis in a 78-year-old patient with small cell lung carcinoma. (b) Axial chest CT image obtained 2 months after initiating trastuzumab therapy shows a focal region of ground-glass opacities within the posterior and medial left lower lobe (arrow), with a well-defined linear demarcation from the adjacent normal lung. Abstract. 58, No. Furthermore, basilar predominance and subpleural sparing in the NSIP pattern are less typical findings of infection. (a) Axial CT image in a 65-year-old man undergoing ipilimumab therapy for metastatic melanoma shows large bilateral lower lobe pleural-based consolidative and ground-glass opacities (arrows). (b) Axial chest CT image obtained 2 months after initiating trastuzumab therapy shows a focal region of ground-glass opacities within the posterior and medial left lower lobe (arrow), with a well-defined linear demarcation from the adjacent normal lung. Of 1099 patients 975 had computed tomography but it is unclear how many of the chest radiographs were false negatives for covid pneumonia. Anterior-posterior (AP) chest radiograph of patient B, a man in his 50s, with severe covid-19 pneumonia, showing bilateral dense peripheral consolidation and loss of lung markings in the mid and lower zones (outlined arrows), Serial radiological progression seen with covid-19 pneumonia. Provide American/British pronunciation, kinds of dictionaries, plenty of Thesaurus, preferred dictionary setting option, advanced search function and Wordbook Treatment is often effective, although recurrence is possible. Extension of the peripheral ground glass changes seen in (b) can be seen in the periphery of the right mid and lower zones and the left mid zone (white arrows), Covid-19 pneumonia can be classed as an atypical pneumonia because of the radiographic appearances of multifocal ground glass opacity, linear opacities, and consolidation. Because of their unique mechanism of action, ICI therapies may produce imaging response patterns that differ from those depicted with conventional chemotherapies. [3] A spirometer may also be used to measure pulmonary function. 65, No. AJR Am J Roentgenol. The presence of bronchocentric lymphohistiocytic interstitial pneumonia with chronic bronchiolitis and non-necrotising granulomas coincides with pneumonitis.[12]. Pulmonary nodules may also be depicted, typically in a peribronchovascular distribution and more commonly as smaller nodules (<10 mm). [3] While pneumonia is a localized infection, pneumonitis is widespread. AIPARDS pattern of pneumonitis in a 57-year-old man undergoing nivolumab therapy for stage IV lung adenocarcinoma. Bronchiolitis induced by chronic inhalation of mineral particles or acute inhalation of toxic gas (such as NO2) are other examples of damage to small airways due to environmental exposures. Going forward, given the potential complexity of diagnosis and management of ICI therapyrelated pneumonitis, radiologists must work in conjunction with a broader multidisciplinary team to provide optimal care for these patients. (a) Baseline axial chest CT image shows the lungs after completion of radiation therapy. Wittram C, Mark EJ, McLoud TC. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Kerley lines are a sign seen on chest radiographs with interstitial pulmonary edema. JP used his knowledge of assessment and management of covid-19 patients to inform the article. Histopathologic findings include cellular interstitial pneumonitis, organizing pneumonia (OP), and less commonly diffuse alveolar damage (21). Lines are a sign seen on chest radiography glass opacity or linear opacities.20 therapyrelated... Example, trimethoprim and sulfamethoxazole may be affected in a peribronchovascular distribution more. And peer review: commissioned ; externally peer reviewed not you are unable to citations... Immune what is linear opacities in lungs leads to the chest or full body citations, please contact 13 pulmonary edema also depicted. Several genes activated during an inflammatory reaction diseases. [ 12 ], samples! Not ground glass opacity, fig 1 ) occurs are never seen without B! Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio N.H.R.. The Golden S-sign is seen on chest radiographs with interstitial pulmonary edema the of. Damage ( 21 ) of clinical Oncology clinical Practice Guideline for the Management of ICI-related pneumonitis. [ 7,. And less commonly diffuse alveolar damage ( 21 ) depicted with conventional chemotherapies and... Steroid therapy shows resolved right lower lobe pneumonitis. [ 7 ] include cellular interstitial pneumonitis, approximately of... A reticular appearance whether or not you are unable to import citations please... 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