144Lu ILD Question Fibrosing Hypersensitivity Pneumonitis

70 year old female presents with Dyspnea 10 Months Ago

Hypersensitivity Pneumonitis
70-year-old female presents with dyspnea
CXR performed 10 months prior shows vague regions of increased density in the mid lung fields bilaterally possibly representing ground glass changes
Ashley Davidoff MD TheCommonvein.net 135790c 144Lu
    • CT PA  (Expiration
      • GGO’s
        • pulmonary edema
        • small airway disease

Hypersensitivity Pneumonitis
Relative Sparing of Lower Lung Fields

Hypersensitivity Pneumonitis Relative Sparing of Lower Lung Fields
70-year-old female presents with dyspnea
CT in the axial plane shows extensive small airway disease characterised by multicentric foci of differing densities that include ground glass normal, and mosaic attenuation and extensive diffuse groundglass nodules. The lower lung fields below are relatively spared of disease. These findings in the appropriate clinical context, are consistent with hypersensitivity pneumonitis (HP)
Ashley Davidoff MD TheCommonvein.net 135792c 144Lu

Hypersensitivity Pneumonitis Head Cheese Sign

Hypersensitivity Pneumonitis Head Cheese Sign
70-year-old female presents with dyspnea
CT performed in expiration shows multicentric foci of differing densities that include ground glass (seen on inspiration images) normal, and mosaic attenuation with air trapping and prominent centrilobular nodules These findings confirm small airway disease and in the appropriate clinical context are consistent with hypersensitivity pneumonitis (HP)
Ashley Davidoff MD TheCommonvein.net 135792c 144Lu
Hypersensitivity Pneumonitis Head Cheese Sign
70-year-old female presents with dyspnea
CT performed in expiration shows multicentric foci of differing densities that include ground glass (seen on inspiration images) normal, and mosaic attenuation with air trapping and prominent centrilobular nodules (teal blue arrowheads). These findings confirm small airway disease and in the appropriate clinical context, are consistent with hypersensitivity pneumonitis (HP)
Ashley Davidoff MD TheCommonvein.net 135792cL 144Lu

Micronodules  and Mosaic Attenuation

Hypersensitivity Pneumonitis Ground Glass Micronodules  and Mosaic Attenuation
70-year-old female presents with dyspnea
CT in the coronal plane shows multicentric foci of differing densities that include ground glass normal, and mosaic attenuation and extensive diffuse groundglass nodules These findings confirm small airway disease and in the appropriate clinical context, are consistent with hypersensitivity pneumonitis (HP)
Ashley Davidoff MD TheCommonvein.net 135794 144Lu

Hypersensitivity Pneumonitis
Segmental and Subsegmental Airway Thickening

Hypersensitivity Pneumonitis Segmental and Subsegmental Airway Thickening
70-year-old female presents with dyspnea
CT in the coronal plane shows thickening of the segmental and subsegmental airways which is no characteristic of hypersensitivity pneumonitis
Ashley Davidoff MD TheCommonvein.net 135793c 144Lu

Lower Lung Field relatively Spared

Hypersensitivity Pneumonitis Lower Lung Field relatively Spared
70-year-old female presents with dyspnea
CT in the axial plane shows relative sparing of the lower lung fields However there is evidence of small airway disease with centrilobular nodules mosaic attenuation and ground glass changes. Noted is some thickening of the subsegmental airways
Ashley Davidoff MD TheCommonvein.net 135796c 144Lu

 

  • 9 months ago
    • PFTs-
      FEV1 1.79 (96%)
      FVC 2.36 (95%)
      FEV1/FVC 1.0
      FEF25-75 89%, BDR 61% (false-elevated due to low FVC?)
      TLC 88%
      RV 73%
      FRC not measured
      ERV 55%
      DLCO 82%
      VA not measured
      DLCO/VA 148%
      Flow volume loop normal
      IC/VC >85%
  • 7 months ago
    • Hi Res
      • Small airway disease
        • basilar airway thickening
        • bronchiolectasis
        • air trapping
        • GGO’s
        • reticular changes

7 months ago
reticular changes
bronchiolectasis

Expiration
Air trapping not significantly different from inspiration image
    • Bronchoscopy
      • Normal Airways
    • Echo Normal
  • Elevated ESR 46

CT 3 months ago

Persistent but improved areas of groundglass opacification, air
trapping and mild dependent subpleural reticulations. Differential
includes small airways/small vessel disease and hypersensitivity
pneumonitis.

3 months ago
Improved but persistent GGO reticular changes and bronchiolectasis
3 months ago
Improved but persistent GGO reticular changes and bronchiolectasis
3 months ago
Improved but persistent GGO reticular changes and bronchiolectasis

Path

1 month ago

RIGHT LOWER LOBE LUNG CRYOBIOPSY
Airway-centered fibrosis, peribronchiolar metaplasia, and mild chronic inflammation with occasional giant cell.
No lymphoid aggregates, germinal centers, or dominant plasmacytosis seen (lymphocytes > plasma cells).
No acute inflammation or foreign material observed.

Note: The pattern of inflammation raises the histologic differential of fibrotic hypersensitivity pneumonitis, however other airway-centered fibrosing disorders could also be considered. Clinical and radiologic correlation is advised. Exclusion of UIP
among other ILD’s cannot be entirely excluded due to sampling method.