Pedro Paulo Teixeira e Silva Torres

Alterações tomográficas pulmonares em mulheres não fumantes com DPOC por exposição à fumaça da combustão de lenha

OBJECTIVE: To identify and characterize alterations seen on HRCT scans in nonsmoking females with COPD due to wood smoke exposure. METHODS: We evaluated 42 nonsmoking females diagnosed with wood smoke-related COPD and 31 nonsmoking controls with no history of wood smoke exposure or pulmonary disease. The participants completed a questionnaire regarding demographic data, symptoms, and environmental exposure. All of the participants underwent spirometry and HRCT of the chest. The COPD and control groups were adjusted for age (23 patients each). RESULTS: Most of the patients in the study group were diagnosed with mild to moderate COPD (83.3%). The most common findings on HRCT scans in the COPD group were bronchial wall thickening, bronchiectasis, mosaic perfusion pattern, parenchymal bands, tree-in-bud pattern, and laminar atelectasis (p < 0.001 vs. the control group for all). The alterations were generally mild and not extensive. There was a positive association between bronchial wall thickening and hour-years of wood smoke exposure. Centrilobular emphysema was uncommon, and its occurrence did not differ between the groups (p = 0.232). CONCLUSIONS: Wood smoke exposure causes predominantly bronchial changes, which can be detected by HRCT, even in patients with mild COPD.

High-resolution computed tomography and histopathological findings in hypersensitivity pneumonitis: a pictorial essay

Hypersensitivity pneumonitis is a diffuse interstitial and granulomatous lung disease caused by the inhalation of any one of a number of antigens. The objective of this study was to illustrate the spectrum of abnormalities in high-resolution computed tomography and histopathological findings related to hypersensitivity pneumonitis. We retrospectively evaluated patients who had been diagnosed with hypersensitivity pneumonitis (on the basis of clinical-radiological or clinical-radiological-pathological correlations) and had undergone lung biopsy. Hypersensitivity pneumonitis is clinically divided into acute, subacute, and chronic forms; high-resolution computed tomography findings correlate with the time of exposure; and the two occasionally overlap. In the subacute form, centrilobular micronodules, ground-glass opacities, and air trapping are characteristic high-resolution computed tomography findings, whereas histopathology shows lymphocytic inflammatory infiltrates, bronchiolitis, variable degrees of organizing pneumonia, and giant cells. In the chronic form, high-resolution computed tomography shows traction bronchiectasis, honeycombing, and lung fibrosis, the last also being seen in the biopsy sample. A definitive diagnosis of hypersensitivity pneumonitis can be made only through a multidisciplinary approach, by correlating clinical findings, exposure history, high-resolution computed tomography findings, and lung biopsy findings.

Tuberculosis latente en la artritis reumatoide. Evaluación de la respuesta celular y tomografía computarizada de alta resolución

INTRODUCTION The diagnosis of latent tuberculosis (LTB) in patients with rheumatoid arthritis (RA) has become important with the introduction of anti-tumor necrosis factor (anti-TNF-α) agents and the appearance of active tuberculosis cases in these patients. The tuberculin skin test (TST) has limited value in patients with RA. Tests based on the release of interferon-gamma (IFN-γ) are being studied, but their role has not been well established for this group of patients. OBJECTIVES To compare the diagnosis of LTB in patients with RA by using cellular immune response to the TST and T.SPOT-TB. Additionally, findings of tomography studies compatible with LTB were used. METHODS Clinical evaluation, TST, T.SPOT-TB and high-resolution computed tomography (HRCT) in a group of patients with RA at the University Hospital of the Federal University of Goiás. RESULTS Response to the TST was lower in patients with RA (13.5%) compared to the predicted values of the general population. T.SPOT-TB identified a higher number of patients with LTB than the TST (36.8%). HRCT showed changes compatible with LTB in 52.9% of the patients, including 8 of the 11 patients with negative TST and T.SPOT-TB. CONCLUSIONS The TST by itself is insufficient to diagnose LTB. A higher number of positive results were obtained with T.SPOT-TB when compared to the TST. Nevertheless, it was negative in a large percentage of patients with tomography findings consistent with LTB. HRCT is readily available in most large health-care centers and it could be incorporated into the diagnostic strategy for LTB in patients with RA.

Aspects of bronchioloalveolar carcinoma and of adenocarcinoma with a bronchioloalveolar component: CT findings.

Bronchioloalveolar carcinoma has various presentations and a wide spectrum of imaging patterns, as does adenocarcinoma with a bronchioloalveolar component. The objective of this essay was to describe and illustrate the CT findings that are most characteristic of these tumors. Three presentations are described: solitary pulmonary nodule, consolidation, and diffuse pattern. The last two should be included in the differential diagnosis, together with infectious diseases. Knowledge of the various presentations and the use of proper diagnostic procedures are crucial to early diagnosis and to improving survival.

Tomographic assessment of thoracic fungal diseases: a pattern and signs approach

Pulmonary fungal infections, which can be opportunistic or endemic, lead to considerable morbidity and mortality. Such infections have multiple clinical presentations and imaging patterns, overlapping with those of various other diseases, complicating the diagnostic approach. Given the immensity of Brazil, knowledge of the epidemiological context of pulmonary fungal infections in the various regions of the country is paramount when considering their differential diagnoses. In addition, defining the patient immunological status will facilitate the identification of opportunistic infections, such as those occurring in patients with AIDS or febrile neutropenia. Histoplasmosis, coccidioidomycosis, and paracoccidioidomycosis usually affect immunocompetent patients, whereas aspergillosis, candidiasis, cryptococcosis, and pneumocystosis tend to affect those who are immunocompromised. Ground-glass opacities, nodules, consolidations, a miliary pattern, cavitary lesions, the halo sign/reversed halo sign, and bronchiectasis are typical imaging patterns in the lungs and will be described individually, as will less common lesions such as pleural effusion, mediastinal lesions, pleural effusion, and chest wall involvement. Interpreting such tomographic patterns/signs on computed tomography scans together with the patient immunological status and epidemiological context can facilitate the differential diagnosis by narrowing the options.

Metastatic pulmonary calcification: contribution of imaging to noninvasive diagnosis

1. MD, Radiologist, Multimagem Diagnósticos, Goiânia, GO, Brazil. E-mail: pedroptstorres@gmail.com. Metabolic pulmonary diseases comprise a heterogeneous and rare group of diseases, each with their own characteristics but with a common origin (metabolic or biochemical dysfunction); diseases in this group can be localized, affecting only the lungs, or systemic, affecting the lungs together with other organ systems(1,2). One such disease is metastatic pulmonary calcification (MPC), which is caused by disturbances in the calcium-phosphorus metabolism and results in abnormal calcium deposits in normal lung tissue(3,4). Although MPC is a common diagnosis at autopsy, antemortem diagnosis is uncommon and much of the information about the disease is found in isolated case reports(4–6). In the previous issue of Radiologia Brasileira, Belém et al.(7) published an interesting retrospective descriptive analysis of the patterns of MPC seen on chest tomography. The sizeable sample of 23 patients, resulting from a multicenter collaboration, made it the largest study of the disease to date. The quality of the sampling was also excellent, histopathological confirmation having been obtained in the vast majority of cases. The number of cases included allowed the spectrum of known tomography presentations of the disease to be expanded. In some of the patients, the authors identified reticular opacities with calcified micronodules, which have not previously been reported in MPC(7). Corroborating the findings of previous studies, Belém et al.(7) demonstrated a clear association between MPC and chronic renal failure, highlighting the strong correlation of the latter condition with cardiovascular events and the greater susceptibility to infections in immunocompromised individuals(1–4,7,8). The Belém et al.(7) finding of ground glass opacities—the most common pattern in their sample—broadens the range of differential diagnoses in this group of patients, including congestive conditions and infections(9). After ground glass opacities, the most common findings were dense consolidations and calcified micronodules, which also involve multiple differential diagnoses, including other metabolic conditions, pneumoconiosis, and drug (amiodarone) toxicity(10). Therefore, knowledge of the tomography patterns of MPC, as described in the article, is useful not only for informing the diagnosis but also for excluding other diagnoses, aspects that could have an impact on patient management. The magnetic resonance imaging patterns of MPC have also been described(11). In the case series conducted by Hochhegger et al.(11), T1-weighted sequences revealed that lung lesions related to MPC produced signals that were hyperintense in comparison with those of muscle tissue, an aspect due to the specific characteristics of the calcium crystals in the MPC lesions and similar to some patterns seen in brain calcification(12,13). Notable among other noninvasive diagnostic imaging techniques is technetium99m methylene diphosphonate scintigraphy, which is considered more specific for the diagnosis of MPC and capable of detecting earlier manifestations of the disease(3). In pulmonary involvement, radiopharmaceutical uptake occurs symmetrically, and its deposition can also be observed in the gastric wall, as well as in a variable manner in the renal parenchyma(3). Although lung biopsy is a valuable tool for the diagnosis of various pulmonary conditions, it is not risk-free and its cost-benefit ratio should be carefully studied by the multidisciplinary team before it is performed(14). Recent studies evaluating complications of lung biopsies at referral centers have reported mortality rates ranging from 1.7% to 3.9%, reaching up to 16% in patients undergoing non-elective biopsy, which underscores the fact that the presence of comorbidities contributes to reducing survival among such patients(15,16). Therefore, studies of diffuse lung diseases with a focus on noninvasive clinical and imaging-based diagnostic techniques, such as that conducted by Belém et al.(7), should be encouraged. Diffuse lung diseases are often a challenge for the multidisciplinary team, and diagnostic imaging plays a decisive role in many situations. The article authored by Belém et al.(7) makes a significant contribution to the tomography-based diagnosis of and noninvasive approach to MPC, highlighting the valuable role that the radiologist plays in the diagnosis of this condition.

Niemann-Pick disease type B: HRCT assessment of pulmonary involvement

Objetivo: Analisar os achados de TCAR em pacientes com doença de Niemann-Pick (DNP) tipo B a fim de avaliar a frequência dos padrões tomográficos e sua distribuição no parênquima pulmonar, além das características clínicas mais frequentes. Métodos: Foram estudados 13 pacientes (3 do sexo masculino e 10 do sexo feminino) com idades variando de 5 a 56 anos. As imagens de TCAR foram avaliadas por dois observadores de forma independente, e os casos discordantes foram resolvidos por consenso. Os critérios de inclusão foram presença de anormalidades na TCAR e diagnóstico confirmado de DNP tipo B por exame anatomopatológico através de biópsias de medula óssea, pulmão ou fígado. Resultados: Os achados clínicos mais comuns foram hepatoesplenomegalia e dispneia leve a moderada. Os padrões tomográficos mais frequentes foram espessamento liso de septos interlobulares e opacidades em vidro fosco, presentes em todos os pacientes. Linhas intralobulares estiveram presentes em 12 pacientes (92,3%). O padrão de pavimentação em mosaico foi observado em 5 pacientes (38,4%). Áreas de aprisionamento aéreo foram identificadas em 1 dos casos (7,6%). O comprometimento pulmonar foi bilateral em todos os casos, sendo o terço inferior dos pulmões a região mais envolvida. Conclusões: O achado de espessamento liso de septos interlobulares, com ou sem opacidades em vidro fosco associadas, em pacientes com hepatoesplenomegalia é o achado mais frequente na DNP tipo B.

Xantomatose cerebrotendínea: relato de dois casos

Cerebrotendinous xanthomatosis is a rare genetic disorder characterized by a decrease in activity of the hepatic sterol 27-hydroxylase involved in the cholesterol metabolism and excretion. Consequently, lipid (cholesterol/cholestanol) deposition is observed in different regions of the body, especially tendons, central nervous system and eye lens. The present report describes the cases of two sisters affected by this disease, highlighting the main imaging findings.