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Original Research: CHEST IMAGING |

Clinical/Pathologic Correlations in 553 Patients With Primary Centrilobular Findings on High-Resolution CT Scan of the Thorax* FREE TO VIEW

Fumito Okada, MD; Yumiko Ando, MD; Sachie Yoshitake, MD; Asami Ono, MD; Shuichi Tanoue, MD; Shunro Matsumoto, MD; Masaki Wakisaka, MD; Toru Maeda, MD; Hiromu Mori, MD
Author and Funding Information

*From the Department of Diagnostic and Interventional Radiology, Oita University Faculty of Medicine, Oita, Japan.

Correspondence to: Fumito Okada, MD, Department of Diagnostic and Interventional Radiology, Oita University Faculty of Medicine, Oita, Japan, Idaigaoka 1-1, Hasama-machi, Yuhu-shi, Oita 879-5593, Japan; e-mail: fumitook@med.oita-u.ac.jp



Chest. 2007;132(6):1939-1948. doi:10.1378/chest.07-0482
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Background: Clinical/pathologic correlations in patients with high-resolution CT (HRCT) scan findings presenting with two patterns of centrilobular opacity remain unclear.

Methods: Chest HRCT scans in 553 patients with predominant centrilobular opacities or preferential centrilobular disease were retrospectively evaluated. In 141 patients who underwent biopsy, CT scan images were compared with actual specimens.

Results: Centrilobular nodules with a tree-in-bud appearance and bronchial wall thickening were observed in most patients who were carriers of human T-lymphotropic virus type 1 (88 patients and 57 of 99 patients, respectively), Mycoplasma pneumoniae pneumonia (44 patients and 45 of 52 patients, respectively), Mycobacterium tuberculosis (38 patients and 37 of 52 patients, respectively), Mycobacterium avium-intracellulare complex (22 patients and 27 of 37 patients, respectively), Mycobacterium kansasii (27 patients and 19 of 33 patients, respectively), allergic bronchopulmonary aspergillosis (6 patients and 7 of 9 patients, respectively), diffuse panbronchiolitis (12 patients and 10 of 12 patients, respectively), and diffuse aspiration bronchiolitis (12 patients and 12 of 13 patients, respectively). On the other hand, ill-defined centrilobular nodules of ground-glass attenuation were frequently seen in patients with subacute hypersensitivity pneumonitis (all 15 patients), metastatic calcification (all 4 patients), Churg-Strauss syndrome (4 of 12 patients), microscopic polyangiitis (27 of 48 patients), systemic lupus erythematosus (7 of 8 patients), and respiratory bronchiolitis-associated interstitial lung disease (all 8 patients). Pathologically, the tree-in-bud appearance correlated well with the plugging of small airways with mucous, pus, or fluid; dilated bronchioles; and bronchiolar wall thickening. Ill-defined centrilobular nodules represented peribronchiolar inflammation or the deposition of hemorrhagic materials.

Conclusions: Knowledge of the two centrilobular patterns is of proven worth for generating differential diagnoses and is of particular value in suggesting a likely infectious etiology in cases with tree-in-bud appearance.

Figures in this Article

Bronchioles are not usually directly visible on CT scans. However, when there is excessive soft tissue in or around the bronchioles, they can become visible at the center of the secondary pulmonary lobe.1 The most common CT scan findings for bronchiolitis are centrilobular nodules and branching linear structures in secondary pulmonary lobules.

CT scan findings considered to represent bronchiolar diseases actually include a large variety of quite different pathologic entities that typically fall into the following two patterns on the CT scan: centrilobular nodules with tree-in-bud appearance; and ill-defined centrilobular nodules of ground-glass attenuation (GGA).110 However, to the best of our knowledge, the clinical/pathologic correlations in patients with high-resolution CT (HRCT) scan findings presenting two patterns of centrilobular opacities remain unclear. We aimed to retrospectively evaluate and compare pulmonary CT scan findings of patients with predominant centrilobular nodules or preferential centrilobular disease with pathologic findings.

Patients

Our institutional review board approved this retrospective study, and waived informed consent. We retrospectively identified 648 patients who fulfilled each diagnostic criterion specific to each entity (Table 1 )7,1018 and with predominant centrilobular nodules or preferentially centrilobular disease, who had undergone chest HRCT scans between January 1996 and December 2005 at three institutions. Thirty-one patients who were carriers of human T-lymphotropic virus type 1 (HTLV-1), 3 patients with Mycoplasma pneumoniae pneumonia, 8 with Mycobacterium tuberculosis (MTB), 7 with Mycobacterium avium-intracellulare complex (MAIC), 2 patients with diffuse panbronchiolitis (DPB), 2 patients with follicular bronchiolitis (FB), and 9 patients with alveolar hemorrhage were excluded from the study because of poor image quality on the HRCT scans, caused by motion artifacts or inadequate window-level settings, or because the hard copies of the CT film had been destroyed. Moreover, 10 HTLV-1 carriers, 8 patients with M pneumoniae pneumonia, 5 patients with DPB, 5 patients with diffuse aspiration bronchiolitis (DAB), and 5 patients with alveolar hemorrhage, in whom concurrent infectious diseases were diagnosed by serologic tests and clinical findings, were excluded from the study.

Thus, the study group comprised 553 patients (298 men; 255 women; age range, 15 to 86 years; mean age, 56 years) with centrilobular diseases whose cases were retrospectively reviewed. The patients included 243 HTLV-1 carriers, 52 patients with M pneumoniae pneumonia, 52 patients with MTB, 37 patients with MAIC, 33 patients Mycobacterium kansasii infection, 9 patients with allergic bronchopulmonary aspergillosis (ABPA), 12 patients with DPB, 7 patients with FB, 13 patients with DAB, 15 patients with subacute hypersensitivity pneumonitis (HP), 4 patients with metastatic calcification, 68 patients with alveolar hemorrhage, and 8 patients with respiratory bronchiolitis- associated interstitial lung disease (RB-ILD).

HTLV-1 is an etiologic retrovirus of adult T-cell leukemia/lymphoma (ATLL). HTLV-1 carriers were characterized by positive human T-lymphotropic virus type 1 antibody staining and polyclonal integration of proviral DNA in the peripheral blood or in biopsied tissue specimens. ATLL, on the other hand, was diagnosed by monoclonal integration of proviral DNA and the presence of abnormal lymphocytes with convoluted nuclei (ATLL cells) in the peripheral blood or from histologic findings compatible with a diagnosis of ATLL in biopsied tissue specimens. In patients with ATLL, ATLL pulmonary infiltration or opportunistic infections were observed. Therefore, 91 patients with ATLL, which was diagnosed during the same time period, were excluded from our study.

In 88 of 243 patients with HTLV-1, some respiratory symptoms such as cough or dyspnea were observed. Of these patients, to diagnose and differentiate from ATLL, surgical lung biopsy was performed in 1 patient, transbronchial lung biopsy (TBLB) was performed in 43 patients, and both surgical biopsy and TBLB was performed in 11 patients.

Among the patients with diffuse pulmonary hemorrhage, underlying diseases included microscopic polyangiitis (MPA) [n = 48], Churg-Strauss syndrome (CSS) [n = 12], and systemic lupus erythematosus (SLE) [n = 8], and all these patients also fulfilled the diagnostic criteria for each entity.1921

99mTc methylene diphosphonate (MDP) scintigraphy was performed in all patients with metastatic calcification. If patients whose medical histories were suggestive of metastatic calcification did not undergo 99mTc MDP scintigraphy, they were excluded from our study.

Moreover, patients with sarcoidosis were excluded because HRCT scan findings in these patients consisted of perilymphatic nodules (ie, peribronchial/perivascular axial interstitial and subpleural/fissural nodules). As well, patients with miliary tuberculosis or lung metastases were excluded from the study because these can manifest as CT scan findings including randomly distributed nodules. Patients with Langerhans cell granulomatosis or pneumoconiosis were also excluded from the study. None of these previous entities present with an HRCT scan pattern of primary centrilobular disease. No patient was immunocompromised (ie, no patient had HIV infection, neutropenia secondary to chemotherapy, or had received immunosuppressants).

CT Scan Examinations

CT scan examinations were performed with a high-speed scanner (Hi-Speed Advantage or Hi-Speed LX/i Advantage; General Electric Medical Systems; Milwaukee, WI; or X-press unit; Toshiba; Tokyo, Japan). HRCT scanning was performed with 1-mm collimation at 10-mm intervals. Images were obtained with lung window settings (width, 1,500 Hounsfield units [HU]; level, −700 HU) and with mediastinal window settings (width, 400 HU; level, 20 to 40 HU). All CT scans were obtained during suspended-end inspiration with the patient in the supine position. IV-administered contrast material was used for 302 of the CT scans.

CT Image Interpretation

Two chest radiologists (Drs. Okada and Ando, with 18 and 10 years of experience, respectively, in chest CT scan image interpretation), who were aware of the underlying diagnoses, retrospectively and independently interpreted the CT scans using hard-copy images. Conclusions were reached by consensus.

CT scan images were assessed for the following radiologic patterns: GGA; consolidation; centrilobular nodules; bronchial wall thickening; interlobular septal thickening; crazy paving appearance; bronchiectasis; enlarged hilar/mediastinal lymph nodes (ie, > 1 cm in diameter on the short axis); and pleural effusion. Areas of GGA were defined as hazy increases in attenuation without obscuration of vascular markings. Areas of consolidation were defined as areas of increased attenuation causing obscuration of normal lung markings. Centrilobular nodules were defined as nodules present around the peripheral pulmonary arterial branches or 3 to 5 mm away from the pleura, interlobular septa, or pulmonary veins. Moreover, centrilobular nodules were divided into the following two patterns: centrilobular nodules with tree-in-bud appearance; and ill-defined centrilobular nodules of GGA without tree-in-bud appearance. Tree-in-bud appearance was characterized by well-defined centrilobular nodules of soft-tissue attenuation that were connected to linear and branching opacities, thus resembling a tree in bud.

The distribution of the parenchymal disease was also noted. If the main lesion was predominantly located in the inner third of the lung, the disease was classified as having a central distribution. On the other hand, if the lesion was predominantly located in the outer third of the lung, the disease was classified as having a peripheral distribution. If the lesions showed no predominant distribution, the disease was classified as having a random distribution. In addition, zonal predominance was classified as upper, lower, or random. An upper lung zone predominance was considered when most abnormalities were seen in the upper level to the tracheal carina, while a lower lung zone predominance referred to most abnormalities being below the upper zone. When abnormalities showed no definite zonal predominance, the lung disease was classified as having a random distribution.

Comparison With Pathology

CT scan-pathologic comparisons for 141 patients were performed using actual specimens by a pathologist and two chest radiologists, using surgical biopsy specimens in 3 patients, using TBLB specimens in 109 patients, and using both TBLB and surgical specimens in 29 patients. Surgical lung biopsies and TBLBs corresponding to abnormal regions observed on chest CT scans were performed within 2 and 22 days after the CT scan, respectively.

CT Scan Patterns

Chest CT scans revealed abnormalities in 99 of 243 patients (40.7%) with HTLV-1, and in all patients with other diseases. The frequencies of CT scan findings are summarized in Table 2 . Centrilobular nodules were the most frequently found in HTLV-1 carriers (n = 99, 100%) with CT scan findings that were abnormal, and they were also found in 48 of 52 patients with M pneumoniae pneumonia (92.3%), 51 of 52 patients with MTB (98.1%), 33 of 37 patients with MAIC (89.2%), 32 of 33 patients (97%) with M kansasii infection, all 12 patients with DPB, all 7 patients with FB, all 13 patients with DAB, all 15 patients with HP, all 4 patients with metastatic calcification, and all 8 patients with RB-ILD (Figs 12345 ).

Among all patients, centrilobular nodules with tree-in-bud appearance were observed in most patients with HTLV-1 (88 of 99 patients; 88.9%), M pneumoniae pneumonia (44 of 52 patients; 84.6%), MTB (38 of 52 patients; 73.1%), MAIC (22 of 37 patients; 59.5%), M kansasii infection (27 of 33 patients; 81.8%), ABPA (6 of 9 patients; 66.7%), DPB (all 12 patients), FB (5 of 7 patients; 71.4%), and DAB (12 of 13 patients; 92.3%) [Figs 123].

On the other hand, ill-defined centrilobular nodules of GGA were frequently seen in patients with HP (all 15 patients), metastatic calcification (all 4 patients), CSS (4 of 12 patients; 33.3%), MPA (27 of 48 patients; 56.3%), SLE (7 of 8 patients; 87.5%), and RB-ILD (all 8 patients) [Figs 45-6].

Bronchial wall thickening was frequently seen in patients with mainly centrilobular nodules of tree-in-bud appearance, as follows: HTLV-1 carriers (57.6%); patients with M pneumoniae pneumonia (86.5%); patients with MTB (71.1%); patients with MAIC (73.9%); patients with M kansasii (57.6%); patients with DPB (83.3%); and patients with DAB (92.3%) [Fig 3]. In addition, bronchial wall thickening was frequently observed in patients with alveolar hemorrhage. In patients with HP (2 of 15 patients) or metastatic calcification (none of 4 patients), the frequency of bronchial wall thickening was lower than with other diseases.

Bronchiectasis was also frequently seen in patients with mainly centrilobular nodules of tree-in-bud appearance, as follows: HTLV-1 carriers (52.5%); MTB (46.2%); MAIC (59.5%), M kansasii (54.5%); ABPA (77.8%); and DPB (83.2%) [Fig 3]. However, bronchiectasis was found in only one patient with M pneumoniae pneumonia. Moreover, bronchiectasis was not frequently observed in patients with diseases with ill-defined centrilobular nodules of GGA revealed by CT scanning.

Consolidation was frequently observed in patients with MTB (44.2%), MAIC (40.5%), M kansasii (54.5%), and alveolar hemorrhage (54.4%). Cavitary nodules and cavitary consolidation were observed in patients with MTB (30.8% and 5.8%, respectively), MAIC (35.1% and 8.1%, respectively), and M kansasii (30.3% and 9%, respectively). Cavitary nodules or cavitary consolidation were not observed in patients with other diseases.

Distribution of Disease

Among patients with diseases whose CT scans showed centrilobular nodules of tree-in-bud appearance, such as HTLV-1 carriers and those with M pneumoniae pneumonia, MTB, MAIC, M kansasii, DPB, FB, and DAB, abnormal findings were predominantly seen in peripheral lungs (71.7%, 59.6%, 71.2%, 70.3%, 69.7%, 66.7%, 71.4%, and 100%, respectively) [Figs 1, 3, and Table 2]. However, in patients with ABPA, abnormal findings were predominantly seen in the central lungs (77.8%). On the other hand, among patients with diseases whose CT scans mainly showed ill-defined centrilobular nodules, abnormal findings were predominantly randomly distributed (Figs 4, 5).

For predominant zonal distribution (Table 2), in patients with HTLV-1 and DPB, random distribution was observed in 72 patients (72.7%) and 10 patients (83.3%), respectively. In patients with M pneumoniae pneumonia and DAB, lower distribution was observed in 30 patients (57.7%) and 12 patients (92.3%), respectively. In patients with MTB, MAIC, and M kansasii, abnormal findings were predominantly seen in the upper lung zone (76.9%, 51.4%, and 60.6%, respectively).

Among the diseases showing mainly ill-defined centrilobular nodules, upper lung zone predominance was seen in nine patients (60.0%) with HP and five patients (62.5%) with RB-ILD. Random predominance was seen in patients with alveolar hemorrhage.

Effusion and Lymph Nodes

Pleural effusions were found in patients with MTB (10 of 52 patients), MAIC (6 of 37 patients), CSS (2 of 12 patients), and SLE (2 of 8 patients). Pleural effusions were mainly found unilaterally, while bilateral effusions were observed in two patients with MTB, one patient with CSS, and three patients with MPA.

Mediastinal and/or hilar lymph node enlargement was observed in seven MTB patients (13.4%), three DPB patients (25%), and two FB patients (28.6%). Enlarged lymph nodes were generally found in the precarinal, paratracheal, tracheobronchial, or subcarinal region.

CT and Pathologic Comparisons

In 141 of 553 patients, surgical biopsy and/or TBLB were performed (Table 3 ). In all 55 patients with HTLV-1, the extents of centrilobular nodules and bronchial wall thickening pathologically corresponded with those of lymphocytic infiltration along respiratory bronchioles (Fig 1). In patients with MTB, MAIC, and M kansasii, the histologic features contributing to the tree-in-bud pattern included caseous materials in terminal bronchioles, bronchiectasis, and bronchial wall thickening. In patients with ABPA, fragments of fungal hyphae, allergic mucin, and inflammatory cells were identified in bronchiectasis. In patients with DPB, centrilobular nodules corresponded to thickened and dilated bronchial walls with intraluminal mucous plugs (Fig 3). In patients with FB, histologic findings consisted of hyperplastic lymphoid follicles with reactive germinal centers distributed along bronchioles, and thickened and dilated bronchial walls.

Among diseases with mainly ill-defined centrilobular nodules, 52 patients underwent surgical biopsy or TBLB. In patients with HP, interstitial lymphocytic infiltrates and poorly defined granulomas along with respiratory bronchioles were found (Fig 5). Bronchial wall thickening or dilatation of the bronchioles was not observed. In patients with alveolar hemorrhage, histologic features consisted of alveolar hemorrhaging, deposition of hemorrhagic materials, and neutrophil infiltration around respiratory bronchioles (Fig 4). No findings of thickened and dilated bronchial walls were observed. The extent of consolidation corresponded to that of diffuse alveolar hemorrhage. In patients with RB-ILD, accumulations of macrophages within respiratory bronchioles and adjacent alveolar ducts were found.

HRCT scanning is a sensitive method for the detection and characterization of diffuse infiltrative lung diseases,15 and centrilobular nodules can be found in patients with several pulmonary diseases.110 They were divided into the following two patterns: centrilobular nodules with tree-in-bud appearance; and ill-defined centrilobular nodules of GGA. However, to the best of our knowledge, the frequencies of each pattern of centrilobular nodules in several diseases and differences in pathologic findings between the two patterns remain unclear.

We reviewed 553 patients with predominantly centrilobular nodules or preferential centrilobular disease. Chest CT scans revealed abnormalities in 99 of 243 patients who were carriers of HTLV-1 whose pulmonary CT scan findings consisted of centrilobular nodules similar to those of patients with DPB,22 and in all patients with other diseases. Centrilobular nodules were the most frequently found in all patients except for those with CSS and MPA. Centrilobular nodules with a tree-in-bud appearance were observed in most patients who were carriers of HTLV-1, or who had M pneumoniae pneumonia, MTB, MAIC, M kansasii, ABPA, DPB, FB, and DAB. These results agreed with those of previous reports.,2,67,2328 Bronchial wall thickening was frequently seen in patients with mainly centrilobular nodules having a tree-in-bud appearance. Bronchiectasis was also frequently seen in all patients except those with M pneumoniae pneumonia. Bronchiectasis was found in only one patient with M pneumoniae pneumonia. Histopathologically, this organism targets the ciliated cells of the respiratory tract, while it is characterized by acute cellular bronchiolitis with edematous lesions of the bronchial walls.,1,2930 Therefore, it is not difficult to understand that the frequency of bronchiectasis was lower than those of other subacute or chronic inflammatory diseases with a tree-in-bud appearance.

No biopsies were performed in patients with DAB. Radiologic and pathologic findings resembled those of patients with DPB.27,31 DAB is characterized by chronic inflammation of bronchioles caused by the recurrent aspiration of foreign bodies. Therefore, it is not difficult to understand that CT scan findings in those patients consisted mainly of the tree-in-bud appearance.

Pathologically, the tree-in-bud appearance represents lymphocytic infiltration distributed along respiratory bronchioles, or bronchiolar luminal impaction with mucous or pus. In addition, the dilated and thickened walls of bronchioles and peribronchiolar inflammation can contribute to the visibility of affected bronchioles with a tree-in-bud appearance.

On the other hand, ill-defined centrilobular nodules of GGA were frequently seen in patients with HP, metastatic calcification, alveolar hemorrhage, or RB-ILD. These results were similar to those of previous reports.910,18,32 Moreover, compared to diseases with a mainly tree-in-bud appearance, bronchiectasis was not frequently observed in diseases with mostly ill-defined centrilobular nodules. Pathologically, ill-defined centrilobular nodules represent peribronchiolar inflammation or the deposition of hemorrhagic materials without the presence of the plugging of small airways or dilated bronchioles. These pathologic findings seem to account for the predominant CT scan findings of ill-defined centrilobular nodules rather than of nodules with a tree-in-bud appearance. Bronchial wall thickening was more frequently observed in patients with alveolar hemorrhage than in other patients with mainly ill-defined centrilobular nodules of GGA such as those with HP or metastatic calcification. MPA and CSS are antineutrophil cytoplasmic antibody-related diseases. Along with SLE, pulmonary hemorrhage is observed in patients with such a disease. Pathologically, bronchial wall thickening in our patients represented neutrophil infiltration around bronchioles.

In this study, biopsies were not performed in patients with metastatic calcification. The most common radiologic manifestation consists of ill-defined centrilobular nodules. These findings reflected the deposition of calcium salts in the alveolar walls around the terminal bronchioles17; therefore, it was not difficult to understand that the tree-in-bud appearance or bronchial wall thickening was not found in the patients.

In summary, in patients with centrilobular nodules with a mainly tree-in-bud appearance the overwhelming likelihood is that the underlying cause was related to infection, except for infection with DAB and DPB. On the other hand, patients with a centrilobular pattern without a tree-in-bud appearance essentially never have underlying infection as an etiology. Moreover, bronchiectasis was also a manifestation of infection in the vast majority of cases. Bronchiectasis was usually only associated with diseases with a tree-in-bud appearance and was not identified in patients with mainly ill-defined centrilobular nodules of GGA.

Finally, there were several limitations in our study. First, this was a retrospective study and CT scan image interpretation was performed by consensus. Second, CT scan findings were not sufficiently compared with pathologic findings because some patients were asymptomatic. In addition, CT scans and histologic specimens were not obtained on the same day.

Knowledge of the two patterns of centrilobular nodules seen on CT scans can be useful in preventing diagnostic errors. In addition, although the causes of these patterns are frequently indistinguishable at radiologic evaluation, the presence of additional radiologic findings, together with a clinical history and clinical presentation, can often be useful in obtaining an appropriate diagnosis

Abbreviations: ABPA = allergic bronchopulmonary aspergillosis; ATLL = adult T-cell leukemia/lymphoma; CSS = Churg-Strauss syndrome; DAB = diffuse aspiration bronchiolitis; DPB = diffuse panbronchiolitis; FB = follicular bronchiolitis; GGA = ground-glass attenuation; HP = subacute hypersensitivity pneumonitis; HRCT = high-resolution CT; HTLV-1 = human T-lymphotropic virus type 1; HU = Hounsfield units; MAIC = Mycobacterium avium-intracellulare complex; MDP = methylene diphosphonate; MPA = microscopic polyangiitis; MTB = Mycobacterium tuberculosis; RB-ILD = respiratory bronchiolitis-associated interstitial lung disease; SLE = systemic lupus erythematosus; TBLB = transbronchial lung biopsy

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Table Graphic Jump Location
Table 1. Diagnostic Criteria for Each Lung Disease*
* 

The diagnostic criteria are based on criteria from references 7, and 10 to 18.

Table Graphic Jump Location
Table 2. Thoracic CT Scan Findings in Each Disease*
* 

Values are given as No. (%). MK = M kansasii; MPP = Mycoplasma pneumoniae pneumonia.

Figure Jump LinkFigure 1. Images obtained in a 26-year-old woman with HTLV-1. Top: a transverse thin-section CT scan (1-mm section thickness) obtained at the level of the right hemidiaphragm shows centrilobular nodules that do not extend to the pleural surfaces, and with a tree-in-bud appearance (arrows) with a peripheral distribution. Bronchial wall thickening is also present in both of the lower lobes (white arrows). Bottom: photomicrograph of the surgical biopsy specimen from the right lower lobe shows infiltration by lymphocytes into respiratory bronchioles and alveolar walls (arrows) [hematoxylin-eosin, original ×100].Grahic Jump Location
Figure Jump LinkFigure 2. Image obtained in a 79-year-old woman with MTB. Transverse thin-section CT scan (1-mm section thickness) obtained at the level of the division of the lingular bronchus shows centrilobular nodules with a tree-in-bud appearance (arrows).Grahic Jump Location
Figure Jump LinkFigure 3. Images obtained in a 16-year-old woman with DPB. Top: a transverse thin-section CT scan (1-mm section thickness) obtained 2 cm below the division of the right lower lobe bronchus shows centrilobular nodules with tree-in-bud appearance (arrows), bronchial wall thickening, and bronchiectasis (arrowheads). Bronchiolar luminal impaction with mucus is also present (white arrows). Bottom: a photomicrograph of the surgical biopsy specimen obtained from the right lower lobe shows thickened and dilated terminal bronchioles with mononuclear cell infiltration (arrows) and foamy cells into the alveolar space. Intraluminal secretions are also present (arrowheads) [hematoxylin-eosin, original ×100].Grahic Jump Location
Figure Jump LinkFigure 4. Images obtained in a 46-year-old man with metastatic calcification. Top: a transverse thin-section CT scan (1-mm section thickness) obtained at the level of the division of the lingular bronchus shows diffuse ill-defined centrilobular nodules (arrows). Bottom: 99mTc MDP scintigraphy demonstrates remarkable 99mTc MDP uptake in the bilateral lungs.Grahic Jump Location
Figure Jump LinkFigure 5. Images obtained in a 24-year-old woman with alveolar hemorrhage (SLE). Top: a transverse thin-section CT scan (1-mm section thickness) obtained at the level of the division of the right lower bronchus shows ill-defined centrilobular nodules of GGA (arrows) and interlobular septal thickening (arrowheads). Bottom: a photomicrograph of the surgical biopsy specimen obtained from the right lower lobe shows alveolar hemorrhage and deposition of hemorrhage materials around respiratory bronchioles (arrows). No thickened and dilated bronchial walls are present (hematoxylin-eosin, original ×40).Grahic Jump Location
Table Graphic Jump Location
Table 3. Lung Biopsies in Patients With Each Disease*
* 

See Table 2 for abbreviations not used in the text.

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Johkoh, T, Ikezoe, J, Nagareda, T, et al Metastatic pulmonary calcification: early detection by high-resolution CT.J Comput Assist Tomogr1993;17,471-473. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Images obtained in a 26-year-old woman with HTLV-1. Top: a transverse thin-section CT scan (1-mm section thickness) obtained at the level of the right hemidiaphragm shows centrilobular nodules that do not extend to the pleural surfaces, and with a tree-in-bud appearance (arrows) with a peripheral distribution. Bronchial wall thickening is also present in both of the lower lobes (white arrows). Bottom: photomicrograph of the surgical biopsy specimen from the right lower lobe shows infiltration by lymphocytes into respiratory bronchioles and alveolar walls (arrows) [hematoxylin-eosin, original ×100].Grahic Jump Location
Figure Jump LinkFigure 2. Image obtained in a 79-year-old woman with MTB. Transverse thin-section CT scan (1-mm section thickness) obtained at the level of the division of the lingular bronchus shows centrilobular nodules with a tree-in-bud appearance (arrows).Grahic Jump Location
Figure Jump LinkFigure 3. Images obtained in a 16-year-old woman with DPB. Top: a transverse thin-section CT scan (1-mm section thickness) obtained 2 cm below the division of the right lower lobe bronchus shows centrilobular nodules with tree-in-bud appearance (arrows), bronchial wall thickening, and bronchiectasis (arrowheads). Bronchiolar luminal impaction with mucus is also present (white arrows). Bottom: a photomicrograph of the surgical biopsy specimen obtained from the right lower lobe shows thickened and dilated terminal bronchioles with mononuclear cell infiltration (arrows) and foamy cells into the alveolar space. Intraluminal secretions are also present (arrowheads) [hematoxylin-eosin, original ×100].Grahic Jump Location
Figure Jump LinkFigure 4. Images obtained in a 46-year-old man with metastatic calcification. Top: a transverse thin-section CT scan (1-mm section thickness) obtained at the level of the division of the lingular bronchus shows diffuse ill-defined centrilobular nodules (arrows). Bottom: 99mTc MDP scintigraphy demonstrates remarkable 99mTc MDP uptake in the bilateral lungs.Grahic Jump Location
Figure Jump LinkFigure 5. Images obtained in a 24-year-old woman with alveolar hemorrhage (SLE). Top: a transverse thin-section CT scan (1-mm section thickness) obtained at the level of the division of the right lower bronchus shows ill-defined centrilobular nodules of GGA (arrows) and interlobular septal thickening (arrowheads). Bottom: a photomicrograph of the surgical biopsy specimen obtained from the right lower lobe shows alveolar hemorrhage and deposition of hemorrhage materials around respiratory bronchioles (arrows). No thickened and dilated bronchial walls are present (hematoxylin-eosin, original ×40).Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Diagnostic Criteria for Each Lung Disease*
* 

The diagnostic criteria are based on criteria from references 7, and 10 to 18.

Table Graphic Jump Location
Table 2. Thoracic CT Scan Findings in Each Disease*
* 

Values are given as No. (%). MK = M kansasii; MPP = Mycoplasma pneumoniae pneumonia.

Table Graphic Jump Location
Table 3. Lung Biopsies in Patients With Each Disease*
* 

See Table 2 for abbreviations not used in the text.

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