Interstitial lung abnormalities: new insights between theory and clinical practice

Interstitial lung abnormalities (ILAs) represent radiologic abnormalities incidentally detected on chest computed tomography (CT) examination, potentially related to interstitial lung diseases (ILD). Numerous studies have demonstrated that ILAs are associated with increased risk of progression toward pulmonary fibrosis and mortality. Some radiological patterns have been proven to be at a higher risk of progression. In this setting, the role of radiologists in reporting these interstitial abnormalities is critical. This review aims to discuss the most recent advancements in understanding this radiological entity and the open issues that still prevent the translation from theory to practice, emphasizing the importance of ILA recognition and adequately reporting in clinical practice.

Pulmonary Radiological Manifestations of Humoral and Combined Immunodeficiencies in a Tertiary Pediatric Center

Respiratory diseases are considered as significant causes of morbidity and mortality in primary immunodeficiencies. This study aimed to reveal the radiologic patterns of thoracic involvement in these disorders. A total of 58 patients, including 38 cases with combined cellular-humoral and 20 cases with humoral immunodeficiencies, were enrolled in this study. The “combined” group consisted of 12 cases with severe combined immunodeficiency (SCID) and 26 cases with combined immunodeficiency. The “humoral” group included seven patients with Hyper IgM syndrome (HIGMs), seven cases with common variable immunodeficiency (CVID), three patients with X-linked agammaglobulinemia, and three patients with other types of humoral primary immunodeficiencies (PIDs). The mean age of patients at the time of evaluation was 3.3±3.8 and 5.3±3.9 years in combined and humoral groups, respectively. The findings of chest X-rays and CT scans were interpreted and compared. There was a significant difference for alveolar opacification between combined and humoral immunodeficiencies (58% vs. 30%). The bronchopneumonia-like pattern was detected as a significant finding in patients with SCID (42%) and HIGMs (43%). Atrophy of the thymus was detected significantly often in cases of SCID (67%). Two patients with CVID and lipopolysaccharide-responsive and beige-like anchor protein deficiency showed parenchymal changes of granulomatous lymphocytic interstitial lung disease. No significant difference was detected for bronchiectasis, bronchitis/bronchiolitis patterns, pleural effusion, and thoracic lymphadenopathy. lymphadenopathy. Distinct subtypes of primary immunodeficiency may provoke differing and comparable radiological patterns of thoracic involvement; which can clue the clinician and radiologist to the diagnosis of the disease.

Upper respiratory tract manifestations in patients with ANCA-associated vasculitides and their association with the presence and type of ANCA

Aim of the work – to compare the frequency of upper respiratory tract (URT) involvement in patients with ANCAassociated vasculitides (AAV), to reveal its main clinical and radiological patterns and to estimate their association with the serological profile (ANCA presence and type).Material and methods. This retrospective study evaluated 369 patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The enrolled patients were diagnosed with AAV according to the ACR criteria, CHCC classification (2012) and EMA algorithm. Patients with URT manifestations underwent standard ENT assessment and X-ray/CT. Serum ANCA levels were measured by ELISA.Results. URT involvement was diagnosed in 280 (75.9%) patients with AAV. It was significantly more common amongthe patients with GPA (86.4%) and EGPA (85.5%) compared with the MPA group (29.2%) (p<0.001).URT manifestations mainly appeared as sinusitis (77.2% – GPA; 33.3% – MPA; 70.8% – EGPA) and rhinitis with crusting (87.8%, 72.2% and 16.9% respectively).Proteinase 3 ANCA positive patients had a significantly higher incidence of bone destructive URT lesions, including sinuses wall destruction (p<0.001) and saddle nose deformity (p=0.016), compared with myeloperoxidase-ANCA-positive patients. Similar results were obtained in the GPA group separately.Localized disease with isolated URT involvement was observed in 41.3% cases of ANCA negative GPA (p<0.001).Conclusion. The frequency and patterns of upper respiratory tract manifestations depend both on the nosologic form of AAV and type of ANCA. Localized forms of URT involvement can be observed in patients with GPA and are closely associated with absence of ANCA, which determines the need for especially high suspicion level.

Spectrum of Imaging Findings in Rhino-Orbito-Cerebral Mucormycosis (ROCM) in Post COVID Patients - A Pictorial Review with Clinico-Radiological Correlation

BACKGROUND Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating fungal infection with very high rates of mortality. Many patients post corona virus disease (COVID) infection are increasingly being diagnosed with mucormycosis (black fungus). Imaging being central to the early diagnosis of the infection, the study aims to characterize the major radiological patterns of involvement of mucormycosis. Computed tomography (CT) & magnetic resonance imaging (MRI) findings of 10 patients who were subsequently conformed to have mucormycosis were analyzed and 7 major patterns of involvement were detected. Imaging plays a vital role in the early diagnosis of ROCM. Knowledge about the common patterns of spread helps in picking the subtle signs of infection. KEYWORDS Mucormycosis, Post COVID, Fungal Sinusitis, ROCM

Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study

OBJECTIVE Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses. METHODS From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting. RESULTS Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3–9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6–63 months). CONCLUSIONS According to the authors’ results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

Clinical Predictors of Wheezing Among Children Infected With Mycoplasma Pneumoniae

Background:Mycoplasma pneumoniae (MP) not only was a common pathogen of respiratory tract infections, but also could trigger the exacerbation of asthmatic symptoms in children with or without asthma.Objective: This study aimed to identify possible risk factors associated with wheezing among children diagnosed with MP infection.Methods: A retrospective analysis of medical records of children aged 28 days to 18 years old who visited the Shanghai Children's Hospital between January 2019 and January 2020 was carried out, and all children were then classified into three groups: two wheezing groups (with or without MP infection) and a non-wheezing group with MP infection. Information including patient's demographics, clinical features, laboratory data, and radiography findings was extracted from the electronic medical record system. Chest radiographs were reviewed independently by two board-certified, blinded pediatric radiologists.Results: A total of 1,512 patients were included in our study, and 21.9% of them belonged to the wheezing group without MP infection. Among 1,181 patients with MP infection, 295 people (25.0%) suffered from wheezing, and males accounted for 61%. Through the multivariable logistic regression analyses, we found that six variables were positively associated with wheezing attacks in children with MP infection: male gender (likelihood ratio [LR] = 2.124, 95% confidence interval [CI]: 1.478–3.053), history of allergy (LR= 3.301, 95% CI: 2.206–4.941), history of wheezing (LR = 7.808, 95% CI: 5.276–11.557), autumn in reference to summer (LR = 2.414, 95% CI: 1.500–3.885), non-end-point infiltration in reference to consolidation or pleural effusion (LR = 1.982, 95% CI: 1.348–2.914), and infiltration scope (LR = 1.773, 95% CI: 1.293–2.432). However, the model showed that the probability of wheezing after MP infection decreased as age increased (LR = 0.257, 95% CI: 0.196–0.337). Moreover, the area under the curve (AUC) of the regression model was as high as 0.901 (0.847–0.955).Conclusion: The model integrated with factors including gender, age, season, radiological patterns, infiltration scope, and history of allergy performed well in predicting wheezing attack after MP infection in children.

Decision-Making Strategy for the Treatment of Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD)

Rheumatoid arthritis (RA) is a common type of autoimmune arthritis. Patient clinical outcomes might be influenced by numerous respiratory diseases, but interstitial lung disease (ILD) is the most important comorbidity. RA-associated ILD (RA-ILD) is divided into acute/subacute and chronic forms. In the acute/subacute course, if the disease is severe as indicated by a diffuse alveolar damage pattern, high-dose corticosteroids combined with antimicrobial agents should be promptly initiated while considering the differential diagnoses, primarily acute exacerbation (AE) of RA-ILD, drug-induced pneumonitis, and Pneumocystis pneumonia. As initial therapeutic management in the chronic course, the RA itself should be stabilized without delay; thereafter, the activity of ILD itself can be stabilized, considering the safety of each anti-rheumatic drug. The formation of the usual interstitial pneumonia (UIP) pattern is the most important determinant because lung function can worsen more quickly with this pattern. However, because clinicians can fail to identify specific radiological patterns, it is important to determine whether each patient with RA-ILD has UIP-like lesions such as subpleural reticulation, traction bronchiectasis, and honeycombing especially progressively enlarged cysts. In patients with progressive RA-ILD and high risk for infection or AE of ILD in whom fibrosis is dominant, clinicians should consider starting an anti-fibrotic agent.

Coronavirus Disease (COVID-19) compared with Middle East Respiratory Syndrome (MERS): A Radiological Perspective

Background: This study aims to describe the radiological findings in chest radiographs (CXRs) of patients with coronavirus disease (COVID-19) and the Middle East respiratory syndrome (MERS) and compare the radiological patterns of the two diseases. Method: A retrospective cohort study was conducted in a tertiary care hospital in the Southern region of Saudi Arabia. The CXRs were evaluated for the presence and distribution of ground-glass opacities (GGO), consolidation, pleural effusions, pneumothorax, cavitation, and nodules. Results: A total of 120 CXRs from 15 MERS and six COVID-19 patients were assessed. In the first available CXR, GGO was present in 11 (73%) of the MERS patients (18% located in the middle zones and 67% located peripherally) and in 100% of COVID-19 patients (peripheral and middle zone involvement in all patients). In the first available CXRs, consolidation was present in 10 MERS patients (67%) and all six COVID-19 patients, while it was present in all patients of both groups when all the available CXRs were considered. Confluent consolidation was present in 47% of the MERS patients and 50% of COVID-19 patients. All the fatal cases had confluent consolidation and radiological signs of acute respiratory distress syndrome (ARDS). Pneumothorax was present in 13% of patients, with 100% mortality, and pleural effusion was present in 47% of patients, with 57% mortality. Lung nodules were present in one patient of each group. Conclusion: COVID-19 patients showed earlier development of GGO and consolidation with greater involvement of the middle and peripheral lung zones. Confluent consolidation and ARDS-like radiological findings were associated with high mortality. Pneumothorax and pleural effusions were more frequent in MERS patients, with high associated mortality.

Clinical presentation and management of hypophysitis: An observational study of case series

Background: Hypophysitis is described as a rare chronic inflammatory affection of the pituitary gland. However, to date, its pathogenesis has not been completely cleared up. Clinical features are polymorphic, including symptoms related to inflammatory compression and/or hypopituitarism. Laboratory tests determine hormone deficiencies orientating replacement therapy’s protocol. MRI of the hypothalamic-pituitary region is crucial in exhibiting major radiological signs such as pituitary homogeneous enlargement and gland stalk’s thickening. The etiological diagnosis is still challenging without affecting the management strategy. Corticosteroids have widely been used but a close follow-up without any treatment has also been approved. Case Description: In this report, seven patients with hypophysitis have been collected over a period of 6 years. The average age of our patients was 32.1 years ± 11.8 with a female predominance (71.4%). Panhypopituitarism was objective in 42.9% of cases, a combined deficiency of the hypothalamic-pituitary thyroid, adrenal and gonadal axes in 28.6% of cases. A central diabetes insipidus was noted in 42.9% of the patients. Idiopathic hypophysitis was the most common etiology. The use of long course corticosteroids was required in 28.6% when compressive signs were reported. Conclusion: Hypophysitis remains a rare disease with nonspecific clinical and radiological patterns. Autoimmune origin seems to be the most frequent etiology. No guidelines have been established for hypophysitis management and the evolution is still unpredictable.