대한흉부영상의학회 Weekly Chest Cases

Case No : 840 Date 2013-12-02

Courtesy of Yu-Whan Oh, Soo-Youn Ham, Sung Ho Hwang, Lim Hyun-ju / Korea University Anam Hospital
Age/Sex 69 / M
Chief ComplaintCough for two months(Hx: chronic renal failure, current smoker)

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Diagnosis With Brief Discussion

Diagnosis: Desquamative Interstitial Pneumonia (DIP)
Radiologic Findings: Chest PA shows haziness in both lung fields.
CT images show multiple patchy areas of ground-glass attenuation, multiple cysts and emphysema in the bilateral lungs. However, the subpleural area is spared in the bilateral lower lobes.
VATS biopsy specimen of the patient shows numerous brown pigmented alveolar macrophages filling alveolar duct and airspaces.
Brief Review: DIP is an uncommon form of interstitial pneumonia that occurs frequently in patients between 30 and 50 years of age. Approximately 90% are cigarette smokers. The DIP is characterized histologically by the presence of numerous macrophages within alveolar airspaces. A DIP-like histopatholgic pattern also has been associated with dust inhalation, metabolic diseases, drug reactions, and connective tissue disease. Unlike usual interstitial pneumonia, DIP involvement is typically more or less uniform in severity within affected lobules. Interstitial inflammation and fibrosis are usually mild but may be moderate or rarely severe. Similarly, architectural distortions of lung parenchyma and traction bronchiectasis are uncommon features.
The most common radiographic appearance of DIP is bilateral basal hazy increased opacification with a reduction in lung volumes. However, the radiographs are normal in about 5% to 20% of patients who have biopsy-proven DIP. The predominant HRCT abnormality is also bilateral area of ground-glass attenuation, reflecting the filling of alveolar airspaces by macrophages. A subpleural and basal predominance is often present. Although reticular opacity may be associated with ground-glass attenuation, honeycombing is uncommon. Of cases, 32%-75% develop small cystic airspaces within areas of ground-glass attenuation. Histopathologic correlation suggests that some of these cysts represent bronchioliectasis and dilated alveolar ducts, without honeycomb fibrosis. Because of its association with cigarette smoking, centrilobular emphysema is also common present. Spontaneous improvement may occur in untreated patients. The response to corticosteroid is unclear; however, most patients report a symptomatic improvement.
References: 1. Akira M, Yamamoto S, Hara H, Sakatani M, Ueda E: Serial computed tomographic evaluation in desquamative interstitial pneumonia. Thorax 1997, 52(4):333-337
2. Hartman TE, Primack SL, Kang EY, Swensen SJ, Hansell DM, McGuinness G, Muller NL: Disease progression in usual interstitial pneumonia compared with desquamative interstitial pneumonia. Assessment with serial CT. Chest 1996, 110(2):378-382
3. Hartman TE, Primack SL, Swensen SJ, Hansell D, McGuinness G, Muller NL: Desquamative interstitial pneumonia: thin-section CT findings in 22 patients. Radiology 1993, 187(3):787-790
Please refer to: Case 4 Case 266 Case 615
Keywords: Lung, Idiopathic interstitial pneumonia, DIP, smoking related, IIP,

No. of Applicants : 77

▶ Correct Answer : 24/77, 31.2%

- kanto Rosai Hp , Japan Takana Yamakawa
- Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
- Niigata City General Hospital , Japan Takao Kiguchi
- Avrasya Hospital , Turkey Murat Ulusoy
- prince salman bin abdulaziz university , Saudi Arabia NABIL GHALEB
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Shiga University of Medical Science , Japan Akitoshi Inoue
- Radiology Department, the First Affliated Hospital of Nanjing Medical University (Jiangsu province Hospital) , China Qiguang Cheng
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
- UWO , Canada S Lee
- Niigata University , Japan Atsushi Uehara
- CHRU Lille , France Paul Lebert
- HUEC , Brazil Diogo Pinheiro
- CHU Poitiers , France CHAN paul
- humiic , Korea (South) Ju Won Lee
- chungbuk uni. hospital , Korea (South) JY Ahn
- NASA SCANS , India RAKESH BHATIA
- CAC Rennes , France nicolas gautier
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- C.B.H. Dpt of Imaging-Clinica , Italy Carlo Florio
- All India Institute of medical sciences , India Justin Moses
- Medicheck health care , Korea (South) Chae Lim

▶ Correct Answer as Differential Diagnosis : 16/77, 20.8%

- Scans world , India Philson Mukkada
- district tuberculosis centre,poonamallee , India gayathri ganesh
- SKG radiology , Australia Yuranga Weerakkody
- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
- ICD,MCH CALICUT , India rikhy krishnan
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Ondokuz Mayis University , Turkey Cetin Celenk
- Northern Yokohama Showa university , Japan Kota Watanabe
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Seoul Asan Medical Center , Korea (South) Sae Rom Chung
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- IRSA La Rochelle , France Denis Chabassiere
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Chonnam National Univ. Hospital , Korea (South) Jaemyeong Jo
- Kyungpook National University Hospital , Korea (South) Jaekwang Lim

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 840 Date 2013-12-02

Discussion

No. of Applicants : 77