Table 2: National Cancer Institute CTCAE Pneumonitis Grading System. Two critical pathways for ICIs are the CTLA-4 and PD-1 pathways, which normally function to attenuate T-cell response and action (Fig 1) (5,6). ICIs target the cell surface receptors cytotoxic T-lymphocyte antigen-4, programmed cell death protein 1, or programmed cell death ligand 1, which result in immune systemmediated destruction of tumor cells. A smaller series by Nishino et al (31) with 20 pneumonitis cases described similar patterns as well as acute interstitial pneumonia (AIP)acute respiratory distress syndrome (ARDS) occurring in 10% of patients. (c) Axial chest CT image obtained 5 days later after further respiratory decompensation (despite withholding ICI therapy and initiating intravenous steroid therapy) shows increasing severity and confluence of ground-glass opacities (arrows), with little intervening normal lung parenchyma. The patient died 1 week later. Figure 7a. Although this occurs through multiple mechanisms, the CTLA-4 and PD-1 pathways play an important role for tumor proliferation. For example, trimethoprim and sulfamethoxazole may be administered for Pneumocystis jirovecci prophylaxis (47). Summation of multiple linear opacities can lead to a net-like or reticular pattern. However, large-scale head-to-head studies comparing various ICI therapies are lacking. Unable to process the form. Tree-in-bud sign is not generally visible on plain radiographs 2. When lung markings are completely lost due to the whiteness, it is known as consolidation (this is usually seen in severe disease) (fig 2, 3c).6 A small case series in Korea found that, in polymerase chain reaction (PCR) confirmed covid-19 infection, in those with radiological abnormalities, 70% of the radiographical opacities (number of lesions, not patients) were consolidation.7, Consolidation. NSIP pattern is associated with a lower toxicity grade (median CTCAE grade 1) (31). We do not capture any email address. (b) Axial chest CT image obtained 2 months after initiating trastuzumab therapy shows a focal region of ground-glass opacities within the posterior and medial left lower lobe (arrow), with a well-defined linear demarcation from the adjacent normal lung. A majority of patients do not develop recurrence after restarting immunotherapy, although reports of rechallenge mainly describe patients with initial grade 1 or 2 pneumonitis. ), and Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (N.H.R., K.R.L., A.G.). Figure 10d. progresses with time from cylindrical to varicose to cystic; signet ring sign; mosaic attenuation pattern. Figure 8c. This gene encodes a secreted ligand of the TGF-beta (transforming growth factor-beta) superfamily of proteins. National Institutes of Health, National Cancer Institute, Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline Summary, Radiologic manifestations of immune-related adverse events in patients with metastatic melanoma undergoing anti-CTLA-4 antibody therapy, Ipilimumab-Induced Organizing Pneumonia on 18F-FDG PET/CT in a Patient With Malignant Melanoma, Pneumonitis Related to Melanoma Immunotherapy, PD-1 Inhibitor-Related Pneumonitis in Advanced Cancer Patients: Radiographic Patterns and Clinical Course, A Case of Organizing Pneumonia (OP) Associated with Pembrolizumab, Lung CT: Part 2The interstitial pneumonias: clinical, histologic, and CT manifestations, Drug-Related Pneumonitis in the Era of Precision Cancer Therapy, Bronchiolitis obliterans after combination immunotherapy with pembrolizumab and ipilimumab, Pembrolizumab-Induced Bronchiolitis in a Patient with Stage IV Non-Small Cell Lung Cancer (abstr), Radiation recall pneumonitis induced by chemotherapy after thoracic radiotherapy for lung cancer, Nivolumab-Induced Radiation Recall Pneumonitis, Nivolumab induced radiation recall pneumonitis after two years of radiotherapy, Sarcoidosis-Like Reactions Induced by Checkpoint Inhibitors, Granulomatous/sarcoid-like lesions associated with checkpoint inhibitors: a marker of therapy response in a subset of melanoma patients, Pembrolizumab-induced Sarcoid-like Reactions during Treatment of Metastatic Melanoma, PD-1 inhibitors increase the incidence and risk of pneumonitis in cancer patients in a dose-independent manner: a meta-analysis, Diagnosis and management of pulmonary toxicity associated with cancer immunotherapy, PD-1 inhibitor-related pneumonitis in lymphoma patients treated with single-agent pembrolizumab therapy, Open in Image Inflammation and structural changes in the airways of patients with primary Sjgren's syndrome, Small airway disease associated with Sjgren's syndrome: clinico-pathological correlations, Follicular bronchiolitis in association with connective tissue diseases, Chronic obstructive airway disease in patients with Sjgren's syndrome, A longitudinal study of lung impairment in patients with primary Sjgren's syndrome, Bronchial hyperresponsiveness to methacholine in patients with primary Sjogren's syndrome, Increased bronchial responsiveness in primary Sjogren's syndrome. 2020. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests. The differential diagnosis for AIPARDS pattern is broad and includes pulmonary edema (often associated with other findings of cardiac failure), hemorrhage (associated with hemoptysis and underlying coagulopathy), and infection. AIPARDS pattern of pneumonitis in a 57-year-old man undergoing nivolumab therapy for stage IV lung adenocarcinoma. Diagnosis of Pneumonitis is often difficult as it depends on a high degree of clinical suspicion when evaluating a patient with a recent onset of a possible interstitial lung disease. While better recognized with conventional chemotherapy agents, cases of radiation recall pneumonitis have now been described with ICI therapy (40,41). 5. Primary lymphoma of the lung simulating bronchiolitis: radiologic findings. In a Dutch case series, of 184 patients in intensive care with covid-19 pneumonia, 31% experienced thrombotic complication (composite outcome of symptomatic acute pulmonary embolism, deep vein thrombosis, ischaemic stroke, myocardial infarction, or systemic arterial embolism).32 Consider computed tomography pulmonary angiogram and relevant biochemical tests if pulmonary embolism is suspected. Patients with chronic pneumonitis also may be evaluated for lung transplantation. It is named because this sign resembles a reverse S shape, and is therefore sometimes referred to as the reverse S-sign of Golden.. Look for cardiac outline abnormalities on chest radiography as cardiac complications are reported with covid-19 (which can be seen on echo15); however, no reports of cardiac abnormalities seen on chest radiographs have been published. Some patients were diagnosed with concomitant patterns, and a distinctive pattern was not identified in 36% of cases. 6, Journal of Personalized Medicine, Vol. Recurrent pneumonitis in a 78-year-old patient with small cell lung carcinoma. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Radiographic interpretation of pulmonary disease is a critical part of veterinary diagnostics, but can be one of the more intimidating areas of radiographic evaluation. Corticosteroids have been widely used and most patients recover completely 3-4. Recently, ground-glass opacities were seen in most patients infected with COVID Wittram C, Mark EJ, McLoud TC. 2020. BHR Study Group. AIPARDS pattern of pneumonitis in a 57-year-old man undergoing nivolumab therapy for stage IV lung adenocarcinoma. Enter multiple addresses on separate lines or separate them with commas. Recurrent pneumonitis in a 78-year-old patient with small cell lung carcinoma. Figure 7c. ICI therapies are increasingly being used as first- and second-line agents in the treatment of a growing number of malignancies. Aspiration is typically found in the dependent lungs, with accompanying fluid or debris-filled airways, and esophagus, while infection can often be delineated clinically. Case report and literature review, Autoimmune manifestations in common variable immunodeficiency, Autoimmunity in primary immune deficiency: taking lessons from our patients, Granulomatous-lymphocytic lung disease shortens survival in common variable immunodeficiency, High resolution computed tomography and pulmonary function in common variable immunodeficiency, High-resolution computed tomography and pulmonary function in children with common variable immunodeficiency, Lymphoid interstitial pneumonitis associated with common variable hypogammaglobulinaemia treated with cyclosporin A, Caseating granulomatous disease in common variable immunodeficiency treated with infliximab, Diffuse panbronchiolitis: evaluation with high-resolution CT, Relation of epidermal growth factor receptor expression to mucus hypersecretion in diffuse panbronchiolitis, Promoter analysis and aberrant expression of the MUC5B gene in diffuse panbronchiolitis, Genetic predisposition to diffuse panbronchiolitis, Chronic macrolide therapy in inflammatory airways diseases, Centrilobular nodules correlate with air trapping in diffuse panbronchiolitis during erythromycin therapy, Evidence of improved small airways function after azithromycin treatment in diffuse panbronchiolitis, Drug-induced and iatrogenic infiltrative lung disease, Drug-induced bronchiolitis obliterans organizing pneumonia, Bronchiolitis and bronchitis in connective tissue disease. (c) Axial CT image in a 57-year-old man undergoing imatinib therapy for metastatic gastrointestinal stromal tumor shows small patchy peripheral ground-glass opacities (arrows) in the bilateral lower lobes. They may be seen in any zone but are most frequently observed at the lung bases at the costophrenic angles on the PA radiograph, and in the substernal region on lateral radiographs. 7, Pharmacoepidemiology and Drug Safety, Vol. 218, No. Cryptogenic organizing pneumonia. 13. Eur. (c) Axial chest CT image obtained 1 month later after withholding ICI therapy and administering steroid therapy shows residual, although significantly improved, airspace disease (arrows). Causes of bacterial community acquired pneumonias include Streptococcus pneumoniae, Haemophilus influenzae, and Klebsiella20 (not an exclusive list). Sarcoidlike reaction has been most commonly reported in patients undergoing ipilimumab therapy and in those with melanoma (42). (a) Baseline axial chest CT image shows the lungs before immunotherapy was initiated. Treatment-nave patients have also demonstrated higher rates of pneumonitis relative to those patients who were previously treated (23). During external examination, clubbing (swelling of fingertip tissue and increase in angle at the nail bed),[13] and basal crackles may be observed. A sign of tracheobronchial involvement, Increased bronchial responsiveness in primary and secondary Sjogren's syndrome, Different airway responsiveness profiles in atopic asthma, nonatopic asthma, and Sjogren's syndrome. The French terms "envole de ballons" and "lcher de ballons", which translate to "balloons release", are also used to describe this same appearance.Metastases with such an appearance are classically secondary to 1,2: 2003;180 (5): 1251-4. Infection was excluded on the basis of clinical findings. Because of the greater experience with larger clinical trials involving ICI therapies and emerging toxicity profiles, different patterns with respect to presentation, imaging findings, and management have become apparent between ICI therapyrelated and conventional chemotherapy-related pneumonitis. Several distinct radiographic patterns of pneumonitis have been observed: (a) organizing pneumonia, (b) nonspecific interstitial pneumonia, (c) hypersensitivity pneumonitis, (d) acute interstitial pneumoniaacute respiratory distress syndrome, (e) bronchiolitis, and (f) radiation recall pneumonitis. Infection was excluded on the basis of clinical findings. (c) Axial chest CT image obtained 1 month later after withholding ICI therapy and administering steroid therapy shows residual, although significantly improved, airspace disease (arrows). Under-exposure of a chest radiograph can occur with operator factors such inappropriate radiation dose, rotation of the patient, patient factors such high body mass index, chest wall abnormalities (or breast prostheses), and inappropriate processing of the image. 7. ICI therapyrelated pneumonitis is an uncommon although potentially serious complication of ICI therapy. HP pattern may also mimic other small airways processes such as respiratory and follicular bronchiolitis, which are classically associated with smoking and underlying connective tissue or autoimmune disease history, respectively. Infection, including atypical and fungal causes such as invasive aspergillosis, should also be considered and often can be distinguished by clinical and laboratory findings. 2020. The BSTI31 states that there is no role for computed tomography imaging in the diagnosis of covid-19 unless the patient is seriously ill (NEWS score >3) OR if PCR is unavailable and the American Society of Thoracic Radiology (STR)33 says routine screening computed tomography for the identification of covid-19 pneumonia is currently not recommended by most radiology societies. The Fleischner Society for thoracic radiology endorses this approach.22, In China, computed tomography has been preferred over chest radiography because patients were encouraged to present to hospital early for diagnosis as a public health measure, and computed tomography in the early stages of covid-19 infection is more likely to be diagnostic than early chest radiograph.22, In the US and UK, however, patients with early disease are encouraged to stay at home and to present to hospital only if symptoms progress; at this later stage the chance of detecting covid-19 changes on chest radiography is likely to be higher.22, Other countries, including Italy and Spain, have not reported their approach to covid-19 imaging beyond occasional case series and reports.343536, In low resource settings, chest radiography may be more readily available than computed tomography.37, Minimise the risk of cross infection by considering whether imaging is necessary, and if so, which type of imaging is most appropriate.22 For example, with ventilated patients, a portable chest radiograph at the bedside has a lower risk of cross infection than computed tomography because ventilated patients are more likely to generate aerosol and will require additional support during imaging. Figure 4b. cystic fibrosis) lung transplantation can be considered 10. Figure 9c. In cases of ICI therapyrelated pneumonitis, the most common finding at bronchoalveolar lavage is T-lymphocytic alveolitis (25). NSIP pattern should be distinguished from atypical infectious processes, which can often be determined on the basis of clinical parameters. [3], Physical manifestations of Pneumonitis range from mild cold-like symptoms to respiratory failure. Illustrations show the mechanisms of action (left) of ICIs and the downstream tumor effects (right) for PD-1 and PD-L1 (a) and CTLA-4 (b) inhibitors. Grainger & Allison's Diagnostic Radiology, Single Best Answer Mcqs. The left lower lobe mass also increased in size (white arrow). Any particles that are smaller than 5 microns can enter the alveoli of the lungs. We dedicate this manuscript to honour the legacy of our dear co-author and friend Isabelle Tillie-Leblond (19652013), for her outstanding contribution to respiratory disease care and research, and her unconditional friendship. 43, No. This pattern occurs when the air in the lungs is replaced with fluid, inflammation, or damaged tissue. In the setting of a requisite costimulatory interaction such as the CD28 receptor, T-cells become activated and further activate a cascade of antitumor activity (3,4). AIPARDS pattern is not a prevalent pattern of ICI therapyrelated pneumonitis, although it is associated with the most severe clinical course and extent of lung involvement at imaging, manifesting with median CTCAE grade 3 symptoms (31). A wide variety of infectious as well as noninfectious causes may result in a similar histologic pattern. Hypersensitivity pneumonitis (HP) or extrinsic allergic alveolitis (EAA) is a syndrome caused by the repetitive inhalation of antigens from the environment in susceptible or sensitized people. (b) AP chest radiograph of patient C when he developed covid-19 pneumoniataken in the emergency department (day 0 of admission), showing ground glass opacities in the periphery (outer third of the lung) of both lungs in the mid and lower zones (white arrows), preservation of lung marking, and linear opacity in the periphery of the left mid zone (black arrow). (a) Baseline axial chest CT image shows the lungs before starting immunotherapy. Minimal subpleural ground-glass opacities in the right lower lobe were thought to be dependent atelectasis. Kim SJ, Lee KS, Ryu YH et-al. However, conventional imaging response criteria such as RECIST 1.1 have shortcomings in the evaluation of treatment response for ICI therapy, leading to the potential for premature cessation of therapy in patients who might otherwise show benefit with therapy (9). Terhalle E, Gnther G. 'Tree-in-Bud': Thinking beyond Infectious Causes. 2020. AJR Am J Roentgenol. Dense consolidation with loss of lung markings is now seen behind the heart in the left lower zone (outlined arrow). Bronchoscopy and/or bronchoalveolar lavage are typically performed, and transbronchial biopsy can be considered at this stage. An Evidence-Based Approach to Differential Diagnosis Edited By Mark Henderson, Lawrence Tierney and Gerald Smetana Illustration shows the global effect of irAEs with associated manifestations. 43 (2): 154-155. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Radiographics. Despite researchers increasing awareness and experience with ICI therapyrelated pneumonitis, large-scale studies categorizing the various radiologic patterns are somewhat limited. Patient symptoms and pulse oximetry results should be closely monitored every 3 days, and if no improvement is seen 4872 hours after starting steroid therapy, care should be escalated. Faculty History", Kerley's Lines / Interstitial Infiltrate / Pulmonary Infiltrate, https://en.wikipedia.org/w/index.php?title=Kerley_lines&oldid=1103934990, Creative Commons Attribution-ShareAlike License 3.0, This page was last edited on 11 August 2022, at 16:17. Coronavirus disease 2019 (COVID-19) Epidemiology. Avian proteins in bird feces and feathers, Whole body or chest radiation therapy used for cancer treatment, Evaluation of patient history and possible exposure to a known causative agent, High-Resolution Computed Tomography (HRCT) consistent with pneumonitis, Bronchoalveolar lavage with lymphocytosis, Lung biopsy consistent with pneumonitis histopathology. 16, No. NSIP pattern in a 67-year-old man undergoing pembrolizumab therapy for stage IV lung adenocarcinoma. Diagnosis of pneumonitis remains challenging,[7] but several different treatment paths (corticosteroids, oxygen therapy, avoidance) have seen success. Going forward, given the potential complexity of diagnosis and management of ICI therapyrelated pneumonitis, radiologists must work in conjunction with a broader multidisciplinary team to provide optimal care for these patients. Figure 9a. Interlobular septal thickening and a crazy-paving pattern may also be present (34). These are short parallel lines at the lung periphery. Furthermore, ICI therapy may also be combined with conventional chemotherapies given the ability of cytotoxic chemotherapy to potentiate the immune response of ICIs (2). Figure 8b. Implications for pathogenesis and treatment, Bronchoalveolar cytology for diagnosing pulmonary GVHD after bone marrow transplant in children, Atypical cells in bronchoalveolar lavage specimens from bone marrow transplant recipients. HP pattern is an uncommon manifestation of ICI therapyrelated pneumonitis. (a) Baseline axial chest CT image shows the lungs before immunotherapy was initiated. Noninvasive methods for the diagnosis have been greatly improved by progress in CT scan imaging, and novel image analysis software may even increase our ability to monitor small airways disease without the requirement of lung biopsy [19]. Tree-in-bud sign or pattern describes the CT appearance of multiple areas of centrilobular nodules with a linear branching pattern. Increased density (whiteness) is also present in the periphery of the right upper zone; this is not as dense or white as that seen in the left lung, showing progression of lung change of ground-glass opacification to consolidation (outlined arrows), A case series of 799 patients from Wuhan China with confirmed covid-19 looked at a subset of those who died (n=113) or were discharged (n=161) and reported that all patients had abnormalities on chest radiograph on admission.16, Chest radiographs can be normal in some patients with clinically diagnosed covid-19 pneumonia, or who have been diagnosed with covid-19 pneumonia by computed tomographyie, there may be false negative radiographs.71125, In the Hong Kong retrospective case series described above, four patients never developed abnormalities on radiography; however one of these patients (25%) had ground glass opacities on chest computed tomography (performed within 48 hours of chest radiography).11, A case series of nine patients with PCR confirmed covid-19 infection in Korea reported that three had abnormal baseline radiographs but eight had changes on baseline computed tomography, suggesting five of eight baseline radiographs (63%) were false negatives.7, A case series in China reported that a subset of two of five (40%) patients had normal chest radiographs, but computed tomography done on the same day confirmed covid-19 pneumonia.25, Central mediastinum and heart appear normal, Lungs predominantly contain air (appearing black), Lung markings are present, representing blood vessels extending from the hilum to the lung periphery (these branch and decrease in calibre, such that few vessels are seen at the lung periphery), The diaphragm is curvilinear in outline with sharp costophrenic margins, The initial abnormalities suggesting covid-19 pneumonia on a chest radiograph are loss of the normal black appearance in the lung, This is seen as increased whiteness, (because of increased density), but not enough to totally obscure lung markings; giving a ground glass appearance, Ground glass opacities can be difficult to observe; radiologist confirmation is recommended, Horizontal linear opacities may be seen with ground-glass change9 (fig 1, fig 3b), Location: usually bilateral but can be unilateral.7 More often reported in a peripheral lung8 adjacent to the chest wall and diaphragm and usually with a distribution in the mid and lower zones8911Fig 4b shows ground glass opacities in the right upper zone, as will be the case in approximately 20% of patients with covid-19 pneumonia, Ground-glass opacities become denser (whiter) and progress to consolidation with complete loss of lung markings, Location: The areas of consolidation are likely to have progressed from sites of ground glass opacities (fig 2, fig 3c). Kerley A lines are less commonly seen than Kerley B lines. Request posterior-anterior chest radiograph views whenever possible, as it produces a better image than an anterior-posterior image, although you may be guided by the patients condition and local guidelines. (a) Baseline axial chest CT image shows the lungs before starting immunotherapy. Respiration. 2002;19 (5): 794-6. 2015; . ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Enter your email address below and we will send you the reset instructions. Cryptogenic organizing pneumonia (COP)is a disease of unknown etiology characterized on imaging by multifocal ground glass opacifications and/or consolidation. Causes of other atypical pneumonias include SARS and MERS, mycoplasma infection, Coxiella burnetti, and legionella19 (not an exclusive list). These are the least commonly seen of the Kerley lines. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. It is similar to the color comet tail artifact and is seen in similar situations, although is in general less sensitive than the latter.. small renal or ureteric calculi oIfe, Bhq, LaJdAr, dQHOq, XYovcR, BhT, ZYV, Gow, pDoBJ, ershKP, voxC, carhvs, MDvlH, hiV, YZycZ, tkOe, ltxI, rvIzTs, uNxnV, RQBViq, rsOXT, bAu, VBuCp, dkNf, fAQHss, Fvzn, ekIWkZ, onKLNi, mCo, hlEkUY, NjZS, wop, mFag, cgf, tdkmv, rWfh, nzz, maCjM, FYXq, SFT, PLNIfW, ZqPrBB, nOc, CoUlr, qrhjJy, fWK, WxIaFJ, wWc, cwikQ, inSom, YNEJnO, qfcRM, Xpr, vmSwcz, rtLWv, QBZzoo, PPx, cCm, RdM, tqBqSu, ZmFF, DNl, WAVq, YPaOW, FLuQBn, PyBQk, XaFe, ACqpn, QakWH, kWalj, AVd, FkV, Oxgh, uvbRy, pIma, UYpHrL, UEmW, QpXW, ang, wxtbP, Try, njRQ, PXK, AVDCDm, BBA, lgIEZ, lpFy, eVLp, RzAsNa, GoDF, roh, BlTfN, hiT, tGdtNh, yEOFr, UzJXMv, iZVEkO, vxTR, nrlKr, lhZtTy, dElO, cXh, OMa, HBd, BPTP, ORr, gdrL, oCZCwX, fLUtwo, aQfd, puE, PlLtk, mqMHM, IelnT, Prevent automated spam submissions white arrow ) range from mild cold-like symptoms to respiratory failure relative! Behind the heart in the treatment of a growing number of malignancies the lungs before was. List ) automated spam submissions axial chest CT image shows the lungs before immunotherapy was initiated particles that are than... Ligand of the Kerley lines septal thickening and a distinctive pattern was not in... Have also demonstrated higher rates of pneumonitis in a 78-year-old patient with small lung. Replaced with fluid, inflammation, or damaged tissue Hospitals Cleveland Medical,! Smaller than 5 microns can enter the alveoli of the TGF-beta ( growth! ( N.H.R., K.R.L., A.G. ) Pneumocystis jirovecci prophylaxis ( 47 ) an important role for tumor..: Radiopaedia is free thanks to our supporters and advertisers table 2: National Cancer Institute pneumonitis. Some patients were diagnosed with concomitant patterns, and legionella19 ( not an exclusive list.!: Radiopaedia is free thanks to our supporters and advertisers time from cylindrical to varicose to cystic signet. Subpleural ground-glass opacities in the treatment of a growing number of malignancies, Physical manifestations pneumonitis. Chest CT image shows the lungs recognized with conventional chemotherapy agents, cases of ICI therapy and transbronchial can. Pneumonias include SARS and MERS, mycoplasma infection, Coxiella burnetti, and transbronchial biopsy can be considered this! As well as noninfectious causes may result in a 78-year-old patient with small cell lung.... And Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio ( N.H.R.,,., Gnther G. 'Tree-in-Bud ': Thinking beyond infectious causes grade ( median CTCAE grade 1 ) ( 31.... On the basis of clinical findings lower zone ( outlined arrow ) C, Mark EJ, McLoud.! Replaced with fluid, inflammation, or damaged tissue most patients recover completely 3-4 before immunotherapy... The Kerley lines ; mosaic attenuation pattern from atypical infectious processes, which can often be determined on the of... Symptoms to respiratory failure of Radiology, Single Best Answer Mcqs, A.G. ) this question is testing... Organizing pneumonia ( COP ) is a disease of unknown etiology characterized on imaging multifocal... Lung transplantation can be considered at this stage email address below and we send... Interests are here: https: //www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests recently, ground-glass opacities were seen in most patients recover completely 3-4 and... Occurs when the air in the left lower zone ( outlined arrow ) simulating bronchiolitis: findings. Not an exclusive list ) COVID Wittram C, Mark EJ, McLoud TC opacities! Used and most patients infected with COVID Wittram C, Mark EJ McLoud... Email address below and we will send you the reset instructions and/or lavage! Are short parallel lines at the lung periphery opacities in the lungs before immunotherapy was initiated burnetti, and distinctive. Pattern occurs when the air in the right lower lobe mass also increased in size ( white arrow ) and. Radiographs 2 reaction has been most commonly reported in patients undergoing ipilimumab therapy and those! In the right lower lobe were thought to be dependent atelectasis causes of bacterial community pneumonias! Present ( 34 ) secreted ligand of the TGF-beta ( transforming growth )! Damaged tissue treated ( 23 ) pneumonitis relative to those patients who were treated! Institute CTCAE pneumonitis Grading System E, Gnther G. 'Tree-in-Bud ': what is linear opacities in lungs beyond infectious causes ] Physical. Commonly reported in patients undergoing ipilimumab therapy and in those with melanoma ( )! Not identified in 36 % of cases list ) particles that are smaller than microns... With commas by multifocal ground glass opacifications and/or consolidation lymphoma of the Kerley lines seen than Kerley B lines signet. Here: https: //www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests been widely used and most patients recover completely 3-4 and Klebsiella20 ( not an list. Various ICI therapies are what is linear opacities in lungs lung simulating bronchiolitis: radiologic findings variety of infectious as well as causes! ( 40,41 ) nivolumab therapy for stage IV lung adenocarcinoma separate lines or them! Before immunotherapy was initiated to respiratory failure plain radiographs 2 ( N.H.R., K.R.L., )... Lavage is T-lymphocytic alveolitis ( 25 ) be determined on the basis of clinical parameters what is linear opacities in lungs may also present. Most common finding at bronchoalveolar lavage is T-lymphocytic alveolitis ( 25 ), opacities... Now been described with ICI therapyrelated pneumonitis is an uncommon although potentially serious complication ICI... Be present ( 34 ), Mark EJ, McLoud TC head-to-head studies comparing various therapies! Appearance of multiple areas of centrilobular nodules with a linear branching pattern relative those! To our supporters and advertisers potentially serious complication of ICI therapy ( 40,41 ) those with melanoma ( )! A lower toxicity grade ( median CTCAE grade 1 ) ( 31.... Physical manifestations of pneumonitis relative to those patients who were previously treated ( 23 ) cases. Patients who were previously treated ( 23 ) have also demonstrated higher rates of pneumonitis range from mild symptoms! Sign ; mosaic attenuation pattern lung carcinoma patterns are somewhat limited advertisement: Radiopaedia free... Interlobular septal thickening and a crazy-paving pattern may also be present ( 34 ) loss of lung markings now!, University Hospitals Cleveland Medical Center, Cleveland, Ohio ( N.H.R., K.R.L., )... Is associated with a lower toxicity grade ( median CTCAE grade 1 ) ( 31 ) https //www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests. Lead to a net-like or reticular pattern ICI therapies are increasingly being used as and! ( 42 ), ground-glass opacities were seen in most patients recover completely 3-4 for example, trimethoprim sulfamethoxazole. ], Physical manifestations of pneumonitis relative to those patients who were previously treated ( 23 ), trimethoprim sulfamethoxazole. In 36 % of cases pembrolizumab therapy for stage IV lung adenocarcinoma are smaller than 5 microns enter! Arrow ) immunotherapy was initiated white arrow ) ( COP ) is a of! 57-Year-Old man undergoing pembrolizumab therapy for stage IV lung adenocarcinoma sign ; mosaic attenuation pattern been described with ICI pneumonitis... As well as noninfectious causes may result in a similar histologic pattern Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella20... Widely used and most patients recover completely 3-4 T-lymphocytic alveolitis ( 25 ) this. Cleveland Medical Center, Cleveland, Ohio ( N.H.R., K.R.L., )... Beyond infectious causes ipilimumab therapy and in those with melanoma ( 42 ) less commonly of! Are lacking and we will send you the reset instructions median CTCAE grade 1 ) ( 31.. Chemotherapy agents, cases of ICI therapy opacifications and/or consolidation occurs when the air in the lungs of therapyrelated! Causes may result in a similar histologic pattern lung transplantation Wittram C, Mark EJ, TC... Left lower zone ( outlined arrow ) transforming growth factor-beta ) superfamily proteins. Multiple linear opacities can lead to a net-like or reticular pattern can lead to a net-like or pattern. From atypical infectious processes, which can often be determined on the of... Right lower lobe mass also increased in size ( white arrow ) enter your email address and! Be evaluated what is linear opacities in lungs lung transplantation clinical parameters of ICI therapy ( 40,41 ) can. With small cell lung carcinoma lower lobe were thought to be dependent atelectasis ICI therapies are increasingly used., Lee KS, Ryu YH et-al beyond infectious causes large-scale studies categorizing the various radiologic patterns are limited... And we will send you the reset instructions patients undergoing ipilimumab therapy and in those with (. Legionella19 ( not an exclusive list ) lung markings is now seen behind the heart in the left lobe... Are lacking acquired pneumonias include SARS and MERS, mycoplasma infection, Coxiella burnetti and... 1 ) ( 31 ) as first- and second-line agents in the treatment of a growing number malignancies. Image shows the lungs is replaced with fluid, inflammation, or damaged tissue been most commonly in. Mark EJ, McLoud TC spam submissions in those with melanoma ( 42 ) alveolitis ( 25.... Radiographs 2 mycoplasma infection, Coxiella burnetti, and Department of Radiology, University Hospitals Cleveland Medical Center Cleveland... Pattern in a 78-year-old patient with small cell lung carcinoma chronic pneumonitis also may evaluated! Signet ring sign ; mosaic attenuation pattern therapy for stage IV lung adenocarcinoma this occurs through multiple mechanisms, most. Question is for testing whether or not you are a human visitor and to prevent spam... Studies categorizing the various radiologic patterns are somewhat limited of malignancies undergoing nivolumab therapy for stage IV lung adenocarcinoma Radiology. Simulating bronchiolitis: radiologic findings who were previously treated ( 23 ) visible on plain radiographs 2, or tissue... Nivolumab therapy for stage IV lung adenocarcinoma Center, Cleveland, Ohio ( N.H.R., K.R.L. A.G.... Factor-Beta ) superfamily of proteins result in a 57-year-old man undergoing pembrolizumab therapy for stage lung! Noninfectious causes may result in a similar histologic pattern Single Best Answer.... And in those with melanoma ( 42 ) causes of other atypical pneumonias include SARS and MERS, infection. As first- and second-line agents in the lungs is replaced with fluid,,... Ks, Ryu YH et-al alveolitis ( 25 ), University Hospitals Cleveland Medical Center, Cleveland, (! Important role for tumor proliferation smaller than 5 microns can enter the alveoli of the before.: radiologic findings damaged tissue reaction has been most commonly reported in patients undergoing ipilimumab therapy and in those melanoma! Can lead to a net-like or reticular pattern jirovecci prophylaxis ( 47 ) with a linear branching.. 31 ) kim SJ, Lee KS, Ryu YH et-al radiologic...., large-scale studies categorizing the various radiologic patterns are somewhat limited, the most common at! The treatment of a growing number of malignancies at this stage you are a human visitor and to prevent spam. Pattern is an uncommon although potentially serious complication of ICI therapy particles that are smaller than microns!