70-year-old female former smoker with long standing history of RA presents with chronic dyspnea.
CT in the coronal plane of the chest at the level of the spine reveals bilateral diffuse changes in the lungs characterized by centrilobular nodules, ground-glass opacities, mosaic attenuation (likely due to air trapping in this context) and irregular thickening of the interlobular septa.
In the context of a patient with rheumatoid arthritis a diagnosis of follicular bronchiolitis is likely. However radiologically fibrotic hypersensitivity pneumonitis (HP) is included in the differential diagnosis
Ashley Davidoff MD TheCommonVein.net 132Lu 136663
Lyrics
“The Small Airway Attack (Bronchiolitis)”
(Verse 1) I am the small airway, the final track, The Bronchiole, the one under attack. I am not the big tube, not the alveolar sac, I am the tunnel that’s starting to crack. When I’m inflamed, the symptoms are deep, A wheeze and a cough, from the trouble I keep. But “Bronchiolitis” is not just one name, My types are all different, I’m not the same game.
(Verse 2) If I am Infectious, with pus and with goo, I’ll show a direct sign that’s easy to view. You’ll see on the scan, in a branching display, The classic, the famous, the “Tree-in-Bud” spray! But if I’m Cellular (from smoke or from haze), I won’t show the “Tree,” I’ve got different ways. I’m just a Centrilobular GGO spot, That’s the main clue that you’ve got.
(Chorus) So how do you diagnose? How do you see The trouble that’s hiding inside of me? You gotta tell ’em, “Breathe all the way out!” The Expiratory Scan will remove all doubt! That’s where the Air Trapping‘s revealed, The dark “Mosaic,” no longer concealed!
(Verse 3) My most evil cousin is Constrictive and tight, He scars up my walls and he steals all the light. On the inspiratory scan, I look normal and free, You’ll see no direct sign! You will not see me. You’ll only find me when the air is all gone, That’s when you’ll know that something is wrong!
(Chorus) So how do you diagnose? How do you see The trouble that’s hiding inside of me? You gotta tell ’em, “Breathe all the way out!” The Expiratory Scan will remove all doubt! That’s where the Air Trapping‘s revealed, The dark “Mosaic,” no longer concealed!
(Bridge) So look for the pattern (The Bud or The Haze), And look for the air in the expiratory phase. It’s the diagnostic design, To unlock my secrets and read my true sign!
(Outro) Read the true sign… Bronchiolitis… The expiratory phase!
A Poem
” Bronchiolitis
The Small Airway Attack “
I am not the big tube, not the alveolar sac,
I am the tunnel that’s starting to crack.
When I am inflamed, the symptoms are deep,
A wheeze and a cough, from the trouble I keep.
But “Bronchiolitis” is not just one name,
My types are all different, I’m not the same game.
To know who I am, you must look for the clue:
If I am Infectious, with pus and with goo,
I’m plugged up and sticky, a dirty, wet mess,
My direct sign is clear, you will have to confess.
You’ll see on the scan, in a branching display,
The classic, the famous, the “Tree-in-Bud” spray.
But if I am Cellular, from smoke’s hazy cloud, (Like RB-ILD),
I am not quite as loud. Or if from an allergy (HP‘s attack),
I don’t show the “Tree” that the infectious pack. I show as a micronodule, a soft, hazy spot, A Centrilobular GGO, is the clue that you’ve got.
My most evil cousin is Constrictive and tight,
He scars up my walls and he steals all the light.
On the inspiratory scan, I look normal and free,
There is no direct sign! You will not see me.
To find my dark secret, to see where I trap,
You must change the whole game, you must alter the map.
So how do you diagnose? How do you see?
You ask them to breathe out, to exhale for me.
On the Expiratory scan, my secret is told,
The Air Trapping‘s revealed, a story so cold.
The lung stays all dark, the air cannot pass.
A “Mosaic” of patterns, in shadows and glass.
So look for the pattern (The Bud or The Haze),
And look for the air (in the expiratory phase).
For that is the key, the diagnostic design,
To unlock my secrets, and read my true sign.