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1. Cereser L, Zuiani C, Graziani G, et al. Impact of clinical data on chest radiography sensitivity in detecting pulmonary abnormalities in immunocompromised patients with suspected pneumonia. Radiol Med. 2010;115(2):205-214. Observational-Dx 64 CXR, 2 independent reviewers To retrospectively evaluate whether the knowledge of clinical data improves the diagnostic sensitivity of CXR in immunocompromised patients after hematopoietic stem cell transplantation. Chest CT was standard of reference. Readers showed sensitivity of 39% and 58.5% for the first reading, and 43.9% and 41.5% for the second reading, respectively. For both readers, these values were not significantly different from those obtained at first reading (McNemar’s test, P>0.05). Interobserver agreement at second reading was fair (Cohen test, k=0.33). Sensitivity of CXR is too low to consider it a stand-alone technique for the evaluation of immunocompromised patients after hematopoietic stem cell transplantation with suspected pneumonia, even if the radiologist knows detailed clinical data. For these patients, an early chest CT evaluation is therefore recommended. 3
2. Franquet T. High-resolution computed tomography (HRCT) of lung infections in non-AIDS immunocompromised patients. Eur Radiol. 2006;16(3):707-718. Review/Other-Dx N/A Review HRCT of lung infections in non-AIDS immunocompromised patients. Imaging plays an important role in the detection and management of patients with pulmonary infectious diseases. When pulmonary infection is suspected, knowledge of the varied radiographic manifestations will narrow the differential diagnosis, helping to direct additional diagnostic measures and serving as an ideal tool for follow-up examinations. Combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infection occurring in the immunocompromised patients. 4
3. Jepson SL, Pakkal M, Bajaj A, Raj V. Pulmonary complications in the non-HIV immunocompromised patient. Clin Radiol. 2012;67(10):1001-1010. Review/Other-Dx N/A To provide the reader with a structured approach to interpret the imaging findings and differentiate between different infective and non-infective complications in these patients. The incidence of non-HIV immunocompromised patients is increasing. This is primarily due to improved immunosuppressive regimes for autoimmune diseases and also increases in stem cell transplantation. Pulmonary complications are a major cause of morbidity and mortality in these patients. Imaging is frequently used to assess these complications and to streamline therapies, as microbiological and/or pathological diagnosis can often be difficult, invasive, or protracted. 4
4. Bierry G, Boileau J, Barnig C, et al. Thoracic manifestations of primary humoral immunodeficiency: a comprehensive review. Radiographics. 2009;29(7):1909-1920. Review/Other-Dx N/A To describe the thoracic abnormalities that are most often observed at radiologic imaging in patients with various primary humoral immunodeficiencies. Humoral immunodeficiencies, which are characterized by defective production of antibodies, are the most common types of primary immunodeficiency. Pulmonary changes are present in as many as 60% of patients with humoral immunodeficiency. Chronic changes and recurrent infections in the respiratory airways are the main causes of morbidity and mortality in those affected by a humoral immunodeficiency. Medical imaging, especially computed tomography (CT), plays a crucial role in the initial detection and characterization of changes and in monitoring the response to therapy. The spectrum of abnormalities seen at thoracic imaging includes noninfectious airway disorders, infections, chronic lung diseases, chronic inflammatory conditions (granulomatosis, interstitial pneumonias), and benign and malignant neoplasms. Recognition of characteristic CT and radiographic features, and correlation of those features with clinical and laboratory findings, are necessary to differentiate between the many possible causes of parenchymal and mediastinal disease seen in patients with primary humoral immunodeficiencies. 4
5. Ketai L, Jordan K, Marom EM. Imaging infection. Clin Chest Med. 2008;29(1):77-105, vi. Review/Other-Dx N/A To review the role of thoracic imaging in normal or minimally compromised hosts, particularly on combinations of imaging and clinical characteristics that may suggest bacterial, fungal, or viral pathogens. Diagnostic imaging of the thorax is routinely used among both immunocompetent and immunosuppressed patients to detect infection, identify its complications, and aid in differentiating infectious from noninfectious intrathoracic disease. Imaging is more effective in suggesting specific types of infection in immunocompromised hosts where imaging findings can be combined with information on the patient's immune status, which in some cases allows treatment to be initiated without a pathologic diagnosis. CT imaging is particularly useful in immunosuppressed hosts with symptoms and minimally abnormal radiographs, such as those patients afflicted with bacterial airway infections. 4
6. Safadi AR, Soubani AO. Diagnostic approach of pulmonary disease in the HIV negative immunocompromised host. Eur J Intern Med. 2009;20(3):268-279. Review/Other-Dx N/A To review the major conditions causing pulmonary symptoms in the HIV negative immunocompromised host and the role of the different diagnostic methods, including the recent advances in non-invasive studies, in reaching a diagnosis of pulmonary disease in this patient population. The advances in medicine have resulted in increasing number of immunocompromised patients with complications related to their underlying disease or the treatment of these conditions. Pulmonary infectious and non-infectious conditions are a major cause of morbidity and mortality in these patients, and represent a diagnostic challenge. 4
7. Sulkowska K, Palczewski P, Golebiowski M. Radiological spectrum of pulmonary infections in patients post solid organ transplantation. Pol J Radiol. 2012;77(3):64-70. Review/Other-Dx N/A To present radiological findings suggestive of a particular causative microorganism and show how they can narrow the differential diagnosis when coupled with clinical data. Pneumonia remains an important source of morbidity and mortality in transplant recipients. Since clinical findings are nonspecific and cultures may be time-consuming, imaging plays an important role in establishing the probable etiology of pneumonia. Plain films are used as an initial study. However, they have a limited capacity in differentiating the causative factors. HRCT is used as a problem-solving tool in patients with unclear plain film findings and/or no response to treatment. The main advantage of HRCT is a very detailed depiction of the lung parenchyma. Even though HRCT findings are not always specific, there are several sings that are more common in certain types of pneumonia. The aim of the article is to present radiological findings suggestive of a particular causative microorganism and show how they can narrow the differential diagnosis when coupled with clinical data. 4
8. Hachem R, Sumoza D, Hanna H, Girgawy E, Munsell M, Raad I. Clinical and radiologic predictors of invasive pulmonary aspergillosis in cancer patients: should the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria be revised? Cancer. 2006;106(7):1581-1586. Observational-Dx 47 cases with invasive pulmonary aspergillosis 49 controls Retrospective study to determine the significant predictive factors that characterize invasive pulmonary aspergillosis in patients with cancer. Leukemia, neutropenia, cavitation, and nodular lesions occurred significantly more often among cases than controls (P=0.04, 0.004, 0.04, and 0.02, respectively). A quantitative scoring system was developed that could be used to identify patients as being at low, medium, and high-risk for invasive pulmonary aspergillosis. Invasive pulmonary aspergillosis should be highly suspected in leukemia patients with profound neutropenia, pleuritic chest pain, and cavitary or nodular lesions detected on CT scan. These predictive factors can be used to indicate when early prophylactic and therapeutic antifungal interventions should be initiated. 4
9. Hardak E, Brook O, Yigla M. Radiological features of Pneumocystis jirovecii Pneumonia in immunocompromised patients with and without AIDS. Lung. 2010;188(2):159-163. Observational-Dx 38 consecutive patients: (9 with AIDS and 29 with other causes of immunosuppression) Retrospective study to compare chest CT findings of PCP in immunocompromised patients with and without AIDS. From a radiographic point of view, non-AIDS patients had a significantly higher proportion of diffuse ground glass lesions, 86% vs 44% (P=0.02), and a lower proportion of cystic lesions, 3% vs 56% (P=0.015). The two subgroups did not differ in smoking status and the number of pack-years. On multivariate analysis, only the presence of AIDS was found to be a risk factor for the formation of pulmonary cystic lesions. Different immune reactions to the parasite PCP in immunocompromised patients with and without AIDS results in a different time lag between symptoms and a correspondingly different radiographic pattern: widespread ground glass opacities in the former and cystic lesions in the latter. 3
10. Park YS, Seo JB, Lee YK, et al. Radiological and clinical findings of pulmonary aspergillosis following solid organ transplant. Clin Radiol. 2008;63(6):673-680. Review/Other-Dx 13 consecutive patients: (5 liver, 4 kidney, and 4 heart transplant), 2 reviewers To retrospectively evaluate the radiological and clinical findings in patients with pulmonary aspergillosis after solid organ transplantation. The most common radiographic and CT findings were pulmonary nodules or masses (n=12). The number of nodules or masses was <10 in 8 patients. Associated findings were surrounding ground-glass opacity (n=4), central low density (n=8), central air cavity (n=5), and air bronchogram (n=3). Follow-up radiographs and/or CT after treatment showed improvement in 8 patients, persistence in two, and deterioration in three. The onset time of pulmonary aspergillosis was a median of 32 days (range 15-165 days). The most common symptom at diagnosis was fever (n=6). Ten of 13 patients did not have leucopaenia. There were two aspergillosis-associated deaths during the follow-up period. The most common radiological finding of pulmonary aspergillosis after solid organ transplantation is multiple nodules or masses, which commonly appear within 1 month following transplantation. 4
11. Vogel MN, Brodoefel H, Hierl T, et al. Differences and similarities of cytomegalovirus and pneumocystis pneumonia in HIV-negative immunocompromised patients thin section CT morphology in the early phase of the disease. Br J Radiol. 2007;80(955):516-523. Observational-Dx 58 patients: (31 with CMV pneumonia and 27 with PCP), CT - 2 reviewers Retrospective study to determine which patterns typical of CMV pneumonia or PCP in patients without AIDS were actually noticeable with varying frequency by means of an early thin section CT. Also, authors looked for significant morphological differences in both of these entities in order to expedite diagnosis for impact on patient management. 18 CT morphological criteria were evaluated for presence or absence. Only 5 of the 18 features were found to have significantly different frequencies in the two entities. Apical distribution (P<0.01), mosaic pattern (P<0.01) and homogeneous structure of ground-glass opacities (P<0.05) were found more frequently in PCP (each K: 0.7-0.9), whereas small nodules or unsharp demarcation of ground-glass opacities and consolidation were typical of CMV pneumonia (P<0.05). Peripheral sparing, consolidation and septal thickening inter alia were found equally in both groups. In conclusion analysis of craniocaudal distribution, demarcation and structure of infiltrates may be helpful in prioritizing differential diagnosis of CMV pneumonia or PCP. However, some features thought typical for one or the other entities appear with similar frequency in both groups in HIV-negative patients. 4
12. Demirkazik FB, Akin A, Uzun O, Akpinar MG, Ariyurek MO. CT findings in immunocompromised patients with pulmonary infections. Diagn Interv Radiol. 2008;14(2):75-82. Review/Other-Dx 57 immunocompromised patients To evaluate computed tomography (CT) findings of pulmonary infections in immunocompromised patients with hematologic malignancies, and to detect the accuracy of first-choice diagnoses. Nineteen patients had a bacterial infection, 20 patients had a fungal infection, 8 patients had a cytomegalovirus (CMV) infection, 8 patients had Pneumocystis jiroveci pneumonia (PCP) and 2 patients had a Mycobacterium tuberculosis infection. There were consolidations in 13 patients (68.4%) and areas of ground-glass attenuation and ground-glass nodules in 6 patients (31.6%) with bacterial infection. Six of 8 eight patients (75%) with CMV infection had centrilobular nodules associated with bronchial wall thickening and ground-glass areas and nodules. There were parenchymal nodules in 18 of 20 patients (90%) who had a fungal infection. All 8 patients who had PCP had bilateral areas of ground-glass densities on CT scans. The first-choice diagnosis was accurate in most of the fungal infections (95.0%) and PCP (87.5%), but was less accurate for bacterial and viral infections (73.7% and 75.0%, respectively). Neither of the 2 tuberculous infections was identified on the basis of CT findings. 4
13. Moser E, Tatsch K, Kirsch CM, Kuffer G, Goebel FD. Value of 67gallium scintigraphy in primary diagnosis and follow-up of opportunistic pneumonia in patients with AIDS. Lung. 1990;168 Suppl:692-703. Review/Other-Dx 40 patients: (10 normal controls and 30 HIV-positive patients with AIDS or AIDS-related complex To assess the value of 67gallium scintigraphy in the primary detection and follow-up of opportunistic pneumonia in patients with AIDS. 67Gallium scan results were compared with current CXRs and the results of pathogen detection. 8/30 patients had a normal scan, while 22/30 showed diffuse (13/22) or focal (9/22) increases of pulmonary uptake. In 7/8 patients with normal scans the CXR was negative as well. The one patient with negative scan but positive CXR had pulmonary Kaposi's sarcoma. In 11/22 patients, the 67gallium scan and CXR were positive simultaneously. In the other 11 of 22 patients with positive scans, CXRs were initially negative but showed pathology in five cases within 1-2 weeks. The reason for positive scans in most cases was an opportunistic lung infection; other forms of pneumonia were observed only in two cases. The defined uptake ratio was demonstrated to be a highly sensitive parameter for monitoring pneumonia and the effects of therapy in follow-up studies. Quantitative 67gallium scintigraphy proved to be a reliable and highly sensitive method for primary detection and follow-up of opportunistic pneumonias in patients with AIDS. 4
14. Tumeh SS, Belville JS, Pugatch R, McNeil BJ. Ga-67 scintigraphy and computed tomography in the diagnosis of pneumocystis carinii pneumonia in patients with AIDS. A prospective comparison. Clin Nucl Med. 1992;17(5):387-394. Observational-Dx 70 consecutive patients, 2 independent obervers To prospectively compare Ga-67 scintigraphy and CT in the diagnosis of PCP in patients with AIDS. Although scintigraphy had a higher true-positive ratio at any false-positive ratio, statistically the areas under the two ROC curves were not significantly different. However, at a false positive rate of 15% to 20% (one in the clinically reasonable range), the sensitivity for scintigraphy was 0.84 and for CT 0.80; corresponding specificities were 0.82 and 0.64, respectively, for the two modalities. It seems from these data that gallium imaging is probably superior to CT in detecting PCP in this group of patients. 2
15. Reynolds JH, Banerjee AK. Imaging pneumonia in immunocompetent and immunocompromised individuals. Curr Opin Pulm Med. 2012;18(3):194-201. Review/Other-Dx N/A To indicate the current role of radiological imaging in immune competent and immunocompromised patients with pneumonia. Three basic patterns of radiographic abnormality are recognized: lobar (nonsegmental) pneumonia; bronchopneumonia (lobular pneumonia); and interstitial pneumonia. The chest radiograph remains the initial radiological investigation. Computed tomography (CT) is more sensitive than the chest radiograph. The appearances on CT with certain infections such as mycoplasma, invasive aspergillosis, and pneumocystis, in the appropriate clinical setting, may allow a treatment decision to be made when obtaining fluid or tissue for culture is problematical. MRI technology is advancing and this technique may provide an option for follow-up of chronic disease in younger patients in whom radiation exposure is a concern, but MRI does not yet match CT as a diagnostic test in this field. 4
16. Franquet T. Respiratory infection in the AIDS and immunocompromised patient. Eur Radiol. 2004;14 Suppl 3:E21-33. Review/Other-Dx N/A Review the imaging findings of some of the most common infectious processes affecting patients with AIDS and patients who are immunocompromised for other reasons, emphasizing the imaging features on CXR and CT examinations. Infections are commonly associated with immunocompromised patients, reflecting the immunologic status of the patient. The combination of pattern recognition with knowledge of the clinical setting is the best approach to diagnosis. The majority of radiographic patterns is nonspecific and must therefore always be interpreted in the appropriate clinical context; however, certain CT findings may be helpful allowing a presumptive diagnosis to be made and treatment to be instituted before microbiologic results become available. 4
17. Schueller G, Matzek W, Kalhs P, Schaefer-Prokop C. Pulmonary infections in the late period after allogeneic bone marrow transplantation: chest radiography versus computed tomography. Eur J Radiol. 2005;53(3):489-494. Observational-Dx 61 patients 94 CXR and 94 CT examinations2 independent reviewers To retrospectively analyze the capabilities of CXR and CT in the evaluation of pulmonary infectious disease in the late period (>100 days) after allogeneic bone marrow transplantation. The correlation with the clinical course and/or BAL revealed a significantly higher sensitivity, NPV, and accuracy for CT than for CXR (89% vs 58%, P<0.0001; 78% vs 47%, P<0.0001; 90% vs 68%, P<0.0001, respectively). CT was significantly more diagnostic in BAL verified fungal and bacterial infections (P<0.05). CT is significantly superior to CXR in the evaluation of infectious pulmonary disease in the late phase after bone marrow transplantation. Therefore, an unremarkable CXR should be followed by a CT scan to reliably detect or to accurately exclude early pulmonary infection in these patients. 3
18. Heussel CP, Kauczor HU, Heussel G, Fischer B, Mildenberger P, Thelen M. Early detection of pneumonia in febrile neutropenic patients: use of thin-section CT. AJR Am J Roentgenol. 1997;169(5):1347-1353. Observational-Dx 87 patients underwent 146 prospective examinations To evaluate the usefulness of thin-section CT for early detection of pneumonia in neutropenic patients with an unknown site of infection and normal or nonspecific findings on CXR. Thin-section CT scans show findings suggestive of pneumonia about 5 days earlier than CXR show suggestive findings. When thin-section CT scans show findings suggestive of pneumonia, the probability of pneumonia being detected on CXRs during the 7-day follow-up is 31%, whereas the probability is only 5% when the findings on the prior thin-section CT scan were normal (P<.005). All neutropenic patients with fever of unknown origin and normal findings on CXRs should be examined with thin-section CT. 3
19. Brodoefel H, Vogel M, Spira D, et al. Herpes-Simplex-Virus 1 pneumonia in the immunocompromised host: high-resolution CT patterns in correlation to outcome and follow-up. Eur J Radiol. 2012;81(4):e415-420. Observational-Dx 25 immunocompromised patients To identify the high-resolution CT (HRCT) patterns of Herpes-Simplex-Virus 1 (HSV) pneumonia in immunocompromised patients and correlate findings to outcome and radiographic follow-up until death or complete resolution of findings. The most frequent CT abnormalities included ground-glass attenuation (n=18; 72%) in a bilateral, symmetric and random distribution, air-space consolidations (n=13; 52%) in a bilateral, asymmetric and peribronchial allocation and interlobular septal thickening (n=6; 24%). When classified by leading HRCT pattern, patients subdivided into distinct groups with either dominant ground-glass attenuation or air-space consolidation. Six patients died after a median 8 days of diagnosis; the median interval until complete radiographic remission of pathology was 20 days. Pre-dominance of air-space consolidations was associated with significant delay of improvement (p=0.023); however, patient outcome was comparable in both subgroups (p=0.9). 3
20. Chandler TM, Leipsic J, Nicolaou S, et al. Confirmed swine-origin influenza A(H1N1) viral pneumonia: computed tomographic findings in the immunocompetent and the immunocompromised. J Comput Assist Tomogr. 2011;35(5):602-607. Observational-Dx 23 patients To retrospectively evaluate the computed tomographic (CT) appearance of cases of swine-origin influenza A(H1N1) viral infection (S-OIV) in immunocompetent and immunocompromised patients confirmed with reverse transcription-polymerase chain reaction and to determine whether the timing of CT relative to the onset of symptoms affected the overall imaging appearance. The most common CT pattern in both groups of S-OIV patients was ground-glass opacities and consolidation (group 1, 86%; group 2, 71%) in a bilateral, subpleural, and peribronchovascular pattern. Small airways disease [corrected] was seen only in a minority of patients (group 1, 7%; group 2, 11%. Onset of symptoms to time of CT showed a mean duration of 9.7 days in group 1 and 6.7 days in group 2 and did not affect the overall imaging appearance. 4
21. Chong S, Kim TS, Cho EY. Herpes simplex virus pneumonia: high-resolution CT findings. Br J Radiol. 2010;83(991):585-589. Observational-Dx 5 patients To evaluate the high-resolution computed tomographic (HRCT) findings of five adult patients (either immunocompromised or immunocompetent) with herpes simplex virus (HSV) pneumonia. HRCT images of 5 patients (all male patients, age range 39-70 years; mean 62 years) with HSV pneumonia were assessed. The specific pathological findings that allowed for a definite diagnosis of HSV pneumonia included the presence of intranuclear inclusion bodies on haematoxylin and eosin staining, or positive immunohistochemical staining. High-resolution CT scans (HiSpeed Advantage or LightSpeed QX/i, GE Healthcare) using 1- or 1.25-mm collimation at 10-mm intervals without intravenous contrast medium injection were assessed, in particular for the presence and distribution of parenchymal abnormalities including ground-glass attenuation, airspace consolidation, nodules and interlobular septal thickening. In two patients, pathological specimens were obtained from open lung biopsy or bronchoscopic biopsy, and were correlated with HRCT findings. Three HRCT patterns of pulmonary abnormalities were identified in our series of HSV pneumonia: predominant areas of diffuse or multifocal ground-glass attenuation, predominant areas of multifocal peribronchial consolidations, and a mixed pattern of both. Histopathologically, areas of ground-glass attenuation seen on HRCT corresponded to diffuse alveolar damage in one patient who underwent open lung biopsy. No specific differences in HRCT findings were seen between the immunocompromised and the immunocompetent patients. In patients suspected of having an acute lower respiratory infection, whether immunocompromised or immunocompetent, a possibility of HSV pneumonia can be included in differential diagnoses when diffuse or multifocal areas of ground-glass attenuation and/or consolidations are seen on HRCT. 3
22. Jiang T, Xue F, Zheng X, et al. Clinical data and CT findings of pulmonary infection caused by different pathogens after kidney transplantation. Eur J Radiol. 2012;81(6):1347-1352. Observational-Dx 446 patients To review clinical data and CT findings of pulmonary infection caused by different pathogens after kidney transplantation in an attempt to help early clinical qualitative diagnosis. Pulmonary infection reached the peak in 3 months after transplantation. Bacterial infection and mixed infection were predominant between 1 and 6 months. And most tuberculosis occurred after one year. Bacterial (38.2%) and mixed infections (38.2%) were the common types. The next was fungal infection, tuberculosis and viral infection (10.1%, 7.9% and 5.6%, respectively). CT manifestations of pulmonary infections after kidney transplantation were diverse and complex, lacking characteristic signs. 3
23. Jung JI, Lee DG, Kim YJ, Yoon HK, Kim CC, Park SH. Pulmonary tuberculosis after hematopoietic stem cell transplantation: radiologic findings. J Thorac Imaging. 2009;24(1):10-16. Review/Other-Dx 10 patients To determine the radiologic features of pulmonary tuberculosis in hematopoietic stem cell transplant (HSCT) recipients. On chest radiography (n=10), the most common abnormalities were air-space consolidation (100%) and nodules (80%). Parenchymal lesions appeared mixed with other findings (80%). The most common mixed pattern was nodules with consolidations (80%). Parenchymal lesions were multilobar (80%), patchy (70%), or bilateral (80%). Evidence of a zonal predominance was not seen. On chest CT scans (n=7), the most common parenchymal lesions were consolidation (100%), nodules (71%), tree-in-bud appearance (43%), and ground-glass opacity (43%). Parenchymal lesions seen on CT scans also appeared mixed (86%) and multilobar in distribution (100%). Significant zonal predominance was not noted on CT scans. Cavity was noted in 14% of the study patients and lymphadenopathy was noted in 71% of these patients on CT scans. 4
24. Lee Y, Song JW, Chae EJ, et al. CT findings of pulmonary non-tuberculous mycobacterial infection in non-AIDS immunocompromised patients: a case-controlled comparison with immunocompetent patients. Br J Radiol. 2013;86(1024):20120209. Observational-Dx 369 patients To describe CT findings of non-tuberculous mycobacteria (NTM) pulmonary infection in non-AIDS immunocompromised patients (ICPs) and to compare these findings with those in immunocompetent patients. A total of 287 lobes were evaluated in ICPs and the control group. The ICPs showed a higher prevalence of ill-defined nodules, with cavities and large opacity >2 cm with/without cavity (p=0.03, 0.04 and 0.02, respectively). Regardless of the immune status, the most common CT findings were bronchiectasis and ill-defined nodules without cavity. 3
25. Marom EM, Holmes AM, Bruzzi JF, Truong MT, O'Sullivan PJ, Kontoyiannis DP. Imaging of pulmonary fusariosis in patients with hematologic malignancies. AJR Am J Roentgenol. 2008;190(6):1605-1609. Observational-Dx 20 patients To assess the radiographic features of pulmonary fusariosis, an increasingly encountered cause of severe opportunistic mold pneumonia. Pulmonary fusariosis has radiographic manifestations that are suggestive of an angioinvasive mold. Nodules or masses were the most common findings at CT, seen in 82% of patients compared with only 45% on chest radiography. The halo sign was not seen. Chest radiographs showed nonspecific findings in 30% of patients, and findings were normal at presentation in 25%. All of the patients had underlying hematologic malignancies. Thirteen of the 20 patients studied (65%) died within 1 month of diagnosis of pulmonary fusariosis. Because early initiation of intense antifungal therapy offers the best chance for survival in pulmonary fusariosis, early CT and appropriate microbiologic investigation should be obtained in severely immunocompromised patients. 3
26. Qin J, Fang Y, Dong Y, et al. Radiological and clinical findings of 25 patients with invasive pulmonary aspergillosis: retrospective analysis of 2150 liver transplantation cases. Br J Radiol. 2012;85(1016):e429-435. Observational-Dx 25 patients To evaluate the radiological and clinical findings of invasive pulmonary aspergillosis (IPA) after liver transplantation. 3 main radiological findings were identified: nodules, 64% (16/25); masses, 36% (9/25); and consolidations in a patchy pattern, 20% (5/25). A tree-in-bud pattern was found in 12% (3/25) of patients. In 8 (32%) of 25 patients, we found a combination of 2 or more of these signs: 5 (20%) patients presented with concurrent nodules accompanied by patchy consolidations and/or tree-in-bud, and 3 (12%) patients showed masses accompanied by large consolidations. A halo sign was observed in 20 (80%) of 25 patients. Hypodense sign and cavitary lesions were encountered in 17 (68%) of 25 patients. Follow-up radiological findings after treatment showed improvement in 18 patients, no change in 4 patients and progression in 3 patients. There were three aspergillosis-associated deaths during the follow-up period. The onset time of IPA was a median of 31 days after transplantation. The most common symptom at diagnosis was fever (n=15). None of the 25 patients had leukopaenia at the time of the diagnosis of IPA. 3
27. Vogel MN, Vatlach M, Weissgerber P, et al. HRCT-features of Pneumocystis jiroveci pneumonia and their evolution before and after treatment in non-HIV immunocompromised patients. Eur J Radiol. 2012;81(6):1315-1320. Observational-Dx 84 consecutive HIV-negative PJP patients To analyze the characteristics and kinetics of pulmonary changes in Pneumocystis jiroveci pneumonia (PJP) before and after treatment as depicted by thin-section-CT in HIV-negative patients. Imaging findings at initial diagnosis differed from those in the posttherapeutic setting. In the acute (initial) PJP-phase, most frequent finding was symmetric, apically distributed ground glass opacities (GGO) with peripheral sparing 43% (n = 36). These initial changes resolved up to 1st follow-up-examination in 57% (n = 48), and finally in all except for two patients after a median period of 13 (mean 26, range 1-58) days following application of specific therapy. In 42% (n = 35) architectural distortions occurred, but they resolved after a median period of 27 (mean 60, range 11-302) days. Only in 9 patients, complete resolution could not be documented. Significant correlations of the underlying disease or the time span between the onset of symptoms and specific antibiotic therapy and morphologic kinetic could not be found. 3
28. Kisembo HN, Boon SD, Davis JL, et al. Chest radiographic findings of pulmonary tuberculosis in severely immunocompromised patients with the human immunodeficiency virus. Br J Radiol. 2012;85(1014):e130-139. Observational-Dx 403 patients To describe chest radiograph (CXR) findings in a population with a high prevalence of human immunodeficiency virus (HIV) and tuberculosis (TB) in order to identify radiological features associated with TB; to compare CXR features between HIV-seronegative and HIV-seropositive patients with TB; and to correlate CXR findings with CD4 T-cell count. Smear or culture-positive TB was diagnosed in 214 of 403 (53%) patients. Median CD4+ T-cell count was 50 cells mm(-3) [interquartile range (IQR) 14-150]. TB patients were less likely than non-TB patients to have a normal CXR (12% vs 20%, p = 0.04), and more likely than non-TB patients to have a diffuse pattern of opacities (75% vs 60%, p = 0.003), reticulonodular opacities (45% vs 12%, p < 0.001), nodules (14% vs 6%, p = 0.008) or cavities (18% vs 7%, p = 0.001). HIV-seronegative TB patients more often had consolidation (70% vs 42%, p = 0.007) and cavities (48% vs 13%, p < 0.001) than HIV-seropositive TB patients. TB patients with a CD4+ T-cell count of 3
29. Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection. AJR Am J Roentgenol. 2012;198(6):W555-561. Review/Other-Dx N/A To review the spectrum of high-resolution CT findings of Pneumocystis jiroveci pneumonia in immunocompromised patients with and without HIV infection. Pneumocystis jiroveci pneumonia is a common opportunistic infection affecting immunosuppressed patients. High-resolution CT may be indicated for evaluation of immunosuppressed patients with suspected pneumonia and normal chest radiographic findings. The most common high-resolution CT finding of Pneumocystis jiroveci pneumonia is diffuse ground-glass opacity. Consolidation, nodules, cysts, and spontaneous pneumothorax also can develop. 4
30. Castaner E, Gallardo X, Mata JM, Esteba L. Radiologic approach to the diagnosis of infectious pulmonary diseases in patients infected with the human immunodeficiency virus. Eur J Radiol. 2004;51(2):114-129. Review/Other-Dx N/A Review radiologic approach to the diagnosis of infectious pulmonary diseases in HIV patients. CT has improved radiologic diagnosis. Greatest value of CT is in excluding lung disease when the radiographic findings are equivocal and in confirming the presence of clinically suspected disease when the radiograph is normal. 4
31. Roy M, Ellis S. Radiological diagnosis and follow-up of pulmonary tuberculosis. Postgrad Med J. 2010;86(1021):663-674. Review/Other-Dx N/A To review radiological diagnosis and follow-up of pulmonary tuberculosis. Approximately 1 in 10 people with primary pulmonary tuberculosis (PTB) present clinically; of untreated cases, approximately 1 in 10 reactivate usually at a time of relative immunodeficiency. The spectrum of radiologic manifestations of PTB can pose a variety of diagnostic and management challenges. PTB infection often leaves long term sequelae of infection, particularly granulomatous nodules, cavitation, and fibrosis; distinguishing dormant disease from reactivation is not always clear-cut. The radiologic presentation of primary PTB infection tends to differ from that of post-primary PTB, but there is significant overlap in the appearances. Primary PTB typically presents with consolidation and regional lymphadenopathy, whereas post-primary PTB more often results in cavitation. The pathology and therefore the radiology of TB infection will be altered based on the efficacy of the immune response and will therefore vary depending on the immune competency. Clinically, in the presence of infection, the main questions are whether M tuberculosis is the infecting organism and, if treated, does the radiology indicate response to treatment. In order to interpret the radiology of TB one needs to be aware of the spectrum of presentation, the expected reaction to treatment, and the myriad of non-pulmonary sites of infection that may prove to be more clinically significant than the pulmonary infection. 4
32. Aderaye G, Bruchfeld J, Assefa G, et al. The relationship between disease pattern and disease burden by chest radiography, M. tuberculosis Load, and HIV status in patients with pulmonary tuberculosis in Addis Ababa. Infection. 2004;32(6):333-338. Observational-Dx 168 patients To evaluate impact of HIV infection on CXR pattern and extent of disease in patients with pulmonary tuberculosis. HIV+ patients had lower colony count of M. tuberculosis than HIV negative patients. 3
33. Fujii T, Nakamura T, Iwamoto A. Pneumocystis pneumonia in patients with HIV infection: clinical manifestations, laboratory findings, and radiological features. J Infect Chemother. 2007;13(1):1-7. Review/Other-Dx 34 episodes in 32 patients To describe the clinical and radiographic features of acute respiratory illness due to pneumocystis infection in patients with HIV. Fever, cough, and dyspnea were the most common presenting symptoms. The most common radiographic presentations were ground glass opacities sparing the lung periphery (41%), ground glass with a mosaic pattern of attenuation (29%), homogenous ground glass, and ground glass with consolidation (21%), with cysts (21%), with linear opacities (18%), with nodules (9%), or with cavities (6%). 4
34. Hidalgo A, Falco V, Mauleon S, et al. Accuracy of high-resolution CT in distinguishing between Pneumocystis carinii pneumonia and non- Pneumocystis carinii pneumonia in AIDS patients. Eur Radiol. 2003;13(5):1179-1184. Observational-Dx 30 patients To prospectively evaluate the utility of HRCT in differentiating PCP from non-PCP in AIDS patients at high risk for PCP. The sensitivity, specificity, positive predictive value and negative predictive value of high-resolution computed tomography (HRCT) for the diagnosis of PCP was 100, 83.3, 90.5 and 100%, respectively. Pneumocystis carinii pneumonia was not demonstrated in any of the cases classified as "examination not suggestive of PCP". Significant small airway disease was not observed in any of the PCP cases. HRCT is a reliable method for differentiating PCP from other infectious processes in HIV positive patients. 2
35. Palestro CJ, Brown ML, Forstrom LA, et al. Society of Nuclear Medicine Procedure Guideline for Gallium Scintigraphy in Inflammation Version 3.0, approved June 2, 2004. 2004; Accessed April 16, 2014. Review/Other-Dx N/A Purpose of guideline is to assist nuclear medicine practitioners in recommending, performing, interpreting, and reporting the results of 67 gallium inflammation scintigraphy. No results stated. 4
36. Barron TF, Birnbaum NS, Shane LB, Goldsmith SJ, Rosen MJ. Pneumocystis carinii pneumonia studied by gallium-67 scanning. Radiology. 1985;154(3):791-793. Observational-Dx 34 patients To evaluate reliability and validity of Ga-67 lung scans for diagnosis of PCP in AIDS patients. Ga-67 had a sensitivity and specificity of 94% and 74%, respectively. Recommended in the diagnosis of PCP in AIDS patients with respiratory symptoms when CXR is normal or equivocal. 3
37. Leach RM, Davidson AC, O'Doherty MJ, Nayagam M, Tang A, Bateman NT. Non-invasive management of fever and breathlessness in HIV positive patients. Eur Respir J. 1991;4(1):19-25. Review/Other-Dx 72 patients (36 with PCP) Prospective study to determine usefulness of non-invasive tests (including CXR) in HIV+ patients with fever and dyspnea. Diethylenetriamine penta acetate lung scan and induced sputum, in combination, detected all cases of PCP. 4
38. Brook O, Guralnik L, Hardak E, et al. Radiological findings of early invasive pulmonary aspergillosis in immune-compromised patients. Hematol Oncol. 2009;27(2):102-106. Observational-Dx 144 patients To describe the radiological features of early stages of IPA. Chest computerized tomography (CT) films of 22 consecutive immune-compromised patients with IPA diagnosed with the aid of ASP PCR testing from BAL fluid were characterized and compared to that of 18 similar patients diagnosed with traditional bacteriological methods and to data from the literature. It was found that patients diagnosed with the aid of ASP PCR testing tended to have focal disease as manifested by more 11-30 mm nodules with halo (68% vs. 33%, p = 0.04), more focal ground glass (single area 32% vs. 6%, p = 0.05, patchy 32% vs. 0%, p = 0.01) and less diffuse ground glass (0% vs. 22%, p = 0.03), less cavitations (5% vs. 28%, p = 0.05) and less consolidations (segmental 14% vs. 50%, p = 0.02 and diffuse 14% vs. 67%, p = 0.001). 2
39. Franquet T, Gimenez A, Hidalgo A. Imaging of opportunistic fungal infections in immunocompromised patient. Eur J Radiol. 2004;51(2):130-138. Review/Other-Dx N/A To assess CXR and CT imaging features of different opportunistic fungal infections in immunocompromised patients. Radiographic appearances of the opportunistic fungal infections in immunocompromised patients overlap significantly. The relatively low diagnostic accuracy of CXR can be improved through familiarity with the clinical settings in which specific infections are likely to occur. CT is helpful in the characterization of parenchymal lung diseases in immunocompromised patients but is of limited value in making a specific diagnosis. Recognition of the various radiologic manifestations of fungal infection in conjunction with patient’s immunologic status is vital for narrowing the differential diagnosis. 4
40. Qin J, Xu J, Dong Y, et al. High-resolution CT findings of pulmonary infections after orthotopic liver transplantation in 453 patients. Br J Radiol. 2012;85(1019):e959-965. Observational-Dx 453 patients To review the high-resolution CT (HRCT) findings in patients with pulmonary infection after orthotopic liver transplantation (OLT) and to determine distinguishing findings among the various types of infection. Bacterial and viral pneumonia made up the bulk of infections (63.4% and 29.4%, respectively), followed by fungal infiltrates (24.5%). Large nodules were most common in patients with fungal pneumonia, having been seen in 38 (54%) of the 70 patients with fungal pneumonia, 22 (10%) of 220 with bacterial pneumonia (p=0.0059) and 6 (8%) of 78 with viral pneumonia (p=0.0011). The halo sign was also more frequent in patients with fungal pneumonia, having been seen in 38 (54%) of the 70 patients with fungal pneumonia, 17 (8%) of 220 with bacterial pneumonia (p=0.0026) and 7 (9%) of 78 with viral pneumonia (p=0.0015). There was no statistically significant difference in the prevalence of the other HRCT patterns including air-space consolidation, ground-glass attenuation and small nodules among bacterial, viral and fungal infections (all p>0.05). 4
41. Althoff Souza C, Muller NL, Marchiori E, Escuissato DL, Franquet T. Pulmonary invasive aspergillosis and candidiasis in immunocompromised patients: a comparative study of the high-resolution CT findings. J Thorac Imaging. 2006;21(3):184-189. Observational-Dx 54 total patients Aspergillus (n=32) or Candida (n=22) pulmonary infection Retrospective study to compare the HRCT findings of pulmonary invasive aspergillosis and candidiasis in immunocompromised patients. Nodules were the most common finding, present in 84% (27/32) of patients with aspergillosis and 95% (21/22) of patients with candidiasis (P>0.3, Fisher exact test). Centrilobular nodules were more common in patients with aspergillosis (26/27, 96%) than in those with candidiasis (11/21, 52%) (P<0.001) and random nodules more common in candidiasis (10/21, 48%) than in aspergillosis (1/27, 4%) (P<0.001). Presence of the CT halo sign, cavitation, and ground-glass opacities was similar in both groups. Pulmonary aspergillosis and candidiasis in immunocompromised patients manifest with similar HRCT findings. Centrilobular nodules and consolidation are more common in aspergillosis. The presence of halo sign or cavitation is not helpful in the differential diagnosis. 3
42. Carrafiello G, Lagana D, Nosari AM, et al. Utility of computed tomography (CT) and of fine needle aspiration biopsy (FNAB) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients. Radiol Med (Torino). 111(1):33-41, 2006 Feb. Observational-Dx 18 patients To evaluate the sensitivity of percutaneous CT-guided lung biopsy in the early diagnosis of fungal pulmonary infections. The sensitivity of percutaneous CT-guided biopsy was 80% and its PPV was 100%. Percutaneous CT-guided lung biopsy is an easy, safe and reliable procedure to obtain diagnostic material. Histological discrimination between Aspergillus and Mucor is important in order to plan the correct therapeutic protocols, as Mucor is usually resistant to azoles. 3
43. Franquet T, Muller NL, Gimenez A, Martinez S, Madrid M, Domingo P. Infectious pulmonary nodules in immunocompromised patients: usefulness of computed tomography in predicting their etiology. J Comput Assist Tomogr. 2003;27(4):461-468. Observational-Dx 78 patients, 2 independent reviewers To retrospectively review the HRCT findings in immunocompromised patients who had nodular opacities and a proven diagnosis to determine whether the various infectious pulmonary nodules have distinguishing features on CT. The infectious causes included mycobacteria (n = 24), fungi (n = 22), bacteria (n = 20), and viruses (n = 12). Multivariate analysis demonstrated that a diameter <10 mm was the only independent predictor of etiology (P<0.0001) and that patients whose nodules all measured <10 mm in diameter were most likely to have a viral infection. Nodules limited in size to <10 mm in diameter were seen in 83% of viral infections compared with 5% of bacterial infections (OR = 95.0; 95% CI: 6.08-4,321.5, P<0.0001), 0% of mycobacterial infections (OR = 91.7; 95% CI: 7.21-4,090.22, P<0.0001), and 14% of fungal infections (OR = 31.67; 95% CI: 3.56-375.09, P=0.0003). Although some overlap exists, nodule size is helpful in the differential diagnosis of infectious causes of nodules in immunocompromised patients. Patients whose nodules are all <10 mm in diameter are most likely to have a viral infection. 4
44. Franquet T, Lee KS, Muller NL. Thin-section CT findings in 32 immunocompromised patients with cytomegalovirus pneumonia who do not have AIDS. AJR Am J Roentgenol. 2003;181(4):1059-1063. Review/Other-Dx 32 patients, 2 reviewers To retrospectively review the thin-section CT findings in immunocompromised patients without AIDS who had proven CMV pneumonia. Causes of immunocompromised included; bone marrow (n = 25) or solid organ transplantation (n = 5) and corticosteroid therapy (n = 2). Bilateral abnormalities were seen in all patients. Areas of ground-glass opacification were seen in 21 (66%) of 32 patients. Ground-glass opacification was the predominant CT feature in nine cases (28%). In 19/32 patients, ground-glass attenuation was associated with other abnormalities. Multiple nodules were identified in 19 patients (59%). Nodules were bilateral in 15 patients and unilateral in 4 patients. Nodules were the only CT finding in 3 patients (9%). Areas of air-space consolidation were identified in 19 patients (59%). Air-space consolidation was the only CT finding in one patient (3%). Other less common CT findings included thickening of the bronchovascular bundles (n = 7) and the tree-in-bud appearance (n = 4). Pleural effusions were seen in 7 patients. The thin-section CT manifestations of CMV pulmonary infection usually consist of a mixture of patterns, most commonly ground-glass attenuation, areas of consolidation, and small nodules. 4
45. Egli A, Bucher C, Dumoulin A, et al. Human metapneumovirus infection after allogeneic hematopoietic stem cell transplantation. Infection. 2012;40(6):677-684. Observational-Tx 8 patients To describe the clinical course in eight HSCT recipients suffering from hMPV infection. Eight patients with hMPV-associated LRTI were identified from 93 BAL samples. Three of the eight patients had co-infections with other pathogens. The median age of the patients was 45 years [interquartile range (IQR) 36.8-53.5], the median time posttransplant was 473 days (IQR 251-1,165), 5/8 patients had chronic graft-versus-host disease (cGvHD), and 6/8 patients received immunosuppression. Chest computed tomography (CT) scanning showed a ground-glass pattern in 7/8 patients. Seven of eight patients required hospitalization due to severe symptoms and hypoxemia. All were treated with intravenous immunoglobulin (IVIG), which was combined with oral ribavirin in six patients. The mortality rate was 12.5 % (1/8). 2
46. Syha R, Beck R, Hetzel J, et al. Human metapneumovirus (HMPV) associated pulmonary infections in immunocompromised adults--initial CT findings, disease course and comparison to respiratory-syncytial-virus (RSV) induced pulmonary infections. Eur J Radiol. 2012;81(12):4173-4178. Observational-Dx 10 patients To describe computed tomography (CT)-imaging findings in human metapneumovirus (HMPV)-related pulmonary infection as well as their temporal course and to analyze resemblances/differences to pulmonary infection induced by the closely related respiratory-syncytial-virus (RSV) in immunocompromised patients. In HMPV, 8/10 patients showed asymmetric pulmonary findings, whereas 13/13 patients with RSV-pneumonia presented more symmetrical bilateral pulmonary infiltrates. Image analysis yielded in HMPV patients following results: ground-glass-opacity (GGO) (n=6), parenchymal airspace consolidations (n=5), ill-defined nodular-like centrilobular opacities (n=9), bronchial wall thickening (n=8). In comparison, results in RSV patients were: GGO (n=10), parenchymal airspace consolidations (n=9), ill-defined nodular-like centrilobular opacities (n=10), bronchial wall thickening (n=4). In the course of the disease, signs of acute HMPV interstitial pneumonia regressed transforming temporarily in part into findings compatible with bronchitis/bronchiolitis. 4
47. Shi JM, Cai Z, Huang H, et al. Role of CT-guided percutaneous lung biopsy in diagnosis of pulmonary fungal infection in patients with hematologic diseases. Int J Hematol. 2009;89(5):624-627. Review/Other-Dx 16 patients To evaluate the efficiency and safety of CT-guided percutaneous lung biopsy for the diagnosis of pulmonary fungal infection in patients with hematologic disease. Of the 16 patients, 10 were diagnosed fungal infection (8 aspergillus, 2 mold fungus), 4 chronic organizing pneumonitis, 1 tuberculosis, and 1 Pneumocystis carinii through histological examination after percutaneous lung biopsy. However, the results of blood culture and sputum culture were negative. CT-guided biopsy showed 100% overall accuracy and 62.5% (10/16) fungal infection rate. The biopsy-induced complications encountered were pneumothorax in 3/16 (18.75%) and hemoptysis in 1/16 (6.25%). No serious complication was found in this series. CT-guided percutaneous lung biopsy is an effective and safe method for the diagnosis of pulmonary fungal infection in patients with hematologic diseases. 4
48. Wallace AB, Suh RD. Percutaneous transthoracic needle biopsy: special considerations and techniques used in lung transplant recipients. Semin Intervent Radiol. 2004;21(4):247-258. Review/Other-Dx N/A To give an overview of transthoracic needle biopsy including its indications, the imaging modalities currently used for guidance and the special techniques utilized in performing the procedure and minimizing complications with an emphasis placed upon the special case of transthoracic needle biopsy performed in lung transplant recipients. Percutaneous transthoracic needle biopsy has become widely established in the diagnosis of focal pulmonary lesions, both infectious and neoplastic. Technical advances in imaging and guidance, needle design, and cytopathologic and histopathologic techniques continue to expand the applications of transthoracic needle biopsy and to reduce the incidence of experienced complications. Among patients more likely to require a lung biopsy eventually are lung transplant recipients, these patients also among the most likely to experience complications during and after the procedure. However, with the use of special techniques available to maximize diagnostic yield and minimize adverse effects, transthoracic needle biopsy may now be a viable option for lung transplant recipients, single or double. 4
49. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293(6):715-722. Observational-Tx 3220 consecutive patients To identify individuals with cancer with an increased thrombotic risk, evaluating different tumor sites, the presence of distant metastases, and carrier status of prothrombotic mutations. The overall risk of venous thrombosis was increased 7-fold in patients with a malignancy (odds ratio [OR], 6.7; 95% confidence interval [CI], 5.2-8.6) vs persons without malignancy. Patients with hematological malignancies had the highest risk of venous thrombosis, adjusted for age and sex (adjusted OR, 28.0; 95% CI, 4.0-199.7), followed by lung cancer and gastrointestinal cancer. The risk of venous thrombosis was highest in the first few months after the diagnosis of malignancy (adjusted OR, 53.5; 95% CI, 8.6-334.3). Patients with cancer with distant metastases had a higher risk vs patients without distant metastases (adjusted OR, 19.8; 95% CI, 2.6-149.1). Carriers of the factor V Leiden mutation who also had cancer had a 12-fold increased risk vs individuals without cancer and factor V Leiden (adjusted OR, 12.1; 95% CI, 1.6-88.1). Similar results were indirectly calculated for the prothrombin 20210A mutation in patients with cancer. 2
50. Mellot F, Scherrer A. [Imaging features of drug-induced lung diseases]. J Radiol. 2005;86(5 Pt 2):550-557. Review/Other-Dx N/A To review imaging features of drug induced lung diseases. Over 350 drugs are now recognized as being implicated in drug-induced lung diseases. Early diagnosis is critical. Discontinuing the drug may result in regression of the adverse effect. Diagnosis is based on a history of drug exposure with a temporal relationship between the introduction of the drug and the onset of symptoms, histologic evidence of lung damage and exclusion of other causes of lung injury. Unfortunately there is no specific test available. Histologic and radiologic findings are often non specific and diagnosis can be difficult. Drugs can cause a constellation of distinct patterns of respiratory involvement and all anatomic compartments of the lungs may be involved. The most common patterns are : non specific interstitial pneumonia and fibrosis, pulmonary eosinophilia, hypersensitivity pneumonitis, pulmonary edema with or without diffuse alveolar damage, bronchiolitis obliterans organizing pneumonia, pulmonary hemorrhage and vasculitis. It is important to be familiar with their common radiologic appearances. 4
51. Schwaiblmair M, Behr W, Haeckel T, Markl B, Foerg W, Berghaus T. Drug induced interstitial lung disease. Open Respir Med J. 2012;6:63-74. Review/Other-Dx N/A To review drug-induced interstitial lung disease(DILD). With an increasing number of therapeutic drugs, the list of drugs that is responsible for severe pulmonary disease also grows. Many drugs have been associated with pulmonary complications of various types, including interstitial inflammation and fibrosis, bronchospasm, pulmonary edema, and pleural effusions. Drug-induced interstitial lung disease (DILD) can be caused by chemotherapeutic agents, antibiotics, antiarrhythmic drugs, and immunosuppressive agents. There are no distinct physiologic, radiographic or pathologic patterns of DILD, and the diagnosis is usually made when a patient with interstitial lung disease (ILD) is exposed to a medication known to result in lung disease. Other causes of ILD must be excluded. Treatment is avoidance of further exposure and systemic corticosteroids in patients with progressive or disabling disease. 4
52. Stein PD, Woodard PK, Weg JG, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators. Radiology. 2007;242(1):15-21. Review/Other-Dx N/A Recommendations based on the PIOPED II trial on the diagnostic pathways in acute pulmonary embolism. PIOPED II investigators recommend stratification of all patients suspected of having pulmonary embolism according to an objective probability assessment. A negative D-dimer rapid ELISA result with a low or moderate probability clinical assessment can safely exclude pulmonary embolism. If pulmonary embolism is not excluded, CT angiography and venography is recommended by 77% of the PIOPED II investigators, although CT angiography alone is an option. In patients with discordant findings at clinical assessment and CT imaging, further evaluation depends on clinical judgment. In pregnant women, ventilation/perfusion scans are recommended by 69% of PIOPED II investigators as the first imaging test. 4
53. Winer-Muram HT, Rydberg J, Johnson MS, et al. Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction pulmonary arteriography. Radiology. 2004;233(3):806-815. Observational-Dx 93 patients, 3 independent readers To determine diagnostic accuracy of four-channel multi-detector CT in emergency room and inpatient populations suspected of having acute pulmonary embolism who prospectively underwent both CT and pulmonary arteriography. Pulmonary arteriography used as the reference standard. Two radiologists later reviewed false-positive CT studies. Sensitivity, specificity, and accuracy of CT were 100%, 89%, and 91%, respectively. Kappa values were 0.71 and 0.83 for CT and pulmonary arteriography, respectively, and were not significantly different between modalities. At pulmonary arteriography, 18 patients (19%) had pulmonary embolism at 50 vessel levels (five main and/or interlobar, 24 segmental, and 21 subsegmental), 17 (94%) of which had pulmonary embolism at multiple sites. At CT, 26 patients (28%) had pulmonary embolism at 71 vessel levels (24 main and/or interlobar, 33 segmental, and 14 subsegmental). Twenty patients (77%) had pulmonary embolism at multiple sites. Review of 8 false-positive CT studies showed an appearance highly suggestive of acute pulmonary embolism in three patients, chronic pulmonary embolism in one, and no pulmonary embolism in three; one study was inconclusive. CT better demonstrated large-level vessel involvement (P<.01), while pulmonary arteriography better demonstrated small-level vessel involvement (P<.01). MDCT has an accuracy of 91% in the depiction of suspected acute pulmonary embolism when conventional pulmonary arteriography is used as the reference standard. 1