1. History : 52-year-old male presented with a left testicular mass. An initial chest radiograph was performed, followed by a CT. Question : What are the key findings on the CXR? Case of the Month 4 October 2015 Authors: S M Mak, SJ Copley

2. Case of the Month 4

4. What is your diagnosis ?

6.  Bibasal reticulonodular pattern  Volume loss Case of the Month 4

7.  Bilateral lower lobe distribution of  Reticulation  Volume loss  Ground- glass opacities  Honeycombing (minor)  With subpleural sparing

8. Case of the Month 4 The patient had several biopsies of his right lung.

9. Case of the Month 4  Histology of the lung parenchyma showed:  Abnormal architecture with widening of the alveolar septa, mild chronic inflammatory infiltrate and fibrosis.  Foci of fibroblastic proliferation, pneumocyte hyperplasia and bronchiolization.  No well-formed or poorly formed granulomata.

10. Case of the Month 4 Diagnosis What is your diagnosis ?

11. Case of the Month 4 Diagnosis Non-Specific Interstitial Pneumonitis

12. Case of the Month 4 Discussion  Non Specific Interstitial Pneumonitis (NSIP) is characterised by spatially and temporally uniform interstitial inflammation with varying degrees of fibrosis.  It typically affects patients aged 40-50 years old, without gender predilection.  Patients present with increasing dyspnoea.  Many cases are idiopathic, although there is a high association with collagen vascular disease. Other causes include drugs and occupational exposure.

13. Case of the Month 4 Discussion  It is important to distinguish NSIP from UIP or HP, (Hypersensitivity Pneumonitis) due to the differences in prognosis and treatment. NSIP has a better prognosis than UIP. (Only a small subset of patients will progress to end-stage fibrosis.)  Diagnosis can be difficult even with biopsy. There are often overlapping clinical, imaging and pathological features. A multidisciplinary approach is often necessary for diagnosis.

14. Case of the Month 4 Discussion CHEST RADIOGRAPHY  Bilateral lower zone reticulonodular pattern  Volume loss HIGH-RESOLUTION CT  Symmetrical lower lobe distribution  Reticular pattern  Ground-glass opacification  Lower lobe volume loss  Traction bronchiectasis  Minor honeycombing

15. Case of the Month 4 Further Reading NON-SPECIFIC INTERSTITIAL PNEUMONITIS 1) Travis et al. An Official American Thoracic Society/European Respiratory Society Statement: Update of the International Multidisciplinary Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med 2013; 733–748, Sep 15, 2013 2) Kilgerman et al. Nonspecific Interstitial Pneumonia: Radiologic, Clinical, and Pathologic Considerations. RadioGraphics 2009; 29:73–87 3) Mueller-Mang et al. What Every Radiologist Should Know about Idiopathic Interstitial Pneumonias. Radiographics 2007; 27:595– 615 4) Hansell et al. Fleischner Society: Glossary of Terms for Thoracic Imaging. Radiology: Volume 246: Number 3—March 2008