Presentation
Long standing cough. Recent worsening of shortness of breath.
Patient Data
There are widespread interstitial and parenchymal abnormalities throughout both lungs, consistent with fibrosis. Changes are axially diffuse, involving both the central and peripheral lung, with peribronchovascular involvement. The mid and lower zones are predominantly involved. There is relative sparing of the extreme costophrenic margins.
There is traction bronchiectasis, with regions of course and fine reticulation, and mosaic attenuation. On the expiratory phase, there is a three density sign, consistent with regions of air trapping, intervening normal lung and ground glass density.
Borderline enlarged mediastinal and hilar lymph nodes.
Case Discussion
This case demonstrates some of the typical features of fibrotic hypersensitivity pneumonitis (HP), although the imaging appearance can be somewhat variable. The presence of fibrotic changes such as coarse reticulations, traction bronchiectasis and honeycombing distinguish inflammatory from fibrotic HP. Diffuse axial distribution of changes and involvement of the central lung can be useful to help differentiate HP from other end-stage fibrotic lung diseases.
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