[Pulmonary lymphangioleiomyomatosis. Radiologic aspects and the diagnostic role of computed tomography]

Lymphangioleiomyomatosis (LAM) is an uncommon disease affecting women of reproductive capacity. It is characterized by non-neoplastic proliferation of smooth muscle in the lungs and, occasionally, in lymph nodes and in the thoracic duct. The patients present with dyspnea, chylous pleural effusion, pnx, and hemoptysis. The authors evaluated 4 patients with biopsy-proven LAM, by means of CT. In all cases, CT revealed small well-defined cystic air spaces with smooth and thin walls, scattered in the lungs. CT was very useful because it was more sensitive and specific than conventional radiography. The CT appearance of LAM distinctly differed from that of other diseases than can produce cystic air spaces in the lungs, such as UIP, eosinophilic granuloma, centri-acinar emphysema, and bronchiectasis. Our experience confirms the clinical usefulness of CT in diagnosing LAM.

[Thoracic manifestations of AIDS (acquired immunodeficiency syndrome)]

AIDS (acquired immunodeficiency syndrome) seems to be related to human immunodeficiency virus (HIV) and is characterized by severe T-helpers lymphocyte dysfunction. Many of the AIDS patients (47-70%) develop pulmonary manifestations, both infectious and neoplastic, in the course of their disease. In the Department of Infectious Diseases of our Hospital are studied many patients HIV+. Every year 246 seropositive new patients have been discovered. Among them we have studied 25 subjects with respiratory disease, by chest radiographs; successively, according to clinical picture, we have performed thoracic computed tomography, Gallium scintigraphy, fiberoptic bronchoscopy with transbronchial biopsy (TBB), bronchoalveolar lavage (BAL); the majority of these patients (68%) had AIDS, only 28% had ARC and 4% had PGL. In our experience, the diagnosed diseases were mainly infections (92%), and most frequently (52%) due to Pneumocystis carinii, alone or in association with other etiologic agents. We have not found pathognomonic radiographic abnormalities, but chest X-ray evaluated with clinical and laboratory data, may often be useful to obtain diagnostic indications and in order to determine a more specific and aggressive diagnostic approach.

[Duplex Doppler study of the transplanted kidney]

The authors examined 34 renal transplant recipients with Duplex US, i.e. real-time sonography associated with pulsed Doppler, thus obtaining morphological and structural data about transplanted kidneys as well as hemodynamic information. Special emphasis was put on intrarenal vascular impedance and the relative resistive index, first mentioned by Rifkin in 1987. US diagnosis was compared with the results obtained at both biopsy and clinical follow-up. Only long-term renal transplants were considered; the patients were examined for a rise in serum creatinine level or for the onset of other signs/symptoms related to renal allografts. Our results confirm the utility of pulsed Doppler US in the diagnosis of renal transplant rejection, and allow reference values to be established for the resistive index. In agreement with literature data and assuming 0.9 as a resistive index value, Duplex-Doppler US specificity in diagnosing acute rejection was 100%, and sensitivity was 50%. However, the authors believed it more useful to assume 0.8 as a reference value for the resistive index, for it allows more renal transplant rejection episodes to be diagnosed, both acute and chronic, with an acceptable combination of specificity, sensitivity and predictive value. While the differential diagnosis of acute and chronic rejection is hardly ever possible with Duplex US alone, the combined use of Duplex US and real-time US makes it nearly always possible. As far as intrarenal impedance is concerned, our results seem to disagree with the scattered literature data on the subject, and to point towards its possible significant (though not extreme) increase also in case of chronic rejection.

[Pulmonary eosinophilic granuloma in adults. Case histories and a review of the literature]

Histiocytosis X is a disease of unknown origin which usually affects multiple organs, including the lung. The age of onset, the clinical course and the pattern of spread allow a distinction to be made between 3 varieties: Letterer-Siwe, Hand-Schüller-Christian and eosinophilic granuloma. The latter form, in adult patients, may predominantly or solely affect the lungs. The authors reviewed clinical, radiographic and CT findings of 7 adult patients with pulmonary eosinophilic granuloma, picked out of a series of 265 cases of interstitial lung pathology, diagnosed since 1973. Typical pulmonary involvement is bilateral, symmetrical and predominates in the upper areas. Honeycomb pattern was found in 1 patient at the onset of symptoms, and in 2 cases during the follow-up, without severe reduction in pulmonary volumes. Pneumothorax was observed in 3 cases and bone lesions in 2. CT added new and important informations such as presence, size and wall thickness of "cystic" lesions. New laboratory tests and bronchoalveolar lavage demonstrated minor diagnostic usefulness than radiological findings. The authors conclude by discussing such problems as prognostic factors and differential diagnosis.

[Exogenous lipid pneumonia. Clinico-radiologic characteristics]

Exogenous lipid pneumonia (ELP) is caused by the aspiration of animal, vegetal or, more often, mineral oils. Even though it may also be acute, ELP is most frequently a chronic disease, affecting people with predisposing factors, such as neuromuscular disorders, structural abnormalities and so on; very often exogenous lipid pneumonia is found in tracheotomized patients. The pathology of lipid pneumonia is a chronic inflammatory process evolving in foreign-body-like reaction, and eventually in "end-stage lung" condition. Clinically, most patients are asymptomatic; few cases only present with cough, dyspnea and chest pain. Eight cases of ELP, studied over the past 3 years, are described in this paper. All the patients were examined by chest radiographs and standard tomograms; 3 patients underwent CT. X-ray features were mono/bilateral consolidation of the lower zones, with air bronchogram and variable reduction in volume. CT density was not specific for fat tissue. In all cases the diagnosis was confirmed at biopsy. In 5 patients, followed for at least one year, clinical-radiological features showed no change. Thus, complications of ELP (especially malignant evolution) could be excluded. The authors conclude that lipid pneumonia must be considered in differential diagnosis of patients with history of usage of oils and compatible X-ray findings. The usefulness of an accurate follow-up is stressed.

[Pulmonary edema in renal insufficiency]

Forty-nine cases of pulmonary edema in nephropatic patients were studied. The most frequent radiologic findings are discussed. The unreliability of a precise differentiation between "cardiac" and "renal" patterns of pulmonary edema in nephropatic patients is emphasized.

[Transbronchial needle aspiration of mediastinal masses during fiber-bronchoscopy]

The authors present their own experience in the diagnosis of thoracic adenopathies and mediastinal masses by transbronchial needle aspiration (Wang needle). The diagnostic usefulness and safety of the method is stressed. Radiology plays an important role in choosing biopsy site (by CT), in monitoring the procedure by fluoroscopy and looking for complications following completion of the examination.

[Rounded atelectasis of the lung]

Rounded atelectasis is an uncommon but increasingly recognized form of pulmonary collapse that often mimics a pulmonary neoplasm. It is suggested that these lesions can occur many years after exposure to asbestos or exudative pleural effusions. The authors report 16 cases of rounded atelectasis seen during a period of over 10 years, 9 of which in the last 18 months. They describe the plain film, tomographic and CT appearances of the lesion. The radiographic features that allow a diagnosis are rounded or oval shadows lying along the posterior surface of the lower lobe, adjacent to thickened pleura. Lateral tomography and CT show the blood vessels and bronchi curving toward the mass and converging on one edge, like a comet tail. Differentiation of rounded atelectasis from neoplastic disease is essential in avoiding unnecessary thoracotomy.

[Echographic diagnosis of acute rejection of the transplanted kidney]

After a general review of the US findings in acute renal allograft rejection, the results are discussed of a retrospective sonographic-histologic study in 17 patients affected by acute rejection. The high sensitivity of sonography in detecting acute rejection is confirmed, but echographic studies were unable to differentiate between vascular and cellular sub-types of rejection and to provide a prognostic evaluation.

[Radiological evaluation of the state of hydration in uremic patients under periodic dialysis]

Seventy-four uremic patients in chronic hemodialysis were studied by X-ray of the thorax before and after the same dialysis. Radiological signs and variables (originally proposed by Milne) related to hemodynamics of pulmonary and systemic circulation were evaluated in relation to fluid subtraction. The study demonstrated the high sensitivity and the clinical value of thoracic radiography in the follow-up of these patients and particularly in the evaluation of fluid overload.

[Radiologic diagnosis in malignant pleural mesothelioma]

The authors summarize clinical findings and radiological aspects of pleural malignant mesothelioma. This tumor, previously uncommon, is now observed with increasing frequency in developed countries (pathogenetic relationship with asbestos fibers inhalation is proved). Common and uncommon findings are described and 8 new cases are presented. Differential diagnosis between malignant mesothelioma and other primary or secondary pleural tumors is difficult and always requires a confirmation by multiple biopsies and/or thoracotomy. The usefulness of CT study in the accurate staging of mesothelioma is particularly emphasized. In this field CT may completely replace the conventional tomography.

[Radiological technics in the study of the pleura and the chest wall]

Authors examine the most actual radiologic techniques for the investigation of pleura and chest wall. Advantages of decubitus views in the study of effusion are considered; diagnostic possibilities of echography and CT in the evaluation of abnormal findings in these regions are analyzed.

[Chests x-ray in status asthmaticus. Relations between radiological abnormalities and impaired respiratory function]

The chest radiographs of 78 adult asthmatic patients admitted with severe acute asthma over a three-years period were reviewed. Radiographic findings were compared with functional data. Overinflation was demonstrated in 32% of chest X-rays. In four patients the presence of atelectasis was shown. On admission only PaO2 was significantly lower in patients with radiological abnormalities than in patients with normal chest radiographs. The usefulness of chest radiographs in patients with acute asthma is discussed.

[Radiological diagnosis of pulmonary arterial hypertension in idiopathic pulmonary fibrosis]

This study evaluates the usefulness of chest x-ray in the diagnosis of pulmonary arterial hypertension. Twelve patients with severe interstitial fibrosis were studied by respiratory functional tests and right heart catheterization. A quantitative radiologic diagnosis of pulmonary arterial hypertension in pulmonary fibrosis results more difficult than in chronic obstructive airway disease, mitral stenosis or pulmonary thromboembolism. Nevertheless in case of severe interstitial fibrosis pulmonary hypertension was regularly present even if specific radiologic findings were not available. We have found some interesting correlations, i.e. a trend to a relationship between mean pulmonary pressure and right descending pulmonary artery diameter.

[Diagnosis of bronchiolo-alveolar carcinoma]

Clinical and radiographic findings in bronchiolo-alveolar carcinoma are presented, with particular emphasis on differential diagnosis between diffuse and localized forms. A series is presented of 18 patients, observed in our Istitutes since 1980. Diagnostic role of radiology and bioptic techniques is discussed and the leading importance of broncoscopic biopsy is stressed.

[The first stage of sarcoidosis: the actual diagnostic possibilities (author's transl)]

A correct staging of sarcoidosis is of the uppermost importance in the diagnosis and treatment of the disease. In the last few years new concepts have been stated: --radiological staging of sarcoidosis is particularly difficult --in no one phase the radiological pattern can be considered typical but sometimes it is highly suggestive for sarcoidosis --anatomical studies recently showed that sarcoid disease seems to begin with a non granulomatous interstitial pneumonia. Following this individual microscopic deposit may conglomerate to form the typical non caseating granulomas. In the lung the disease seems to procede from the interstitium to the lymphnodes. Usually, in the first stage, possible sarcoidosis is diagnosed by the radiologist, but a confident diagnosis needs a pathological confirmation. Transbronchial biopsy guided by fluoroscopy is the first diagnostic choice for obtaining confirmation of the disease and for determining the type and entity of parenchymal lesions.

[Colpocystographic study of female genital prolapse and urinary stress incontinence (author's transl)]

Colpocystography consists of a static and dynamic study of the opacified pelvic viscera (bladder, vagina, rectum) in lateral projection. This method is non traumatic and easy to perform. It is an useful diagnostic complement in the evaluation of bladder, uterine, rectal prolapse and urinary stress incontinence.