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The Egyptian Journal of Radiology and Nuclear Medicine

journal homepage: www.elsevier.com/locate/ejrnm

Original Article

Emphasizing the role of multi-detector computed tomography chest in theetiological diagnosis of pulmonary bronchiectasis

Youssriah Y. Sabria,⁎, Mona A.F. Hafeza, Hebata-Allah H.M. Assalb, Muna A.H. Al-Duraa

a Diagnostic and Intervention Radiology Department, Cairo University Medical School, Egyptb Pulmonology Department, Cairo University Medical School, Egypt

A R T I C L E I N F O

Keywords:MDCTChestBronchiectasis

A B S T R A C T

In this study we aimed to highlight the role of multi-slice computed tomography (MSCT) and high resolutioncomputed tomography (HRCT) of the chest in the detection of pulmonary bronchiectatic lesions and to displaythe approach used in determining the proper etiological diagnosis.Patients and methods: This study involved 62 patients; 36 females and 26 males, were referred to the radiologydepartment for MSCT of the chest from the pulmonary department in the period from October 2016 – April 2017.Results: Pulmonary bronchiectatic lesions were classified according to bronchiectasis distribution; with bilaterallesions were more common in 62.5% of patients, classification according to morphological type with the cy-lindrical bronchiectasis was the most common shape in 37.5% of case, classification according to bronchiectasisetiology, most of cases were post inflammatory in 42.2% of cases, followed by traction bronchiectasis in 34.4%of cases. Then the diagnostic approach to reach different etiologies was displayed.Conclusion: The role of MDCT imaging in diagnosis and evaluation of bronchiectasis is crucial.

1. Introduction

Bronchiectasis is a permanent irreversible dilatation of the airways[1]. Permanent architectural changes in the airways causing bronchialdilatation attributed to many etiologies mainly resulting from the re-current infection and inflammation [2].

Clinical diagnosis of bronchiectasis is based on a history of dailyviscid excessive sputum production, so it is frequently misdiagnosed asasthma or chronic obstructive pulmonary disease (COPD) due to thesimilarities in clinical findings [2].

It can cause potential morbidity secondary to recurrent infectionsand in severe cases, death could occur from massive hemoptysis [3].Characteristic computed tomography (CT) scan findings is the maindifferentiating factor [2].

Multi detector row computed tomography (MDCT) especially vo-lumetric high resolution computed tomography (HRCT) provides en-hanced quality of multi-planar reconstructed images in axial, coronaland sagittal planes with minimum intensity projection reconstructedimages as well, is the most sensitive imaging modality for the detectionand diagnosis of bronchiectasis [4]. HRCT findings in bronchiectasisinclude bronchial wall thickening with dilatation of the bronchi to adiameter greater than that of the accompanying artery (the signet-ring

sign); lack of normal tapering of bronchi; and visualization of airway inthe outer 1–2 cm of the lung [2].

Bronchiectasis can result from a variety of pathological conditions.Both congenital and acquired conditions can cause bronchiectasis.Acquired causes are more common, such as infection, pulmonary fi-brosis, recurrent or chronic aspiration, stenosis or obstruction of air-ways by neoplasm, granulomatous disease, broncholithiasis, andasthma. Congenital conditions that cause bronchiactasis include, cysticfibrosis, and cartilage development disorders [5,6]. Bronchiectasiscould be a part of numerous multi-systemic diseases, such as cystic fi-brosis (CF), immunodeficiencies, alpha 1-antitrypsin deficiency, pri-mary ciliary dyskinesia (PCD), rheumatoid arthritis and inflammatorybowel diseases, especially ulcerative colitis [2].

It is beneficial to identify the cause as it aids in management deci-sion, reduce the exacerbations and alter the course of the disease bypreserving lung function [2].

In this study, we aimed to confirm the role of multi-slice computedtomography (MSCT) of the chest in the detection of pulmonarybronchiectatic lesions and to discuss the appropriate approach to itsmost possible etiology.

https://doi.org/10.1016/j.ejrnm.2018.05.004Received 11 February 2018; Accepted 15 May 2018

Peer review under responsibility of The Egyptian Society of Radiology and Nuclear Medicine.⁎ Corresponding author at: Kasr Alainy Hospital at Kasralainy Street, Radiology Department, Egypt.E-mail address: chestradiologydepartment@gmail.com (Y.Y. Sabri).

The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651

Available online 19 May 20180378-603X/ © 2018 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

T

2. Patients and methods

This cross-sectional study included 64 patients; 36 females and 28males, age range 7–74 years (average of 47.2 years). All patients pre-sented with productive cough and dyspnea and were all referred from

the pulmonary to the radiology department in Kasr Alainy hospital forMSCT of the chest in the period from October 2016 – April 2017.

Inclusion criteria: Cases with bronchiectasis in MSCT chest wereincluded in this study.

Exclusion criteria: Cases with CT contraindications as pregnancy.Patients were subjected to:

(2.1) Thorough clinical examination with history taking, general andchest examination.

(2.2) Relevant laboratory tests were considered according to the casee.g., tuberculin test, analysis test of sputum.

(2.3) Pulmonary function test was done in 20 cases suspected of havingchronic lung diseases (chronic diffuse interstitial lung disease(CDILD) or chronic obstructive pulmonary disease (COPD).

(2.4) MSCT chest was done to all patients using 16 channels MSCT inKasr Al –Ainy.

• Assessment of CT chest: Bronchiectasis was evaluated for thefollowing:

(1) Distribution:– Diffuse or Focal.– Laterality: right lung, left lung or bilateral.– Lobar: RT upper, middle or lower.

LT upper and lingual or lower.(2) Types of bronchiectasis: signet ring, cystic, cylindrical or varicoid.(3) Bronchial wall thickening.(4) Auxiliary findings.(5) According to these CT findings together with clinical data and

laboratory results the etiologies of bronchiectasis were con-sidered.

(2.5) Histo-pathological assessment was needed in two cases with CTsuggesting bronchogenic carcinoma.

3. Results

This study involved 64 patients with bronchiectasis detected in theirMSCT of the chest.

In our study female were more commonly affected with bronch-iectasis, 56.25% (N.= 36 cases), however male cases were 43.75%(N.= 28 cases). 54.7% of our patients were in the 5th and 6th decades.

In this study, bilateral lung affection in 62.5% of cases (N.= 40)was more prevalent than unilateral affection in 37.5% of cases(N.= 24), as 26.5% (N.= 17) cases had only right sided affection, and11% (N.= 7) cases had left sided affection.

See Table 1 for the number and percentages of patient's lobar dis-tribution of pulmonary bronchiectasis.

Signet ring sign was the most common finding of bronchiectasisfound in 35.9% (N.= 12 cases), followed by the cylindrical type ofpulmonary bronchiectasis was most common morphological type ofbronchiectasis in 37.5% of cases (N.= 9), see Table 2.

Post-inflammatory etiology was most encountered in our study in42.2% (N.= 27) followed by traction bronchiectasis 34.4% (N.= 22)see Tables 3 and 4.

Table 1Number and percentages of lobar distribution of the right, left and bilateral lung bronchiectasis in a single lobe, multiple lobes and diffuse bronchiectasis.

Lobar affection Right lung only Number (N.) and Percentage/17cases

Left lung only Number (N.) and Percentage/7cases

Bilateral Number (N.) and Percentage/40cases

Upper lobe 5 (29.4%) 4 (57.1%) 8 (20%)Middle lobe/lingula 2 (11.7%) 1(14.2%) 2 (5%)Lower lobe 8 (47%) 2 (28.5%) 12 (30%)Diffuse 1 (5.8%) 9 (22.5%)Middle and lower lobes 1 (5.8%) 3 (7.5%)Upper and mid zonea 1 (2.5%)Upper and lower lobes 5 (12.5%)

a Mid zone: middle lobe and lingual.

Table 2The frequency of different morphological types and other CT pictures ofbronchiectasis.

Morphological types Number (percentages)

Signet ring 12 (18.75%)Cystic 8 (12.5%)Cylindrical 14 (21.9%)Varicose 1 (1.6%)Honey combing 4 (6.25%)Bronchocele 3 (4.7%)Signet ring and cystic 4 (6.25%)Cylindrical and varicose 3 (4.7%)Signet ring, cystic and cylindrical 3 (4.7%)Signet ring and varicose 1 (1.6%)Cystic and varicose 4 (6.25%)Signet ring, cystic, cylindrical and varicose 2 (3.1%)Varicose and bronchocele 1 (1.6%)Signet ring and cylindrical 1 (1.6%)Cystic and bronchocele 2 (3.1%)Cystic, cylindrical and bronchocele 1 (1.6%)Bronchial wall thickening 31 (48.4%)

Table 3Number of cases in different causes of bronchiectasis met during the studyperiod.

Etiologies Number andpercentage

Acquired Post inflammatory 27 (42.2%)

Tractionbronchiectasis

Post granulomatous 15 (23.4%)Atypical mycobacterialinfection

2 (3.1%)

UIPa 3 (4.7%)Sarcoidosis 2 (3.1%)

COPDb 2 (3.1%)Aspiration 2 (3.1%)Central bronchogenic carcinoma (provenNSCLCc)

2 (3.1%)

Broncholith 1 (1.6%)ABPAd 1 (1.6%)

Congenital Cystic fibrosis 3 (4.7%)Tracheobronchomegally 2 (3.1%)Bronchial atresia and bronchocele 1 (1.6%)Kartagner Syndrome 1 (1.6%)

a UIP: usual interstitial pneumonia.b COPD: chronic obstructive lung disease.c NSCLC: non-small cell lung cancer.d ABPA: allergic bronchopulmonary aspergillosis.

Y.Y. Sabri et al. The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651

646

Table4

Thediag

nostic

approa

chto

reachdifferen

tetiologies

ofbron

chiectasis.

Loba

rdistribu

tion

/Num

ber

ofcases

Bron

chiectasis

shap

eBron

chialwall

thicke

ning

Aux

iliaryCTfind

ings

Age

grou

pClin

ical

complaint

Diagn

osis

Other

confi

rmatory

inve

stigation

Foca

l(lob

ar/seg

men

tal)

Cystic,

bron

choc

ele

Absen

tDistalairtrap

ping

You

ngIncide

ntal/recurrent

infection

Bro

nchial

atresiaan

dbr

onch

ocele

Bron

chosco

peco

nfirm

ation

Tubu

larwithcalcified

endo

bron

chialno

dule

Absen

tBilateralap

ical

scarring

,cav

itary

lesion

sMiddle

Night

feve

ran

dnigh

tsw

eat

Bro

ncho

lith

Labo

ratory

(tub

ercu

lintest)

Tubu

lar,

varico

idwith

prox

imal

masslesion

Presen

tor

absent

Pulm

onaryno

dulesan

dhilar

lymph

aden

opathy

Middle

Che

stpa

in,h

emop

tysis.

Cen

tral

bron

chog

enic

carcinom

aBron

chosco

pyan

dhistop

atho

logical

assessmen

tBilateral/U

La

pred

ominan

ce,diffus

elate

Any

shap

ewithmuc

ous

plug

ging

Presen

tCellularbron

chiolitis,a

irtrap

ping

You

ngChron

icco

ugh,

expe

ctoration,

recu

rren

tinfection.

History

ofPa

ncreatic

disease.

CFb

Labo

ratory

sweatch

loride

test

Bilateral/U

La

pred

ominan

ceCen

tral

Tubu

lar,

varico

idwith

muc

ousplug

ging

(fing

erin

glov

e),h

ighde

nseco

nten

ts

Absen

tMigratory

areasof

consolidation,

atelectasis,

grou

nd-glass

opacities,

mosaicattenu

ation,

andsm

allairw

aydisease.

Middle

Recurrent

asthma,

low

grad

efeve

ran

dprod

uctive

coug

h.ABPA

cLa

boratory

hype

rsen

sitivity

test

Bilateral/u

pper

lobe

pred

ominan

ceAsy

mmetric

Any

shap

ePresen

tor

absent

Volum

eloss,s

urroun

ding

scarring

,cavitation

,calcified

gran

ulom

aor

hilar

lymph

node

s.

Middle,

old

Night

feve

r,nigh

tsw

eat

Post

myc

obac

terial

infection

Labo

ratory

tube

rculin

test

Bilateral/m

iddlean

dling

ual

Any

morecylin

drical

Presen

tSu

rrou

ndingsm

allairw

aydisease,

scarring

Old

man

with

chronic

COPD

d

Chron

icpe

rsistent

coug

h,he

mop

tysis,

malaise,weigh

tloss,a

ndfatigu

e

Atypica

lMyc

obac

terial

Infection

Labo

ratory

inve

stigation,

sputum

/blood

culture

Bilateral/L

Le,po

sterior

segm

entof

ULa

Tubu

lar

Presen

tSu

rrou

ndingsm

allairw

aydisease

Any

Chron

ichistoryof

esop

hage

aldisease,

who

deve

lops

attacks

ofdy

spne

aan

dco

ugh

Chr

onic

aspiration

Bilateral/L

LeAny

,withho

neyco

mbing

Presen

tSu

rrou

ndingreticu

lation

s,grou

ndglass

opacitiesan

dho

neyco

mbing

Middle,

old

age

Chron

icprog

ressiveno

nprod

uctive

coug

han

ddy

spne

aTr

action

bron

chiectasis

with

Pulm

onaryfibr

osis

Bilateral/low

er,middle

lobe

san

dling

uaVaricoidwithmuc

ous

plug

ging

Presen

tAssoc

iatedde

xtrocardia

You

ngRecurrent

infection,

recu

rren

tsinu

sitis,

situsinve

rsus

Kartage

nersy

ndro

me

Bilateral/trach

eaan

dce

ntralbr

onch

iAny

withdive

rticulae,

bron

choc

ele

Absen

tSu

rrou

ndingsm

allairw

aydisease

detected

Middleag

eChron

icco

ughan

drecu

rren

tinfection

Trac

heob

ronc

homeg

aly

(Mou

nier-K

uhnsy

ndro

me)

Foca

lor

Bilateral/

Asy

mmetric

Any

,bronc

hocele

may

bepresen

tPresen

tor

absent

Surrou

ndingsm

allairw

aydisease

mostlyde

tected

.Abscess

in1case,Volum

eloss

in

Any

History

ofinfection

Post

inflam

mator

yLa

boratory

Bilateral/A

symmetric

Any

,bronc

hocele

may

bepresen

tPresen

tor

absent

Diffusehy

perinfl

ation,

mosaic

attenu

ationan

dem

physem

a.Pu

lmon

aryhy

perten

sion

.

Middle,

old

age

Chron

icsm

oker

withhistory

ofrecu

rren

tasthmatic

symptom

s.

Post

COPD

Pulm

onaryfunc

tion

tests

aUL:

uppe

rlobe

.bCF:

cystic

fibrosis.

cABP

A:A

llergic

bron

cho-pu

lmon

aryaspe

rgillosis.

dCOPD

:chron

icob

structivepu

lmon

arydisease.

eLL

:low

erlobe

.

Y.Y. Sabri et al. The Egyptian Journal of Radiology and Nuclear Medicine 49 (2018) 645–651

647

Table 4 shows the diagnostic approach to reach different etiologiesof bronchiectasis.

4. Discussion

MDCT using High resolution computed tomography (HRCT) tech-nique is considered the modality of choice for airway disease assess-ment as it shows presence, distribution, morphological type ofbronchiectasis and associated findings as well [7].

In this study bronchiectasis was more common in females in56.25%, which agrees with most of studies [8–10]. Bronchiectasis ismore common in 7th decade of life as stated by Izhakian and co-workers, 2016 [11], however in this study the most common age groupwas middle age 50–59-year-old in 30.6%, followed by age group of60–69 year-old in 24.1%, among both males and females.

Bronchiectasis could be encountered in one or both lungs, single ormultiple lobes and many diffuse lung diseases may manifest withbronchiectasis as the primary abnormality [5]. In our study, bronch-iectasis was more prevalent bilaterally and in case of focal lesions rightsided unilateral affection and lower lobe affection was more prevalent,these results were in accordance with many studies [8,11,12].

In this study, right pulmonary bronchiectatic lesions were more inthe lower lobes in 47% of cases, left pulmonary bronchiectatic lesionswere more in the upper lobe in 57.1% of cases. However, in Izhakianet al., 2016, the right pulmonary bronchiectatic lesions were found tobe more in the right middle lobe (25.9%) than in the right lower lobe(20.7%), and the left pulmonary bronchiectatic lesions were found to bemore in the lower lobe (20.4%) than that in the upper lobe (20%) [11].

The cylindrical (or tubular) bronchiectasis, is the most commonlyidentified morphologic type [13]. The three forms of bronchiectasisoften are present in the same patient, with the extent and nature ofbronchial dilatation often falling along a spectrum of imaging findings[5]. In this study, signet ring sign was the most common finding in18.75% of cases, and according to morphological type, the cylindricaltype of pulmonary bronchiectasis was most common in 21.9% of cases.

Bronchial wall thickening is the common final response of the air-ways to irritants, which causes the bronchi to become swollen and in-flamed [5]. Bronchial wall thickening present in 48.4% of our cases.

Bronchiectatic lesions of the lung usually contain air but occasion-ally contain fluid or solid material [1], fluid containing bronchiectasis(bronchoceles) were found in 4.7% of cases.

The etiology of bronchiectasis is varied, and, in most series, anunderlying cause can only be definitively identified in 50% of cases [2].In our study, we reached definite diagnosis in 57% of cases. The dis-tribution of bronchiectasis together with concomitant findings, such ascentrilobular nodules, mass lesions, cavities, and lymphadenopathy,can assist in narrowing the differential diagnosis of bronchiectasis [6].

Regarding the etiology of bronchiectasis post inflammatory was thecommonest cause of bronchiectasis in this study involving 42.2% of thepatients, followed by traction bronchiectasis representing 34.4% ofcases. Lonni and co-workers, 2015 found that the bronchiectasis mostfrequent etiologies are post inflammatory related bronchiectasis (20%),chronic obstructive pulmonary disease related bronchiectasis (15%),and traction bronchiectasis (10%) [14].

Post inflammatory bronchiectasis could be focal or diffuse [5]. Inthis study, lower lobe was the commonest site involving up to 81.4% ofpost inflammatory patients (Figs. 1 and 2). Though, in Johnson and co-workers, 2014, and Izhakian and co-workers, 2016, right middle lobewas more common [15,11].

Allergic bronchopulmonary aspergillosis was found to cause rightmiddle lobe consolidation and bronchiectasis with endobronchialhyper-density representing the fungus, and the classic sign of finger inglove (Fig. 3) [4].

Upper lobes were the most common site in traction bronchiectasis[16], as in our study involving up to 55% patients of traction bronch-iectasis patients (Fig. 4).

Fig. 1. HRCT chest axial image lung window shows right lower lobe signet ringsign and left lower lobe cystic bronchiectasis. Marked oligemia denotingbronchiolitis obliterans in case with post inflammatory bronchiectasis.

Fig. 2. CECT chest axial image lung window shows right lower lobe Post in-flammatory bronchiectasis with bronchocele.

Fig. 3. NECT chest axial image show right middle lobe consolidation withtubular hyper-dense lesion representing dilated bronchi with aspergillus in acase of ABPA.

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Sarcoidosis bronchiectasis tends to be bilateral upper lobar andsymmetrical and associated with bilateral enlargement of hilar andmediastinal lymph nodes, in up to 90% of patients and diffuse re-ticulonodular opacities in 20% of patients [17]. Fibrosis with tractionbronchiectasis and bronchiolectasis in cases of idiopathic interstitialpneumonia, is most pronounced in lower lung lobes (Fig. 5) [19].

Chronic obstructive pulmonary disease cause bilateral diffusebronchiectasis more in the lower lungs. CT demonstrates bronchial wall

thickening, a mosaic attenuation pattern of the pulmonary parenchyma,and mucous plugging (Fig. 6) [5,20].

Focal bronchiectasis related to aspiration was common in the de-pendent upper lobes and the bronchocentric areas of the lower lobestogether with the presence of esophageal lesions include large hiatalhernias predisposing to gastroesophageal reflux, diseases resulting in apatulous esophagus (scleroderma), and esophageal motility disorders[5,21].

Fig. 4. NECT chest axial, coronal images show bilateral upper lobes mostly posterior segments fibrosis and traction bronchiectasis, cicatritial emphysema anddistortion of upper airway, in a known case with tuberculosis.

Fig. 5. HRCT chest axial images show bilateral interstitial fibrosis (idiopathic interstitial pneumonia) with lower lobes traction bronchiectatic changes.

Fig. 6. HRCT chest Axial (a) and coronal (b) images show hyperinflation of both lung fields with cystic bronchiectasis in right middle lobe, fusiform bronchiectasis inright lower lobe and signet ring sign of bronchiectasis in left lower lobe. In a case of COPD with bronchiectasis.

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Slow-growing endobronchial or peri-bronchial lesions, such as car-cinoid or carcinogenic tumors (Fig. 7) and calcific intra-pulmonarylymph node (broncholith) (Fig. 8) cause mucoid impaction, post-ob-structive atelectasis, air-trapping, and distal lobar segmental, or evensingle bronchial bronchiectasis [4,5].

Cystic fibrosis classic diagnostic triad includes an abnormal sweatchloride test result, manifestations of pulmonary and pancreatic dis-ease. Bronchiectasis due to cystic fibrosis was commonly diffuse bi-lateral (Fig. 9), with upper lobar predominance [4,18].

Bronchial atresia was found to cause typical CT changes includebrochocele, occlusion of the bronchus central to the bronchocele, andemphysematous changes of the peripheral lung field (Fig. 10), [22].

In Kartagner Syndrome commonest lobes to be affected are lowerlungs, right middle lobe and lingua, and associated dextro-cardiashould be observed [23].

An adequate understanding of the underlying causes with theirspecific multi-slice computed tomography (MSCT) imaging appearanceswill allow radiologists to more confidently determine the cause of thiscommon radiologic finding, also clinical history and patient demo-graphic characteristics play an integral role in determining the appro-priate differential diagnosis [24].

5. Conclusion

the role of MDCT imaging in diagnosis and evaluation of bronch-iectasis is crucial, as it confirms the presence of bronchiectasis; and theetiology may thus be determined by means of its site, distribution,specific imaging appearance; content, shape, size; associated CT find-ings, knowledge of the associated clinical context assist to reach a de-finite diagnosis or concise the differential diagnosis.

Fig. 7. HRCT chest axial mediastinal (a) and lung (b) windows images show central mass lesion with two punctate peripheral punctate calcific foci. Distal Tubularbronchiectatic changes in right middle lobe noted in a histopathology proved case of non-small cell lung cancer.

Fig. 8. HRCT chest axial images show endobronchial nodular high density lesion with focal tubular and fusiform bronchiectatic changes in right medial basalsegment of lower lobe A case of bronchiectasis due to broncholith.

Fig. 9. HRCT chest axial image shows bilateral lower lobes signet ring signsdenoting early bronchiectasis with bronchial wall thickening. Hyperinflationand hyperlucency of both lungs lobes. In a case of cystic fibrosis with bronch-iectasis.

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Compliance with ethical standards

Conflict of interest.The authors declare they have no conflict of interest.

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Fig. 10. CECT chest axial (a) mediastinum window and (b) lung window images show Left lower lobe bronchocele with distal air trapping, in a case of Leftbronchocele due to bronchial atresia.

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