0:00

So here's another somewhat complex case,

0:03

but I think that we, this can be broken down pretty easily.

0:06

So in scrolling through, clearly there are areas

0:09

of reticular abnormality and mild ground blast opacity,

0:13

but more concentrated in the lung periphery than

0:15

central aspect to lungs.

0:17

And there's definitely a basar gradient.

0:20

Look at this beautiful traction bronchis like, oh,

0:23

it's beautiful, isn't that?

0:25

And so what do I say about NSIP, right?

0:28

Remember the NSIP can give you this very exuberant traction

0:31

bronchiectasis almost looks like a beaded appearance here.

0:33

So NSIP likes to do that.

0:35

And the ground lasts opacity plus the reticulation.

0:37

That also we can see an NSIP,

0:40

but we see a lot of these cystic abnormalities.

0:43

And so these cysts, at least when we get down

0:46

to the Coran angles, they meet the definition

0:49

for honeycomb cyst.

0:50

So someone might be tempted to just kind

0:54

of call this UIP.

0:55

And I think if someone called this UIP, they would be

0:59

70%, right?

1:01

'cause it is, if you were to biopsy this, almost

1:03

as surely you get UIP back.

1:05

But it doesn't capture the true pattern

1:07

of diffuse lung disease here, does it?

1:09

Because there are elements of both NSIP and UUIP here

1:15

and that actually is really a known phenomenon.

1:18

So NSIP, as it becomes more

1:20

and more severe, can start to look more

1:22

and more like UIP instead.

1:23

In fact, end stage fibrotic NSIP will look very,

1:27

very similar to UIP.

1:29

And that's probably what's going on in this case.

1:31

This is, if we were to find, if we're able to get a hold

1:33

of like the earliest CT scan possible,

1:36

let's say from like 10 years ago at an outside hospital,

1:38

I bet you this looked like classic NSIP.

1:41

Okay? And so that's, that's quite helpful here.

1:44

So if you have someone

1:45

with this combined N-S-I-P-U-I-P pattern,

1:48

well now we're talking, right?

1:50

This is great because we know that NSIP,

1:54

that's gonna be more common to in the setting

1:57

of secondary lung disease.

1:58

So things like connective tissue disease, fibrotic, hp

2:01

or drug related pulmonary fibrosis.

2:03

And so even though there are UIP elements here, the fact

2:08

that we feel like this emanated from NSIP makes us think,

2:12

okay, this is likely not idiopathic pulmonary fibrosis.

2:15

We should dig deeper. We should talk to our pulmonologist.

2:18

We talked to our rheumatologist

2:19

and try to really figure out

2:20

what is the best diagnosis for this patient.

2:23

And probably the most helpful thing would be let's get hold

2:25

of that CT from five or six years ago or 10 years ago.

2:28

'cause this pulmonary fibrosis is not mild.

2:30

This patient was dyspneic a long time

2:33

before they came to your hospital and

2:34

or your imaging center.

2:36

And so you have that opportunity to make that diagnosis.

2:39

Small pearl here, if you have someone

2:42

with significant pulmonary fibrosis like, like this,

2:46

very commonly from a diagnostic standpoint,

2:49

this is not gonna be the most helpful CT scan for you.

2:53

From a diagnostic standpoint.

2:54

Obviously from prognosis it's helpful

2:56

'cause you could tell how much lung is involved. But in

2:58

Terms of of diagnosis, the most helpful CT very often is

3:02

the earliest CT scan on your pacs

3:05

or the ones that you get a hold of.

3:06

And why is that? Is

3:08

because as I, I alluded in this case almost all types

3:12

of pulmonary fibrosis, as they get more

3:13

and more severe, they start to look more and more like UIP.

3:17

And so there's gonna be more

3:18

and more overlap in terms of that disease pattern

3:22

that you're seeing and the UIP pattern.

3:24

So try to find that earliest CT possible,

3:26

it'll pay dividends.