Chapter. Imaging of SARS in North America. Introduction. Clinical Manifestations of SARS in North America

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1 content Chpter 13 Nestor L. Müller, Hrry Shulmn Introduction Clinicl Mnifesttions of SARS in North Americ Rdiogrphic Mnifesttions of SARS in North Americ High Resolution CT Findings of SARS in North Americ

2 1 Introduction The first dignosis of SARS in North Americ ws mde in Toronto on Mrch 13, This ws the first recognized cse of the disese outside of Asi 2. By June 2, 198 cses of prole SARS were reported in Cnd, 30 (15%) of whom hd died 3. In the United Sttes t the sme time 66 cses of prole SARS hd een reported, none of whom hd died. 3 The first ptient with SARS in North Americ ws 78-yer-old womn who returned home to Toronto on Ferury 23, 2003 fter visit to reltives in Hong Kong. 1 Two dys lter she developed fever, mylgi, sore throt, nd mild nonproductive cough. Five dys lter she developed incresing cough nd dyspne. She died three dys lter, on Mrch 5, t home, nine dys fter the onset of her illness. The dignosis of SARS ws only mde in retrospect. The index ptient s 43-yer-old son developed fever nd sweting on Ferury 27, two dys fter his mother first noted symptoms. 1 He susequently developed nonproductive cough, chest pin, nd dyspne nd eventully high fever (temperture, 39.8 C). A chest rdiogrph reveled ilterl lower loe consolidtion. He ws dmitted to the hospitl with dignosis of community-cquired pneumoni. On the second dy fter dmission, he developed respirtory filure, ws intuted nd received mechnicl ventiltion. He died on Mrch 13, 2003, 15 dys fter ecoming ill. On Mrch 8 nd 9, ecuse of concern out possile tuerculosis in the fmily, the remining five dult fmily memers nd their three children, who hd ll een exposed to the index ptient, underwent screening chest rdiogrphy. 1 All hd fever, cough, or dyspne, nd norml chest rdiogrphs, except for the three children nd one of the dults. One of the dults met the criteri for suspected SARS, nd three met the criteri for prole SARS. All four were dmitted to the hospitl, three of them to intensive cre units; one ptient required mechnicl ventiltion. Unfortuntely, ecuse spred to contcts hd lredy occurred efore the first ptients presented to hospitl the SARS outrek spred rpidly. By Mrch 31, contct trcing hd identified n dditionl 100 ptients s hving prole or suspected SARS in the Greter Toronto re. Trnsmission ws limited to close contcts of ptients, including household memers, helth cre workers, or other ptients who were not protected with contct or respirtory precutions. Furthermore, cse-finding mesures identified dditionl individuls

3 2 who hd developed SARS fter returning from trvel to res in Asi where there hd een documented trnsmission of SARS. The only other cluster of cses in North Americ occurred in Vncouver. The first ptient ws 55-yer-old mn who presented to the emergency deprtment t Vncouver Generl Hospitl on Mrch 7, 2003 with history of recent trvel from Hong Kong nd symptoms of pneumoni. 2 He hd rrived from Hong Kong on Mrch 6 th. He hd little contct outside of immedite fmily. He ws provided with msk within minutes fter rriving t the emergency deprtment. Shortly therefter, he ws dmitted into full respirtory isoltion. Becuse of these circumstnces he did not spred the disese. Susequently only 3 more cses were oserved in Vncouver, two in individuls with recent trvel to Asi nd one in helth cre worker exposed to one of these ptients. Key Points Initil experience: North Americ:! Cse clusters hd trcele contct with Hong Kong or Asi Clinicl mnifesttions of SARS in North Americ The clinicl mnifesttions of the first 10 ptients with SARS in North Americ, including 9 from Toronto nd 1 from Vncouver were descried y Poutnem et l. 1 The ptients rnged from 24 to 78 yers in ge. The min presenting symptoms included fever (in 100 percent of cses), nonproductive cough (in 100 percent) nd dyspne. Commonly seen lortory findings included lymphopeni (in 89 percent of cses), elevted lctte dehydrogense levels (in 80 percent), nd elevted sprtte minotrnsferse levels (in 78 percent). Five of the 10 ptients required mechnicl ventiltion nd three died. Booth et l reviewed the clinicl findings nd short-term outcomes of 144 ptients with dignosis of suspected or prole SARS in the Greter Toronto Are. 4 The study included ptients who hd fever, known exposure to SARS, nd respirtory symptoms or prenchyml normlities seen on chest rdiogrph. Ptients were excluded if n lterntive dignosis ws determined. Of the 144 ptients, 111 (77%) were exposed to SARS in the hospitl setting. The most common clinicl mnifesttions included fever (99%), nonproductive cough (69%), mylgi (49%), nd dyspne (42%). Common lortory

4 3 fetures included elevted lctte dehydrogense (87%), hypoclcemi (60%), nd lymphopeni (54%). Twenty-nine ptients (20%) were dmitted to the ICU with or without mechnicl ventiltion, nd 8 ptients died (21-dy mortlity, 6.5%). Multivrile nlysis showed tht the presence of dietes nd other co-morid conditions were independently ssocited with poor outcome. All 4 ptients with proven SARS in Vncouver hd temperture greter thn F (greter thn 38 C) nd one or more clinicl findings of respirtory illness including cough, shortness of reth, difficulty rething, or hypoxi. All hd lymphopeni (solute lymphocyte count < 1000 per cuic millimeter) nd elevted serum liver trnsminses (Asprtte minotrnsferse nd Alnine minotrnsferse). One of the 4 ptients required mechnicl ventiltion. All 4 ptients survived. Key Points Clinicl presenttion: fever, nonproductive cough, mylgi, dyspne Lortory findings:! LDH, hypoclcemi, lymphopeni Rdiogrphic mnifesttions of SARS in North Americ The rdiogrphic findings of SARS t presenttion include unilterl or ilterl res of consolidtion (Figure 1) or poorly defined hzy incresed opcities without oscurtion of underlying vsculr mrgins (ground glss opcities) (Figure 2) 5, 6, 7. These findings my involve ny or ll lung zones nd e rndom in distriution, ut tend to involve minly the lower lung zones nd the outer third of the lungs. In smll percentge of symptomtic ptients the chest rdiogrph my e norml t presenttion ut unilterl or ilterl consolidtion is usully evident in these ptients on rdiogrphs performed 24 to 48 hours lter 6, 7, 8. In ptients who present with focl consolidtion, the consolidtion my remin unchnged for severl dys nd then cler 8. More commonly however the consolidtion remins focl ut increses in extent nd then grdully clers. [8]. In ptients with more severe symptoms the consolidtion cn progress to multifocl ptchy or confluent ilterl consolidtion. Ptients with multifocl unilterl or ilterl disese t presenttion often develop more extensive disese fter dmission nd tend to hve more protrcted clinicl course (Figure 3) 8.

4 Figure 1 29-yer-old mn with SARS Chest rdiogrph t presenttion

(ground-glss opcity) in right middle lung zone.

5 4 Figure 1 29-yer-old mn with SARS Chest rdiogrph t presenttion demonstrtes ptchy ilterl res of consolidtion. Figure 2 29-yer-old womn with SARS. Chest rdiogrph on dmission shows ill-defined hzy incresed density (ground-glss opcity) in right middle lung zone.. Chest rdiogrph 24 hours lter shows dense focl consolidtion. Form Müller NL et l. AM J Roentgenol 2003;181:July 2003, with permission.

5 Figure 3 64-yer-old womn with SARS. Initil chest rdiogrph shows re of consolidtion in right perihilr region nd ground glss opcities in right middle nd lower lung zones.

6 5 Figure 3 64-yer-old womn with SARS. Initil chest rdiogrph shows re of consolidtion in right perihilr region nd ground glss opcities in right middle nd lower lung zones.. Chest rdiogrph performed the following dy demonstrtes extensive consolidtion in right lung nd focl consolidtion in left lung. From Müller NL et l. Am J Roentgenol 2003;181:July 2003, with permission. Severl groups of investigtors hve reviewed the rdiogrphic mnifesttions of SARS seen in Toronto nd Vncouver 1, 7, 8, 9, 10. Grinlt et l. reviewed the rdiogrphic findings in 40 ptients with SARS seen t University of Toronto teching hospitl 8. The ptients rnged from 17 to 73 yers of ge; 55% were femle. Fifty eight per cent (23/40) of ptients presented with unilterl or ilterl res of consolidtion nd 42% (17/40) presented with norml chest rdiogrph. All ptients with initilly norml rdiogrph developed focl unilterl (12/17, 71%) or ilterl consolidtion (5/17, 29%) within 24 to 48 hours. Overll, the men durtion from the dte of exposure to the first norml chest rdiogrph in the 40 ptients ws 12 dys (rnge 4-26). The men time period from onset of fever to n norml rdiogrph ws 5 dys (rnge 1-19) 8. Twenty of the forty (50%) ptients in the study y Grinlt et l. hd focl consolidtion nd 20 hd multifocl or ilterl consolidtion (Figure 4) 8. In ll cses the consolidtion hd poorly defined mrgins. In 26 (52%) ptients the consolidtion hd predominntly peripherl distriution; in the remining cses there ws no pprent centrl or peripherl

The remining 25% (5/20) of ptients with focl consolidtion progressed to ilterl disese within men of 2.2 dys (rnge 1-4 dys) of the initil focl findings (Figure 4).

7 6 predominnce. In 70% (28/40) of ptients the consolidtion involved the middle or lower lung zones, nd 30% (12/40) the middle or upper lung zones. Seventy-five per cent of the ptients (15/20) with focl consolidtion s the initil normlity did not worsen or clered completely on susequent rdiogrphs. The remining 25% (5/20) of ptients with focl consolidtion progressed to ilterl disese within men of 2.2 dys (rnge 1-4 dys) of the initil focl findings (Figure 4). Ptients with multifocl unilterl of ilterl disese t presenttion often developed more extensive disese fter dmission nd frequently hd protrcted clinicl course 8. Rdiogrphs in ptients with residul disese fter severl weeks often show predominntly reticulr pttern suggestive of firosis (Figure 5). Nicolou et l reported the rdiogrphic nd CT findings in the first cse of SARS seen in Vncouver 9. The ptient ws 55-yer-old previously helthy mn who hd trveled to Hong Kong nd presented with 2-week history of fever, hedche, mlise, dyspne, nd cough. Bedside computed rdiogrph demonstrted extensive ilterl ground-glss opcities nd dependent res of consolidtion (Figure 6). Figure 4 44-yer-old mn with SARS. Chest rdiogrph t hospitl dmission shows focl consolidtion in the region of the right costoprenic sulcus.. Chest rdiogrph three dys lter demonstrtes incresed right lower loe consolidtion nd ptchy res of consolidtion in the left upper nd lower loes.

Chpter 13 Figure 5 62-yer-old mn with SARS.

dmission demonstrtes corse reticulr opcities

8 Chpter 13 Figure 5 62-yer-old mn with SARS. Chest rdiogrph performed six dys fter hospitl dmission shows extensive ilterl consolidtion.. Chest rdiogrph performed seven weeks fter hospitl dmission demonstrtes corse reticulr opcities involving minly the middle nd upper lung zones. A trcheostomy tue is in plce. 7

The normlities re diffuse in the right lung, ut the rdiogrph shows reltive spring of the left lung pex. Mild irspce consolidtion is seen in the retrocrdic region of the right lower loe.

9 8 c Figure 6 55-yer-old previously helthy mn with recent trvel history to Hong Kong.. Bedside nteroposterior computed rdiogrph otined with ptient upright shows extensive ilterl ground-glss opcities nd poorly defined nodulr pttern. The normlities re diffuse in the right lung, ut the rdiogrph shows reltive spring of the left lung pex. Mild irspce consolidtion is seen in the retrocrdic region of the right lower loe. Also noted is mild crdiomegly.. Bedside nteroposterior computed rdiogrph otined with the ptient supine 12 hours fter initil rdiogrph () shows diffuse ilterl irspce consolidtion. Note prominent ir ronchogrms, low position of endotrchel tue, nd gseous distension of the stomch. The rdiogrphic findings nd the rpid progression re consistent with dult respirtory distress syndrome (ARDS). c. CT imge (5mm collimtion) otined t the level of the right upper loe ronchus shows diffuse ilterl res of ground glss ttenution nd dependent res of consolidtion. d. CT imge t the level of the lower loe ronchi, shows similr findings to those in. From Nicolou S et l. Am J Roentgenol 2003;180:1247-9, with permission. Müller et l reviewed the rdiogrphic findings in 12 ptients with SARS, including 5 from Vncouver nd 7 from Hong Kong 7. The min rdiogrphic findings t presenttion consisted of unilterl or ilterl ground glss opcities (n=5), focl unilterl or ilterl res of consolidtion (n= 5), nd diffuse smll nodulr opcities (n=1) (Figs 2 nd 3). In one ptient the dmission chest rdiogrph ws norml. In one other ptient the chest rdiogrph hd een prospectively interpreted s negtive, lthough in retrospect sutle ilterl ground glss opcities could e seen. Ground glss opcities were ilterl, extensive nd firly symmetric in three ptients, limited to one lung in two ptients, limited to the lower loes in one ptient, nd ilterl nd symmetric in one ptient. The res of consolidtion involved minly the upper lung zones in two ptients, the lower zones in two ptients nd the middle lung zones in one ptient 7. Eight of the 10 ptients who were hospitlized nd hd follow-up chest rdiogrphs performed within 24 hours of presenttion demonstrted progression of disese. In these eight ptients follow-up rdiogrphs d

10 9 demonstrted extensive unilterl (n=2) or ilterl res of consolidtion (n=6) regrdless of the initil rdiogrphic pttern 7. Key Points Chest Rdiogrph mnifesttions: My e initilly norml in smll numer of ptients Opcities:! unilterl of ilterl res of consolidtion OR! poorly defined hze incresed opcities without oscurtion of underlying vsculr mrgins (ground glss opcities) Loction of lesions:! rndom involvement! minly the lower lung zones nd the outer third of the lungs Key Points Rdiogrphic Progression: Focl consolidtion t presenttion:! consolidtion increses in extent nd then grdully clers.! ptients with more severe symptoms, my progress to multifocl ptchy or confluent ilterl consolidtion. Multifocl disese t presenttion:! often develop more extensive disese fter dmission nd tend to hve more protrcted clinicl course High resolution CT of SARS in North Americ The high resolution CT mnifesttions of SARS consist of unilterl or ilterl ground glss opcities nd/or unilterl or ilterl res of consolidtion (Figure 7) 7, 11, 12. Smooth thickening of interloulr sept nd smooth intrloulr lines re often present superimposed on res of ground glss ttenution. The prenchyml normlities tend to involve minly the lower loes. The findings cn e diffuse or rndom in distriution ut tend to involve minly the outer third of the lungs 11, 12. In ll cses reported so fr high resolution CT

Müller et l reviewed the initil CT findings seen t presenttion in 5 ptients from Vncouver nd 7 from Hong Kong 7.

11 10 hs een norml t initil presenttion even when concurrent rdiogrphs re norml or show only questionle normlities (Figures 7, 8) 7,11,12. Furthermore, in the mjority of ptients high resolution CT shows more extensive disese thn pprent on the rdiogrph 12. Müller et l reviewed the initil CT findings seen t presenttion in 5 ptients from Vncouver nd 7 from Hong Kong 7. One of the ptients hd norml chest rdiogrph, one hd rdiogrph prospectively interpreted s norml ut in retrospect demonstrted ilterl ground glss opcities, two hd ilterl ground glss opcities nd one hd focl consolidtion seen on the rdiogrph. High resolution CT in the one ptient with norml chest rdiogrph showed ptchy ilterl res of ground glss ttenution nd focl consolidtion in the superior segment of the left lower loe. High resolution CT in the three ptients with ground glss opcities on the rdiogrph demonstrted extensive ilterl res of ground glss ttenution (n=3) nd smll focl res of consolidtion (n=2) (Figure 9). The res of consolidtion involved minly the dorsl lung regions. High resolution CT in the remining ptient showed focl consolidtion in the right lower loe. Figure 7 30-yer-old womn with SARS. Chest rdiogrph shows hziness (ground glss opcity) over the lterl spect of the right lung se with some loss of definition of the right hemidiphrgm.. High-resolution CT demonstrtes ilterl focl res of consolidtion.

Chpter 13 11 Figure 8 66-yer-old womn with SARS.

The rdiologist reviewing the rdiogrph the following morning noted vgue opcity overlying the nterior right second

12 Chpter Figure 8 66-yer-old womn with SARS. Chest rdiogrph ws interpreted y the emergency room physicin s eing norml. The rdiologist reviewing the rdiogrph the following morning noted vgue opcity overlying the nterior right second ri nd recommended high-resolution CT for further evlution. &c.high-resolution CT imges of the right upper loe demonstrte focl re of consolidtion, ground-glss opcities, mild septl thickening nd smooth intrloulr lines. c

Rdiogrphic findings were similr to those seen just prior to dmission. &c.

Am J Roentgenol 2003;181:July 2003, with permission.

13 12 Figure 9 48-yer-old mn with SARS. Chest rdiogrph performed 12 hours fter hospitl dmission shows sutle ilterl ground glss opcities with reltive spring of left upper loe. Rdiogrphic findings were similr to those seen just prior to dmission. &c.high-resolution CT performed concomitnt with chest rdiogrph demonstrtes extensive ilterl ground glss opcities. From Müller NL et l. Am J Roentgenol 2003;181:July 2003, with permission. c In susequent study, Müller et l reviewed the high-resolution CT findings in 29 ptients with SARS, including 4 from Vncouver nd 25 from Hong Kong 12. The ptients included 16 men nd 13 women rnging from 25 to 82 yers of ge. Twelve of the 29 ptients hd CT performed t presenttion or within 12 hours fter hospitl dmission. All ptients hd prenchyml normlities on initil high-resolution CT, including 8 ptients who hd norml concurrent chest rdiogrphs. The predominnt high-resolution findings t

14 13 presenttion consisted of unilterl (n=6) or ilterl (n=2) ground glss opcities or focl unilterl (n=2) or ilterl (n=2) res of consolidtion. Four of the 12 (33%) ptients hd ssocited mild thickening of the interloulr sept within the res of ground glss ttenution or djcent to res of consolidtion. The normlities involved predomintely or exclusively the lower lung zones in five ptients, the middle lung zones in five ptients, nd upper lung zones in two ptients. A predominntly supleurl distriution ws evident on high-resolution CT in eight ptients, ptchy rndom distriution in three, nd diffuse normlities in one ptient. None of the ptients hd hd evidence of hilr or medistinl lymphdenopthy or pleurl effusion t presenttion. Twenty-five ptients in the study y Müller et l hd high-resolution CT scns performed 2-27 dys fter hospitl dmission (medin 9 dys) 12. The predominnt high-resolution CT findings in hospitlized ptients consisted of unilterl (n=2) or ilterl ground glss opcities (n= 13) or unilterl (n= 2) or ilterl consolidtion (n= 5), or mixed ilterl pttern of ground glss ttenution, consolidtion, nd reticultion (n=3). Common findings seen in ssocition with ground glss opcities included mild smooth thickening of interloulr sept nd smooth intrloulr lines. Reticultion with ssocited irregulr interfces, rchitecturl distortion nd mild trction ronchiectsis ws present in 8 ptients (32%). Other findings seen on follow-up high-resolution CT included pneumothorx (n=2), pneumomedistinum (n=3), nd smll pleurl effusions (n=2)). The unilterl nd ilterl res of consolidtion seen on high resolution CT in ptients with SARS re similr to those seen in vriety of cteril, fungl, nd virl pneumonis 11. The findings in ptients with SARS differ, however, from those descried in other virl pneumonis, y the sence of centriloulr nodulr opcities. Centriloulr nodules nd rnching centriloulr opcities resulting in tree-in-ud pttern re commonly seen in ptients with cteril, virl, nd mycoplsm pneumoni 13, 14, 15. Reittner reviewed the high-resolution CT findings in 114 ptients with different types of pneumoni 13. In their study 7 of 9 (78%) ptients with virl pneumoni hd centriloulr nodules. Septl thickening ws seen t presenttion in 3 (33%) ptients with virl pneumoni in the study y Reittner et l. nd in 3 of 12 (25%) ptients with SARS in the current study. In ptients with protrcted clinicl course reticulr pttern is commonly seen on the rdiogrph nd high resolution CT two weeks or more fter hospitl dmission (Figure 10) 6, 8, 11, 12. On high resolution CT the reticulr pttern is often ssocited with irregulr interfces nd mild trction ronchiectsis. These findings suggest the presence of firosis 16. However, long tem follow-up will e required to determine whether these chnges resolve over time or whether they represent irreversile firosis.

Chpter 13 14 c d Figure 10 48-yer old womn with SARS. The dmission chest rdiogrph ws norml.

The consolidtion progressed rpidly; the ptient developed respirtory filure nd required intution nd

. Chest rdiogrph performed 7 dys fter hospitl dmission shows extensive ilterl consolidtion.

15 Chpter c d Figure yer old womn with SARS. The dmission chest rdiogrph ws norml. The rdiogrphs remined norml until 4 dys fter dmission when miniml consolidtion ws evident. The consolidtion progressed rpidly; the ptient developed respirtory filure nd required intution nd mechnicl ventiltion.. Chest rdiogrph performed 7 dys fter hospitl dmission shows extensive ilterl consolidtion.. Chest rdiogrph performed 1 month fter hospitl dmission shows smll foci of consolidtion nd extensive ilterl corse reticulr pttern. c. High resolution CT t the level of the left min ronchus demonstrtes ilterl ground glss opcities, irregulr liner opcities nd distortion of rchitecture. d. High resolution CT t the level of the right inferior pulmonry vein demonstrtes predominntly right sided normlities.

16 15 Key Points HRCT mnifesttions: Loction of lesions:! unilterl or ilterl distriution! lower loe predominnce! diffuse or rndom in distriution! minly the outer third of the lungs Lesion ppernce:! ground glss opcities nd/or consolidtion! smooth thickening of interloulr sept nd smooth intrloulr lines, often present superimposed on ground glss opcities! sence of centriloulr nodulr opcities or tree-in-ud pttern! No hilr or medistinl lymphdenopthy or pleurl t presenttion Follow up HRCT findings:! Reticultion with irregulr interfces, rchitecturl distortion nd mild trction ronchiectsis (32%)! Pneumothorx! Pneumomedistinum! Smll pleurl effusion Sensitivity of HRCT:! Anorml on ptients with norml initil rdiogrph! Showed more extensive disese thn pprent on the rdiogrph

17 reference i References 1. Poutnen SM, Low DE, Henry B, et l. Identifiction of severe cute respirtory syndrome in Cnd. N Engl J Med 2003 My 15;348(20): Ptrick DM. The rce to outpce severe cute respirtory syndrome (SARS). CMAJ 2003;168: World Helth Orgniztion. Cumultive numer of reported prole cses of SARS Booth CM, Mtuks LM, Tomlinson GA, et l Clinicl Fetures nd Short-term Outcomes of 144 Ptients With SARS in the Greter Toronto Are. JAMA 2003 My 6; [epu hed of print] Aville t entrezquery.fcgi?cmd=retrieve&d=pumed&list_uids= &dopt=astrct 5. Lee N, Hui D, Wu A, et l. A Mjor Outrek of Severe Acute Respirtory Syndrome in Hong Kong. N Engl J Med 2003 Apr 14; [epu hed of print] Aville from: URL: 6. Wong KT, Antonio GE, Hui DS, et l. Severe Acute Respirtory Syndrome: rdiogrphic ppernces nd pttern of progression in 138 ptients. Rdiology 2003 My 20; [epu hed of print] from URL: 7. Müller NL, Ooi GC, Khong PL, Nicolou S. Severe cute respirtory syndrome: rdiogrphic nd CT findings. Am J Roentgenol 2003; 181: July 2003, in press. 8. Grinlt L, Shulmn H, Glickmn A, Mtuks L, Nrinder P. The rdiology of SARS: review of 40 prole cses in Toronto, Cnd 9. Nicolou S, Al-Nkshndi NA, Muller NL. SARS: Imging of Severe Acute Respirtory Syndrome. AJR Am J Roentgenol 2003;180: Nicolou S, Al-Nkshndi NA, Muller NL. Imges in clinicl medicine. Rdiologic mnifesttions of severe cute respirtory syndrome. N Engl J Med 2003 My 15;348: Wong KT, Antonio GE, Hui DS, et l. Thin-Section CT of Severe Acute Respirtory Syndrome: Evlution of 74 Ptients Exposed to or with the Disese. Rdiology 2003 My 8; [epu hed of print] from: URL: Müller NL, Ooi GC, Khong PL, Nicolou S. Severe Acute Respirtory Syndrome: High-resolution CT findings t presenttion nd fter dmission. Sumitted for puliction. 13. Reittner P, Wrd S, Heynemn L, Johkoh T, Müller NL. Pneumoni: high-resolution CT findings in 114 ptients. Eur Rdiol 2003; 13: Gruden JF, We WR, Nidich DP, McGuinness G. Multinodulr disese: ntomic locliztion t thin-section CT multireder evlution of simple lgorithm. Rdiology 1999; 210: Collins J, Blnkenker D, Stern EJ. CT ptterns of ronchiolr disese: wht is tree-in-ud? Am J Roentgenol 1998; 171: Remy-Jrdin M, Girud F, Remy J, Copin MC, Gosselin B, Duhmel A. Importnce of ground-glss ttenution in chronic diffuse infiltrtive lung disese: pthologic-ct correltion. Rdiology 1993;189:

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