Skill Checkup: A 63-Year-Old Man With Persistent Cough and New Shortness of Breath

Zab Mosenifar, MD


January 27, 2023

Usual interstitial pneumonia (UIP) is the hallmark radiologic pattern of IPF, with honeycombing as a distinguishing and diagnostic feature. Honeycombing may be observed with or without peripheral traction bronchiectasis or bronchiolectasis. Ultimately, a diagnosis of UIP can be made upon the presence of UIP on HRCT scan and the absence of other causes of ILD. Fine bibasilar rales, fixed split S2 heart sound, holosystolic tricuspid regurgitation murmur, clubbing, and pedal edema are physical examination findings in patients with IPF.

HRCT findings that would suggest other diagnoses include consolidation, marked mosaic attenuation, cysts, and nodules. The typical distribution of UIP is subpleural with basal predominance, although some upper lobe involvement is common; therefore, predominant peribronchovascular, perilymphatic, or upper or midlung distribution point to other conditions in the differential diagnosis. Pleural plaques would suggest asbestosis, dilated esophagus would suggest connective tissue disease, pleural effusions or thickening would suggest connective tissue disease or medication use, and distal clavicular erosions would suggest rheumatoid arthritis. Finally, extensive lymph node enlargement should prompt investigation of other etiologies.

In the present case, honeycombing with bronchiolectasis is seen on HRCT.


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