Dr Mazen QusaibatyMD, DIS

Head Pulmonary and Internist Department Ibnalnafisse Hospital

Ministry of Syrian healthEmail:

Qusaibaty@gmail.com

1. Tree-in-bud sign2. Golden S sign

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Topic Outline

1. Tree-in-bud sign2. Golden S sign

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Tree-in-bud sign

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Airways

Central

Peripheral

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Airways

Central Cartilage

Peripheral

Non cartilage

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Airways

Central Cartilage

>2mm of internal diameter

Peripheral Non cartilage

<2mm internal diameter

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Airways

Central Cartilage

>2mm of internal diameter

0-16

Peripheral Non cartilage

<2mm internal diameter

7 - 23

Airways

Central

Conducting zone

Peripheral

Transitional and Respiratory

zone

Dead Space The portion of each

breath that does not

participate in gas exchange

Dead SpaceDS

Anatomic DS

Dead SpaceDS

Anatomic DS

Conducting zone150 ml

Dead SpaceDS

Anatomic DS

Conducting zone150 ml

Physiologic DS

Dead SpaceDS

Anatomic DS

Conducting zone150 ml

Physiologic DS

Conducting zone

Dead SpaceDS

Anatomic DS

Conducting zone150 ml

Physiologic DS

Conducting zone

Alveoli that are well-ventilated but poorly perfused

Quiz

• Asthma always attacks:A. Lung parenchymaB. Central airwaysC. Peripheral airwaysD. B + C

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Quiz

• Asthma always attacks:A. Lung parenchyma

B. Central airwaysC. Peripheral airwaysD. B + C

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Quiz

• COPD always attacks:A. Central airwaysB. Peripheral airwaysC. Lung parenchymaD. B + C

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Quiz

• COPD always attacks:A. Central airwaysB. Peripheral airwaysC. Lung parenchyma

D. B + C

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Volume-rendered images demonstrate normal central and peripheral airways / Axial image

Volume-rendered images demonstrate normal central and peripheral airways / Coronal image

Volume-rendered images demonstrate normal central and peripheral airways / Sagittal image

Peripheral airways

TB: Terminal BronchioleRB1: Respiratory

Bronchiole 1RB2: Respiratory

Bronchiole 2RB3: Respiratory

Bronchiole 3AD: Alveolar DuctAS: Alveolar sac

Tree-in-bud sign

Inflammatory material filling:TBRBAD

Quiz / Tree-in-bud sign

This sign could be seen in :

A. HRCT scanner of thorax

B. CT scanner of thorax

C. PA chest x rayD. Left profile chest x

ray

Tree-in-bud sign

This sign could be seen in :A. HRCT scanner of

thoraxB. CT scanner of

thoraxC. PA chest x rayD. Left profile chest x

ray

Tree-in-bud sign could be seen

• In:A. Endobronchial

TuberculosisB. AsthmaC. Bronchoalveolar

carcinoma

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Tree-in-bud sign could be seen

• In:A. Endobronchial

TuberculosisB. AsthmaC. Bronchoalveolar

carcinoma

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Case 1

• A 29-year-old man• Acute myeloid leukemia after bone marrow

transplantation• The patient had a history of fever and cough

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Case 1

HRCT in RLL

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Case 1

• Multiple, small, centrolobular nodules of soft-tissue attenuation connected to linear branching opacities (arrows)

• Tree-in-bud sign

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Case 1At serologic examination, an infection with

A. Klebsiella pneumoniae

B. Mycoplasma pneumoniae

C. Streptococcus pneumoniae

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Case 1At serologic examination, an infection with

A. Klebsiella pneumoniae

B. Mycoplasma pneumoniae

C. Streptococcus pneumoniae

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Tree-in-bud sign associated with bronchiolar infection

• Transverse thin-section CT scan through right lower lobe in a patient with airways disease and bacterial infection related to AIDS (acquired immunodeficiency syndrome)

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Tree-in-bud sign associated with bronchiolar infection

• Multiple impacted centrilobular bronchioles result in tree-in-bud appearance (arrowheads).

• Bronchiectasis is also present

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Lung slice from patient with bronchopneumonia

• Impacted mucus- and pus-filled bronchioles (arrows) are visible throughout the lung

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Golden S sign

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Concave

Convex

Golden S sign

Refers to a reverse S shaped shadow

Golden S sign

Caused by right upper lobe collapse

Golden S sign

The upper curve of the reverse S

(concave infero-laterally)

Golden S sign

A central mass causing the collapse forming the lower curve (convex infero-medially)

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• When a lobe collapses around a large central mass, the peripheral lung collapses and the central portion of lung is prevented from collapsing by the presence of the mass.

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• The relevant fissure is concave toward the lung peripherally but convex centrally, and the shape of the fissure resembles an S or a reverse S .

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Conclusion

• Golden S sign - indicates lobar collapse with a central mass, suggesting an obstructing bronchogenic carcinoma in an adult