Canadian Association of Radiologists Journal xx (2016) 1e7

www.carjonline.org

Thoracic and Cardiac Imaging / Imagerie cardiaque et imagerie thoracique

Pitfalls in Radiographic Interpretation of Emphysema Patients

Jun Hyun Baik, MD, Jeong Min Ko, MD, Hyun Jin Park, MD*
Department of Radiology, St Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea

Abstract
Emphysema commonly accompanies various complications such as pneumonia. Sometimes, these comorbidities look so strange on
images, because destroyed airspaces could change the usual disease progression. So, we demonstrated various cases of common comor-
bidities with unusual radiographic findings in emphysema patients. Awareness of various findings of emphysema with commonly coexistent
diseases may aid in the proper diagnosis and management of emphysema patients.

R
esum
e
L’emphyseme est souvent associ
e a diverses complications telles que la pneumonie. Ces comorbidit
es ont parfois un aspect
etrange en
imagerie m
edicale puisque la destruction des voies a
eriennes peut changer la façon dont la maladie
evolue. Nous avons donc compil
e des
exemples de caract
eristiques radiographiques inhabituelles chez des patients pr
esentant de l’emphyseme et diverses comorbidit
es courantes.
Savoir reconna^ıtre de telles caract
eristiques peut favoriser l’
etablissement d’un diagnostic exact et la prise en charge efficace de ces patients.
Ó 2016 Canadian Association of Radiologists. All rights reserved.

Key Words: Computed tomography; Emphysema; Lung

Emphysema is defined as abnormal, permanent enlarge-
ment of airspaces distal to the terminal bronchioles and
accompanied by the destruction of airspace walls without
obvious fibrosis [1]. The main purpose of radiographs in
emphysema patients is to exclude comorbidities such as
pneumonia, pulmonary oedema, lung cancer, and so on [2].
We are already well informed of the image findings of
emphysema and other common pulmonary diseases, so we
can easily diagnose those conditions. However, there are
often unfamiliar cases of emphysema with unusual radio-
graphic findings. Dilated airspaces without intact walls can
influence disease progression of common pulmonary dis-
eases in emphysematous lungs, causing changes in the usual
radiographic patterns [3]. Herein, we demonstrate various
cases of pulmonary diseases commonly accompanied by
emphysema, showing unusual image findings. Many articles
about the radiographic findings of emphysema have been
* Address for correspondence: Hyun Jin Park, MD, Department of Radi-
ology, St Vincent’s Hospital, College of Medicine, The Catholic University
of Korea, 93 Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do 442-723,
Korea.
E-mail address: radiodoc@catholic.ac.kr (H. J. Park).
published, but there have been none emphasizing radio-
graphic findings of emphysema-related complications and
their unusual radiographic changes.
Pitfalls
Pneumonia
Typical appearance of pneumonia is a consolidation,
but in patients with emphysema or bullae, lung consolidation
may be inhomogeneous, with consolidation outlining areas
of lung destruction or holes. In this situation, the lung may
have a cystic or ‘‘Swiss cheese’’ appearance, mimicking
cavitations (Figure 1). Occasionally these cavity-like holes
within the pneumonic consolidations can be confused with
other cavity forming conditions such as tuberculosis,
necrotizing pneumonia, and adenocarcinoma in situ. Infec-
tion in a preexisting bulla can result in an air-fluid level
within the bulla or collapse or distension of the bulla
(Figure 2) [4]. Kim et al [5] reported 2 cases of intra-
parenchymal air fluid in emphysematous lungs caused by
pneumonia. They explained that exudates could freely move

0846-5371/$ - see front matter Ó 2016 Canadian Association of Radiologists. All rights reserved.
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2 J. H. Baik et al. / Canadian Association of Radiologists Journal xx (2016) 1e7
Figure 1. ‘‘Swiss cheese’’ appearance in pneumonia superimposed on
emphysema in a 67-year-old man. High-resolution computed tomography
shows a large area of heterogeneous air space opacity with innumerable
small air cysts, emphysema cysts, resulting in Swiss cheese appearance. This
appearance may be confused with one of ground glass opacity with bubbly
lucency in bronchioloalveolar carcinoma. A drainage tube is kept in the right
pleural cavity (arrow).
into nearby alveolar spaces through the destroyed alveolar
walls, making air fluid levels (Figure 3). This condition can
be misinterpreted as hydropneumothorax.
Tuberculosis
The most common computed tomography (CT) findings
of reactivation pulmonary tuberculosis (TB) is focal
consolidation with centrilobular nodules, tree-in-bud, and
cavitation involving upper lungs [6]. In patients with
impaired host immunity, active TB can be manifested as a
lobar or segmental airspace consolidation in the basal seg-
ments of the lower lobes, mimicking pneumonia. In this case,
multiple cavities within the consolidation or nearby tree-in-
bud can be helpful in diagnosis of atypical TB [7]. Some-
times, differentiation of atypical TB and pneumonia can be a
hard one in patients with underlying emphysema, because of
cystic destruction of the lung [8]. However, centrally located
vascular structures within the cysts can suggest emphysema
not cavitation by TB (Figure 4) [4].
Figure 2. Air-fluid levels in giant bullous emphysema with superimposed
infection in a 48-year-old man. Plain radiography shows 2 air fluid levels
within a large transradiant vascular area with diffusely thickened walls. The
volume of the avascular area is over two-thirds of the right lung.
Pulmonary Oedema
Hydrostatic pulmonary oedema is usually manifested as
alveolar opacities and smooth interstitial thickening with
bilateral and symmetric distribution. However, changes in
blood flow or hydrostatic pressure in ipsilateral or contra-
lateral lungs can cause asymmetric distribution of pulmonary
oedema. The most common cause of such asymmetry is
underlying chronic pulmonary disease such as emphysema,
which obliterates portions of the pulmonary vascular bed.
Oedema appears in normal or less severely abnormal por-
tions of the lung (Figure 5) [4,9].
Lung Cancer
Emphysema is a risk factor of lung cancer. Lung cancer
usually appears to be a round nodule or mass. However, its
appearances can be changed in emphysematous lungs, as
tumours tend to grow along the intervening normal lung
with unusual shapes. Some cases mimic postinflammatory
changes with a thick band-like structure or a cystic lesion
with focal nodularity (Figures 6 and 7) [3]. Adenocarci-
noma in situ, formerly known as bronchioloalveolarcarci-
noma, is a well-differentiated adenocarcinoma without
invasion of the pleura, vessels, or lung stroma [10,11]. On
high-resolution CT (HRCT), it may present as a focal area
of ground glass opacity containing bubbly lucencies or
pseudocavitation [4,11]. In this situation, adenocarcinoma
might resemble ‘‘Swiss cheese’’ in appearance and be
 Pitfalls of emphysema / Canadian Association of Radiologists Journal xx (2016) 1e7 3

Figure 3. Parenchymal air-fluid level in pneumonia superimposed on emphysema in a 79-year-old man. (A) Plain radiograph shows an ill-defined irregular
consolidation in left middle lung zone. The air-fluid level is visible in the left lower lung field (arrows), which could be confused with hydropneumothorax.
Extensive calcification of the pericardium is seen, with engorged hilar vasculatures. The patient had a history of tuberculous pericarditis. (B) Computed to-
mography scan obtained on the same day shows parenchymal air-fluid level (arrows) between the aerated lung and the consolidation in left lower lobe.
Numerous emphysematous cysts are seen in both lungs.

difficult to be distinguished from pneumonia superimposed
on emphysema. However, there are no emphysema cysts in
the nonaffect lung (Figure 8).
Fibrosis
On HRCT, ground glass opacity can be a result of active
inflammation or chronic fibrosis. In the differential diag-
nosis, it is important to find any evidence for fibrosis in the
regions of ground glass opacities, such as reticular opacities,
traction bronchiectasis, and small cysts of honeycombing
[12]. When pulmonary oedema or pneumonia occurs in
emphysematous lungs, emphysema cysts can be surrounded
by ground glass opacities, and the cyst walls within the le-
sions can be thickened on HRCT. It could be interpreted as
pulmonary fibrosis rather than an active inflammation
(Figure 9).
Smoking-Related Interstitial Lung Disease

Emphysema is common in smokers, so smoking-related

interstitial lung diseases could coexist in emphysematous
lungs. Combined pulmonary fibrosis with emphysema
(CPFE) has become increasingly recognized as a distinct

Figure 4. Atypical pulmonary tuberculosis initially misdiagnosed as pneu-

monia in a 75-year-old man with emphysema. Computed tomography
through upper lobes shows lobar consolidation with numerous cystic ra-
diolucencies in right upper lobe and superior segment of right lower lobe.
Most cysts contain central fine linear or linear branching opacities, cen-
trilobular core structures, representing centrilobular emphysema (arrow- Figure 5. Atypical distribution of pulmonary oedema in an emphysema
heads). Some radiolucent spaces appear larger, more irregular, and patient. Computed tomography through the upper lobes shows a large area of
radiolucent than the others without any structure within them, suggestive of ground glass opacity in the left lung. Emphysematous areas are relatively
cavities by tuberculosis (arrows). spared.
4 J. H. Baik et al. / Canadian Association of Radiologists Journal xx (2016) 1e7

Figure 6. Lung cancer arising from emphysema in a 74-year-old man, mimicking a postinflammatory scar. (A) Computed tomography (CT) shows an irregular
opacity in the superior segment of left lower lobe (arrow). (B) A 1-year follow-up CT shows the increased extent of the preexisting irregular lesion in left
lower lobe (arrow). However, it still appears irregular rather than mass-like. This lesion was proven to be squamous cell carcinoma by a transthoracic needle
biopsy. (C) A follow-up CT the next year shows marked growth of the lung cancer with a typical mass-like appearance. The patient has refused all treatment in
the past year.

clinical entity and one of smoking related disease. Hon-
eycombing with reticular opacities and traction bronchiec-
tasis are frequent HRCT findings in the lower lungs, while
the upper lungs exhibit paraseptal and centrilobular
emphysema [13,14]. In this situation, differentiation be-
tween paraseptal emphysema and honeycombing is very
difficult (Figure 10). Desquamative interstitial pneumonia
is also a smoking-related interstitial lung disease. Ground
glass opacity is a main HRCT feature and fibrosis is rare in
this entity. However, the combination of ground glass
opacity in desquamative interstitial pneumonia and small
cysts in emphysema can mimic findings of CPFE and

Figure 7. Lung cancer arising from emphysema in a 66-year-old man. (A) Computed tomography (CT) with a lung window setting shows a nodular
wall thickening of a large bulla (arrows). (B) CT with a mediastinal setting shows a subpleural band-like soft tissue attenuation with heterogeneous
enhancement along outer wall of bulla, which destructs a nearby rib. This lesion was proven to be squamous cell carcinoma by a transthoracic needle
biopsy.
 Pitfalls of emphysema / Canadian Association of Radiologists Journal xx (2016) 1e7 5

Figure 8. Adenocarcinoma in a 48-year-old woman, showing ‘‘Swiss
cheese’’ appearance. Computed tomography shows diffuse ground glass
attenuation with internal bubbly lucencies throughout the right middle and
lower lobes. Multiple faint nodules are clustered in left lower lobe. The
lesion is similar to pneumonia superimposed on emphysema with Swiss
cheese appearance. However, there are no emphysematous cysts in left lung.
Compare with Figure 1.
Figure 10. Combined pulmonary fibrosis and emphysema in a 78-year-old
man. High-resolution computed tomography scan shows multiple air cysts in
a mixture of paraseptal emphysema and pulmonary fibrosis in the same areas
of the lungs. Thin walled cysts with bullae larger than 1 cm (arrows)
represent paraseptal emphysema and multilayered small cysts with re-
ticulations and traction bronchiectasis (thin arrows) indicate pulmonary
fibrosis with honeycombing. However, the exact differentiation between
them seems to be impossible.

nonspecific interstitial pneumonia. Respiratory bronchioli- Pneumothorax

tis or respiratory bronchiolitis-interstitial lung disease is
another smoking related disease, and commonly presents
with upper lobe emphysema. The typical HRCT findings
are centrilobular nodules or ground glass opacities [14].
However, centrilobular ground glass opacities within
emphysema cysts occasionally resemble a bullseye
appearance (Figure 11).
Pneumothorax may occur in patients with emphysema
with bullae. Sometimes, differentiation of pneumothorax
from bullae may be difficult on plain radiographs or CT
scans, especially in cases where the pneumothorax is local-
ized. Air collection in the pneumothorax looks like a cres-
cent; but a round to oval shape indicates a bulla. Thin septae

Figure 9. Pneumonia superimposed on emphysema in a 54-year-old man, mimicking pulmonary fibrosis. (A) Computed tomography (CT) shows a large ground
glass opacity area with superimposed reticulations and multiple small cysts. (B) A follow-up CT obtained 1 year later shows complete regression of the previous
opacity in left lower lobe. There are many emphysematous cysts, which were rather prominent when they were surrounded by ground glass opacity.
6 J. H. Baik et al. / Canadian Association of Radiologists Journal xx (2016) 1e7

Giant Bullous Emphysema (Vanishing Lung Syndrome,

Primary Bullous Disease of the Lung)

Giant bullous emphysema, not a specific pathologic entity,

refers to the presence of giant, progressive, upper lobe bullae
occupying at least one-third of a hemithorax. Most patients
are young men and smokers with centrilobular emphysema,
but it can also occur in nonsmokers. Giant bullae of the upper
lung can compress the normal lower lung and mediastinal
structures [4]. Some normal compressed lungs resemble
consolidation with volume loss on a plain radiograph, and
are sometimes misunderstood as pneumonia.

Senile Emphysema

Structural alteration of the lung occurs with aging. The

rarefaction of alveolar structures is known to occur in older
nonsmokers, termed senile emphysema. The structural
changes of the senile lung are considered to be nondestruc-
tive and homogeneous compared with the destructive and
focal alterations in emphysema. Despite the histological
difference, they result in similar changes such as signs of
hyperinflation and centrilobular emphysematous changes on
plain radiography and CT imaging in elderly asymptomatic
adults [15].

Figure 11. Respiratory bronchiolitis and emphysema in a 51-year-old man.
Computed tomography through the right upper lobe shows multiple
emphysematous cysts with imperceptible walls, surrounding centrilobular
vascular cores. Small centrilobular ground glass opacities are seen around
the cores in the centres of the emphysematous cysts (arrows). They resemble
bullseyes.
within the air collection also indicate a preserved interstitium
within the bullous destruction. These are unusual in a
pneumothorax (Figure 12).
HIV Infection
HIV may be an independent risk factor for emphysema.
Nonsmoking HIV-infected patients have higher rates of
emphysema than do nonsmoking noneHIV-infected pa-
tients. The pathogenesis of emphysema in HIV remains
unclear. Multiple interacting factors including increased lung
oxidative stress and infection in the setting of aging and HIV
are likely to be involved. Symptoms, pulmonary function
testing, and CT findings are the same as for noneHIV-
infected patients [16,17].

Figure 12. Giant bullous emphysema in a 43-year-old man, misdiagnosed as pneumothorax. (A) Plain radiograph shows a large lucency in left upper lobe and
compressed bronchovascular bundles inferiorly. Note a thin linear opacity within the lucency (arrow). A chest tube was inserted immediately. (B) At follow-up
the next day, the plain image shows the chest tube in the left upper hemithorax. However, the lucent area remains unchanged in volume.
 Pitfalls of emphysema / Canadian Association of Radiologists Journal xx (2016) 1e7
Conclusion
Emphysema is very common and its radiographic findings
are well known. However, a diagnosis of emphysema is not
always easy, especially, when comorbidities occur in patients
with emphysema. Emphysematous cysts are troublesome
because they cause changes in the usual disease progression.
Recognition of these problems may be helpful in image
interpretation of emphysema patients.
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