Systemic lupus erythematosus CT

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Pulmonary

Pulmonary hypertension (right ventricular prominence, or loud P2)

• ECG-gated CT pulmonary angiography shows:

• • Right ventricular hypertrophy: defined as wall thickness of >4 mm
  • Straightening or bowing (towards the left ventricle) of the interventricular septum
  • Right ventricular dilatation (a right ventricle–to–left ventricle diameter ratio of more than 1:1 at the midventricular level on axial images)
  • Decreased right ventricular ejection fraction
  • Ancillary features
    • dilatation of the inferior vena cava and hepatic veins
    • pericardial effusion

• Enlarged pulmonary trunk (measured at pulmonary artery bifurcation on an axial slice vertical to its long axis)

• Enlarged pulmonary arteries
• Mural calcification in central pulmonary arteries
• Centrilobular ground-glass nodules
• Neovascularity: tiny serpiginous intrapulmonary vessels that often emerge from centrilobular arterioles but do not conform to usual pulmonary arterial anatomy

Pulmonary fibrosis

• Honeycombing: Fibrotic cystic changes
• Traction bronchiectasis: Dilatation of bronchi and bronchioles within fibrotic lung tissue
• Lung architectural distortion
• Reticulation
• Interlobular septal thickening

Shrinking lung

• Reduced lung volumes with diaphragmatic elevation +/- occasional basal atelectasis but without any major parenchymal lung or pleural disease 
• Pulmonary infarction 
• Wedge-shaped (less often rounded) juxtapleural opacification (Hampton hump) without air bronchograms 
• Consolidation with an specific pattern called "bubbly consolidation" that is the co-existing non-infarcted lung parenchyma side-by-side with infarcted lung in the same lobule 
• Cavitation

Pneumonitis

unilateral or bilateral patchy and focal consolidation typically in the lung bases

accompanying pleural effusion may be present

Cardiac

Pericarditis

Noncalcified pericardial thickening with pericardial effusion is suggestive of acute pericarditis

Cardiomyopathy (ventricular dysfunction)

Valvular disease (diastolic murmur, or systolic murmur >3/6)

Pericarditis

Abnormal thickening and enhancement of the pericardium as well as a pericardial effusion in contrast-enhanced chest CT

neurology

CT scans are useful for detecting structural and focal abnormalities (such as infarcts/hypodense areas, hemorrhage, tumors, cerebral calcification, abscess, and basilar meningitis) [38]. Brain atrophy has been noted in some patients; this finding has been thought by some (but disputed by others) to reflect the effects of steroid therapy [6] or age [4]. We have seen brain atrophy out of proportion to a patient's age, and prior to steroid therapy.

Abdominal computed tomography (CT) scan fi ndings compatible with mesenteric vasculitis include prominence of mesenteric vessels with a comb-like appearance supplying dilated bowel loops, small bowel thickening and ascites. Excessive fatty infi ltration (steatosis) in liver/

Gastrointestinal

Bowel ischemia due to mesentric vascuitis

Organ	Disease	CT	SONO
Gastrointestinal system	Intestinal pseudo-obstruction	Dilated bowel loops with or without the presence of fluid levels A distinct transition point where bowel calibre changes from normal to abnormal Dilated bowel loops proximal to the transition point Small bowel >3.5 cm Large bowel >5 cm Collapsed or normal calibre bowel distal to the transitional point Bowel wall thickening Obstruction: Pneumoperitoneum indicating perforation Bowel ischaemia
	Hepatitis	Hepatic granulomas Nonspecific, ranging from normal to hepatomegaly and cirrhosis. Discrete, sharply defined nodular lesions within the liver
	Acute pancreatitis	Abnormalities that may be seen in the pancreas include: Typical findings Focal or diffuse parenchymal enlargement Changes in density because of edema Indistinct pancreatic margins owing to inflammation Mesenteric fatty infiltration around the pancreas Liquefactive necrosis of pancreatic parenchyma Lack of parenchymal enhancement Often multifocal Abscess formation Circumscribed fluid collection Little or no necrotic tissues (thus distinguishing it from infected necrosis) Phlegmon formation Haemorrhage High-attenuation fluid in the retroperitoneum or peripancreatic tissues	to identify gallstones as a possible cause diagnosis of vascular complications, e.g. thrombosis identify areas of necrosis which appear as hypoechoic regions
	Aotpsplenectomy	Abnormally small and irregular splenic remnant May show calcified spleen	Ultrasound will either not be able to demonstrate a spleen at all, or identify a small irregular and shadowing nodule in the splenic bed.
	Mesenteric vasculitis	Ascites Fluid in the abdomen  Dilated bowel Mural thickening Abnormal wall enhancement Mesentric vessel engorgement Comb sign Hypervascular appearance of the mesentery  Linear densities on the mesenteric side of the affected segments of small bowel, which lead to the appearance of the teeth of a comb
	Acute cholecystitis	gallbladder distension gallbladder wall thickening mural or mucosal hyperenhancement pericholecystic fluid and inflammatory fat stranding enhancement of the adjacent liver parenchyma due to reactive hyperaemia tensile gallbladder fundus sign 7 fundus bulging the anterior abdominal wall	gallbladder wall thickening (>3 mm) and pericholecystic fluid  Positive Murphy sign gallbladder distension
Pulmonary involvement	Pleural effusion	May be associated with thickening of the pleura Fluid density	echo-free space between the visceral and parietal pleura
	Pulmonary emboli	filling defects within the pulmonary vasculature with acute pulmonary emboli vascular CT signs include direct pulmonary artery signs complete obstruction partial obstruction eccentric thrombus calcified thrombus - calcific pulmonary emboli pulmonary arterial bands/pulmonary arterial webs 1,4-5 post stenotic dilatation signs related to pulmonary hypertension enlargement of main pulmonary arteries the peripheral pulmonary arteries in affected segments may be narrowed ref required pulmonary arterial calcification tortuous pulmonary vessels right ventricular enlargement/hypertrophy signs of systemic collateral supply enlargement of bronchial and nonbronchial systemic arteries Signs of chronic obstruction: webs or bands, intimal irregularities 3/ abrupt narrowing or complete obstruction of the pulmonary arteries 3 / “pouching defects” which are defined as chronic thromboembolism organised in a concave shape that “points” toward the vessel lumen parenchymal signs (often non-specific on their own): scars mosaic perfusion pattern focal ground-glass opacities bronchial anomalies The central filling defect from the thrombus is surrounded by a thin rim of contrast, appearing like the popular sweet, the polo mint
	Shrinking lung syndrome	reduced lung volumes with diaphragmatic elevation +/- occasional basal atelectasis but without any major parenchymal lung or pleural disease
Cardiac involvement	Mitral stenosis	valve thickening or leaflet fixation
	Acute pericarditis	enhancement of the thickened pericardium generally indicates inflammation
	Pericardial effuson	Fluid density material is seen surrounding the heart	Echocardiography is the method of choice to confirm the diagnosis, estimate the volume of fluid and most importantly assess the haemodynamic impact of the effusion
	Coronary artery disease	coronary CT angiography (cCTA) can show the amount of stenosis
Neurological involvement	Stroke	Early sign: a hyperdense segment of a vessel, representing direct visualisation of the intravascular thrombus / embolus and as such is visible immediately Early hyperacute: loss of grey-white matter differentiation, and hypoattenuation of deep nuclei cortical hypodensity with associated parenchymal swelling with resultant gyral effacement elevation of the attenuation of the cortex. This is known as the CT fogging phenomenon a region of low density with negative mass effect. Cortical mineralisation can also sometimes be seen appearing hyperdense.
	Raynaud phenomen		Doppler sonography: flow volume and vessel size irregularities