[COVID-19 pneumonia]. / COVID-19-Pneumonie.

The prognosis of patients with the coronavirus disease 2019 (COVID-19) is determined by the severity of lower respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The majority of patients demonstrate mild symptoms only. However, development of pneumonia is associated with the risk of severe respiratory insufficiency. Reverse transcriptase polymerase chain reaction (RT-PCR) of specimens from the upper and/or lower respiratory tract is the gold standard for the diagnosis of COVID-19. Radiology and especially high-resolution computed tomography (HRCT) are important for diagnosis and follow-up. This narrative review provides an overview of clinical signs and the complex and unique pathophysiology of COVID-19 pneumonia. Radiological features are addressed. Therapy is mainly supportive with the most important task being management of respiratory insufficiency. Recently, promising data were presented regarding effectiveness of antiviral and anti-inflammatory drugs.

[COVID-19 pneumonia]. / COVID-19-Pneumonie.

Coronavirus disease 2019 (COVID-19) continues to pose a major global threat. Although a wide range of organ manifestations have now been described, the respiratory system remains in the forefront in terms of the course of infection. Severe pneumonia can develop and is generally prognostically relevant. The following article discusses currently known features of these pulmonary manifestations from a pathophysiological, symptomatological, and radiological perspective. With regard to pathophysiology, the complex nature of the acute pulmonary disease involving severe injury to the alveolar epithelium and pulmonary vascular endothelium resulting in severe respiratory failure in a proportion of patients is discussed. The differences from "classic" acute respiratory distress syndrome and the major effects these have on the treatment of COVID-19 are elucidated. Following a brief description of PCR-based pathogen identification and information on typical laboratory findings, imaging of COVID-19 pneumonia is described in greater details (typical findings, differential diagnoses, grading of the likelihood of COVID-19 pneumonia). This is followed by a description of symptoms, which develop in three phases. With regard to treatment, supportive and intensive care approaches are discussed, including O2 administration and (non-)invasive ventilation. The article concludes with a summary of the insights gained into pharmacological therapies: thrombosis prevention on the one hand, and specific antiviral and immunomodulatory therapies (remdesivir, tocilizumab, anakinra, dexamethasone) on the other.

[The Diagnosis is Obvious]. / Die Diagnose liegt auf der Hand.

Clinically amyopathic dermatomyositis (CADM) is a rare entity of dermatomyositis. As a rule, CADM presents without muscular involvement. Thus, the level of creatine kinase is most commonly within the normal range. Dermal manifestations of CADM are Gottron's papules and mechanic's hands. In the case of melanoma differentiation-associated gene 5 intracellular pathogen sensor (MDa5 antibodies), CADM is often associated with a rapidly progressive and severe form of interstitial lung disease. Pulmonary function tests reveal restriction and hypoxemia of varying degree. Features of ground-glass opacities, reticulations and consolidations are detected in high-resolution CT scan. Lymphocytes are sometimes predominant in bronchioloalveolar lavage. Pathologists see a picture similar to non-specific interstitial lung disease or organizing pneumonia. Pronounced immunosuppression is the most common therapy. However, sometimes a combination of different immunosuppressive therapies is necessary. A novel strategy to treat CADM with rapidly progressive interstitial lung disease is the Janus kinase inhibitor tofacitinib. Treatment can be monitored with the level of ferritin and MDa5-antibody titer. Mortality is as high as 84 %.

[Idiopathic pulmonary fibrosis : Radiological diagnosis in light of the current guidelines]. / Idiopathische pulmonale Fibrose : Radiologische Diagnose unter Berücksichtigung der aktuellen Leitlinie.

Idiopathic pulmonary fibrosis (IPF) is a specific form of chronic progressive fibrosing interstitial lung disease with a poor prognosis. High-resolution computed tomography (HRCT) plays an important role in the work-up of patients with suspected IPF. In HRCT IPF is characterized by the pattern of usual interstitial pneumonia (UIP). For a long time only supportive or immunosuppressive treatment was possible. The approval of antifibrotic agents in 2012 marked a turning point and triggered further clinical and scientific interest. Based on the recently gained knowledge the revised version of the international guidelines for the diagnosis of IPF was published in 2018, including instructions for HRCT interpretation. In this continued medical education article the relevant signs in HRCT are presented. The specifications given in the guidelines are elucidated.

[Crazy Paving Pattern of the Lung]. / Pflastersteine in der Lunge.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease. PAP results from impaired surfactant clearance. In adults, autoimmune pulmonary alveolar proteinosis is present in 90 - 95 % of the cases. In 5 - 10 %, other etiologies such as toxins and dust exposure, hematological disorders and infections have to be considered. Men between 30 - 60 years are commonly affected. Typical symptoms are cough, dyspnea and alteration in ventilatory function. CT scan of the lung is characterised by a crazy paving pattern. In serological testing, granulocyte macrophage colony-stimulation factor can be identified in most patients with autoimmune pulmonary alveolar proteinosis. Whole-lung lavage remains the therapy of choice. In the current case, treatment with whole-lung lavage resulted in clinical and functional improvement.

[Glossary of Terms for Thoracic Imaging--German Version of the Fleischner Society Recommendations]. / Glossar thoraxradiologischer Begriffe entsprechend der Terminologie der Fleischner Society.

UNLABELLED: The Fleischner Society has published several recommendations for terms for thoracic imaging. The most recent glossary was released in 2008. One glossary in German language was published in 1996. This review provides an updated German glossary of terms for thoracic imaging. It closely adheres to the Fleischner Society terminology. In some instances adaptions to the usage of German language were necessary, as well as some additions of terms which were later defined or redefined. These deviations are summarized in a revision report. KEY POINTS: The Fleischner Society has published a revised version of her glossary of terms for thoracic imaging in 2008. This paper presents a German adaption of this glossary. Some terms not contained in the original version have been added. The general use of the presented terminology in radiological reports is recommended.

[Drug-induced interstitial lung diseases: often forgotten]. / Medikamenteninduzierte interstitielle Lungenerkrankungen : Häufig vergessen.

Drug-induced interstitial lung diseases (DILD) are probably more common than diagnosed. Due to their potential reversibility, increased vigilance towards DILD is appropriate also from the radiologist's point of view, particularly as these diseases regularly exhibit radiological correlates in high-resolution computed tomography (HRCT) of the lungs.Based on personal experience typical relatively common manifestations of DILD are diffuse alveolar damage (DAD), eosinophilic pneumonia (EP), hypersensitivity pneumonitis (HP), organizing pneumonia (OP), non-specific interstitial pneumonia (NSIP) and usual interstitial pneumonia (UIP). These patterns are presented based on case studies, whereby emphasis is placed on the clinical context. This is to highlight the relevance of interdisciplinary communication and discussion in the diagnostic field of DILD as it is a diagnosis of exclusion or of probability in most cases.Helpful differential diagnostic indications for the presence of DILD, such as an accompanying eosinophilia or increased attenuation of pulmonary consolidations in amiodarone-induced pneumopathy are mentioned and the freely available online database http://www.pneumotox.com is presented.

[Management of solid pulmonary nodules]. / Management solider pulmonaler Rundherde.

The increasing availability of computed tomography has meant that the number of incidentally detected solitary pulmonary nodules (SPN) has greatly increased in recent years. A reasonable management of these SPN is necessary in order to firstly be able to detect malignant lesions early on and secondly to avoid upsetting the patient unnecessarily or carrying out further stressful diagnostic procedures. This review article shows how the dignity of SPNs can be estimated and based on this how the management can be accomplished taking established guidelines into consideration.

[Bone marrow edema in magnetic resonance imaging. A misleading term?]. / Knochenmarködem in der Magnetresonanztomographie. Ein irreführender Begriff?

Magnetic resonance imaging (MRI) is a mainstay in musculoskeletal imaging. The term"bone marrow edema" is frequently used for describing the radiological findings, especially with respect to rheumatic diseases. The referring physician should be aware that this term has a purely descriptive character and the pathophysiology of signal alterations in MRI shows a broad spectrum certainly not always corresponding to increased liquid contents. The recommendations therefore tend towards the use of the neutral terms"osteitis","bone marrow edema-like lesion" or"bone marrow lesion" instead of the misleading term"bone marrow edema".

Endovascular treatment of acute arterial hemorrhage in trauma patients using ethylene vinyl alcohol copolymer (Onyx).

PURPOSE: This study was designed to determine the feasibility and efficacy of endovascular embolization with liquid embolic agent ethylene vinyl alcohol copolymer (Onyx) in patients with acute traumatic arterial bleeding. METHODS: This is a retrospective review of 13 patients (9 men and 4 women; mean age 45 years) with severe trauma who underwent embolotherapy using Onyx from November 2003 to February 2009. Bleeding was located in the pelvis (5 patients), kidney (3 patients), mesenteric region (2 patients), retroperitoneal space (2 patients), neck (1 patient), and thigh (1 patient). In three cases (23.1%), Onyx was used in conjunction with coils. We evaluate the technical and clinical success, procedural and embolization time, occurrence of rebleeding, and embolotherapy-related complications, such as necrosis or migration of Onyx into nontarget vessels. RESULTS: In all patients, embolotherapy was technically and clinically successful on the first attempt. Control of bleeding could be reached with a mean time of 19 (range, 4-63) min after correct placement of the microcatheter in the feeding artery. No recurrent bleeding was detected. No unintended necrosis or migration of Onyx into a nontarget region was observed. During the follow-up period, three patients (23.1%) died due to severe intracranial hemorrhage, cardiac arrest, and sepsis. CONCLUSIONS: Transcatheter embolization with new liquid embolic agent Onyx is technically feasible and effective in trauma patients with acute arterial hemorrhage.

Multidetector computed tomography mesentericography for the diagnosis of obscure gastrointestinal bleeding.

PURPOSE: To evaluate the diagnostic yield of 16-row multidetector computed tomography (CT) mesentericography in patients with obscure gastrointestinal bleeding. MATERIALS AND METHODS: The radiological information system database was used to retrospectively identify all patients in whom CT mesentericography (CTM) was performed for the diagnosis of obscure gastrointestinal bleeding between July 2002 and September 2006. A subsequent prospective study was conducted between October 2006 and September 2009 to evaluate CTM in patients with major obscure gastrointestinal bleeding. The retrospectively identified patients (six patients) as well as the prospectively evaluated patients (seven patients) constitute the study population. Following mesenteric DSA the catheter was left in the superior mesenteric artery, the patient was transferred to the CT suite and CTM was carried out by scanning the abdomen after contrast material injection via the catheter. Active bleeding was suspected if a focal area of high attenuation consistent with contrast material extravasation was found within the bowel lumen. RESULTS: CTM detected the site of active bleeding in three of 13 patients (23 %). In the subpopulation of patients who were prospectively evaluated, CT mesentericography identified the site of active bleeding in one of seven patients (14 %). Depiction of active bleeding by CTM prompted surgical intervention in each case and surgery confirmed the findings of CT mesentericography. CONCLUSION: Due to the relatively low rate of positive findings and inherent drawbacks, we feel that CTM cannot be recommended in general. However, in selected patients who are continuously bleeding at a low rate and in whom iv-CT was negative, CT mesentericography might be helpful.

Semiquantitative characterization of hepatocellular carcinoma (HCC)--perfusion with contrast-enhanced ultrasound and perfusion analysis.

BACKGROUND: At the moment, there is only poor specificity of HCC-detection in tumors smaller than 2 cm in a cirrhotic liver. Thus, efforts have to be made to optimize the distinction between regenerative nodules and HCC. AIMS: The aim of our study was to describe the particular perfusion pattern of hepatocellular carcinoma using a specific quantification software. METHODS: We evaluated 25 patients with proven hepatocellular carcinoma, who underwent dynamic contrast-enhanced ultrasound (CEUS) using a second generation contrast agent (SonoVue, Bracco, Germany). Retrospectively, we applied the quantification software Qontrast (Bracco, Milan, Italy) to obtain contrast-enhanced sonographic perfusion maps for each lesion. RESULTS: We found a close positive correlation of the perfusion parameters peak, time-to-peak and regional blood volume between the entire tumors, the center (center/total) and the periphery of the tumors (periphery/total), respectively. Moreover, we found significant higher peak values, a significant higher regional blood volume and a trend to lower time-to-peak in the center of the tumors compared to the tumor periphery. CONCLUSION: These results suggest a better established vascular bed in the center of the tumors. This could be a sonographic marker of HCC in contrast to regenerative nodules.

[Characterization and management of incidentally detected solitary pulmonary nodules]. / Charakterisierung und Management inzidentell diagnostizierter solitärer Lungenrundherde.

How to deal with solitary pulmonary nodules (SPN) which are incidentally detected by computed tomography (CT) is an increasingly important task in the era of modern multislice CT. This paper reviews the morphological and functional characteristics and their value for discrimination between benign and malignant SPNs. In particular, the importance of nodule size, growth rate, margin morphology, density, calcifications or fatty components within the nodules, the significance of cavitations or aerobronchograms, enhancement patterns at dynamic contrast-enhanced CT and findings on positron emission tomography (PET) are discussed. The Bayesian analysis to calculate the probability of malignancy is presented. Finally, flow charts demonstrate the national and international recommendations for nodule management.

Severe acute pancreatitis requiring drainage therapy: findings on computed tomography as predictor of patient outcome.

BACKGROUND/AIMS: To evaluate whether morphologic features on computed tomography (CT) correlate with outcome of patients with severe acute pancreatitis (SAP). METHODS: 80 patients with SAP requiring percutaneous drainage therapy were retrospectively analyzed. Twelve CT features beyond the CT severity index (CTSI) were studied. Endpoints for patient outcome were patient death, length of hospital and ICU stay. The twelve features and the CTSI score were correlated with mortality using Kaplan-Meier estimator and correlated with length of hospital and ICU stay using the χ(2) test. A p value ≤0.05 was considered statistically significant. RESULTS: Two CT features exhibited a significant correlation with mortality: (1) the number of parts of pancreas (head, corpus, tail) that exhibited areas of necrosis and (2) the presence of distant fluid collections (posterior pararenal space and/or paracolic gutter). Mortality was 42% (21 of 50 patients) and 20% (6 of 30 patients) if two/all three parts or none/one part of the pancreas exhibited necrosis, respectively. Mortality was 46% (18 of 39 patients) and 22% (9 of 41 patients) if distant fluid collections were present or absent, respectively. All other imaging features including the CTSI showed no significant correlation with patient outcome. CONCLUSION: We identified two morphologic features on CT that might be helpful to predict prognosis of patients suffering from SAP. and IAP.

[A 47-year-old patient with longstanding nicotine abuse, increasing dyspnea on exertion and lower and peripheral lung predominant ground-glass opacities]. / 47-jähriger Patient mit langjährigem Nikotinabusus, zunehmender Belastungsdyspnoe und diffusen, peripher und basal betonten Milchglastrübungen in der Lunge.

The causal relationship between cigarette smoking and a number of interstitial lung diseases continues to evolve. These "smoking-related interstitial lung diseases" (SR-ILD) are a heterogeneous group of entities which have overlapping imaging findings and which can coexist. The presented case of a patient with smoking history and pulmonary ground-glass opacities demonstrates that thorough knowledge of the various manifestations of SR-ILD is essential for a confident diagnosis.

[A 74-year-old female patient with histologically proven carcinoid of the lungs and pulmonary mosaic pattern]. / 74-jährige Patientin mit histologisch gesichertem Karzinoid der Lunge und pulmonalem Mosaikmuster.

Diffuse idiopathic neuroendocrine cell hyperplasia (DIPNECH) can be idiopathic or reactive to chronic airway disease, then termed pulmonary neuroendocrine cell hyperplasia (PNECH). DIPNECH can be complicated by obliterative bronchiolitis and is presumably often misdiagnosed because the clinical symptoms are unspecific, the entity is relatively unknown and high-resolution computed tomography (HRCT) in inspiration and expiration is necessary for the diagnosis. However, the HRCT findings of air-trapping in combination with nodules are very characteristic and should raise suspicion of this entity. DIPNECH is thought to be a precursor of tumorlets and carcinoids and usually runs a benign course. The diagnosis is confirmed by histology.

Mucoid impaction secondary to mucin-producing metastatic adenocarcinoma of the cervix.

Endobronchial metastases are an uncommon complication of malignant tumours. The vast majority are secondary to carcinoma of the breast, colorectum and kidney, or to melanoma. Occasionally, endobronchial tumours can result in partial or complete bronchial obstruction. Here, we describe an uncommon case of endobronchial metastasis of adenocarcinoma of the cervix causing mucoid impaction owing to mucous production by the tumour cells.