CTICasesChronic Lung Allograft Rejection: Upper Lobe Scarring Pattern
Imaging findings
Sequential chest radiographs in two bilateral lung transplant patients demonstrate progressive upper lobe fibro-consolidative scarring developing over several years from a previously clear baseline, consistent with chronic allograft dysfunction. CT shows predominantly non-subpleural upper lobe fibrosis with a pristine, uninvolved visceral pleura, argued to be distinct from true pleuroparenchymal fibroelastosis (PPFE).
Key takeaways
Chronic lung allograft rejection (CLAD) can manifest as an upper lobe scarring pattern on imaging that has been mislabeled as pleuroparenchymal fibroelastosis (PPFE). However, true PPFE requires subpleural fibrosis with pleural involvement as a defining histologic feature, which is often absent in transplant-associated upper lung scarring. This distinction is important as PPFE and CLAD have different natural histories and management implications.
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