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Sandhya Samavedam1, Vimal Ravi1
1. Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, United States.

Purpose of Study: 'Tree-in-bud' pattern is usually seen on thin section-CT scan of chest. This is seen in multiple respiratory conditions. It is important to recognize this important radiologic sign for an accurate diagnosis.

Methods Used: A 55-year-old Russian female with past medical history of coronary artery disease presented with cough, chest pain, shortness of breath and low grade fevers for 1 week. Physical exam showed bilateral crackles at lung bases and mild leg edema. Oxygen saturation was above 95% on room air. EKG, BNP and other laboratory results were within normal limits. Chest X-ray showed mild pulmonary edema. Patient's physical exam and diagnostic studies were not consistent with any particular diagnosis. Hence, a CT chest was done which showed appearance of the so-called tree-in-bud pattern. Based on CT finding, symptoms and history of immigration, a PPD skin test and tests for atypical pneumonia were ordered. Emperic antibiotics for pneumonia were started. Serology for Mycoplasma pneumonia was positive. PPD skin test was negative. Patient's symptoms dramatically improved with antibiotics.

Summary of Results: 'Tree-in-bud' pattern is seen when peripheral airways are filled with pus or fluid with peribronchial inflammation. These airways get well demarcated on CT scan giving a tree like pattern. When respiratory bronchioles and alveolar ducts are inflamed, a bud like pattern is seen. Hence the name 'Tree-in-bud'. It is seen in a variety of conditions. This was originally described in endobronchial spread of Mycobacterial Tuberculosis. Subsequently, it was described in multiple conditions aspiration, atypical Mycobaterial infections, Pneumonia (Staphylococcus Aureus, Hemophilus Influenza and Mycoplasma pneumonia), Aspergillosis, low grade adenocarcinoma, immunological diseases etc.

Conclusions: Knowledge of pathophysiology and etiology of this CT sign is important to make a correct and timely diagnosis.
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