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Interstitial lung disease (ILD) and sarcoidosis
ILD presents with progressive breathlessness, "Velcro" crackles at the bases, a restrictive pattern with a low DLCO and a typical HRCT; in IPF treatment is antifibrotic and not steroids, while in sarcoidosis it is the reverse — steroids when treatment is needed.
Why it matters in the exam
Exam questions usually present a man over 60, a former smoker, with gradual breathlessness, a dry cough, clubbing and fine dry crackles at the bases. The candidate must recognise a restrictive pattern on lung function (low FVC, normal or high FEV1/FVC, low DLCO) and a UIP pattern on HRCT — basal subpleural reticulation, honeycombing and traction bronchiectasis. With a typical picture no biopsy is needed, and treatment is nintedanib or pirfenidone. Steroids and azathioprine harmed IPF patients in a trial, which is why they are a standard distractor.
The second theme is finding a cause: exposure to birds or mould (hypersensitivity pneumonitis), drugs (amiodarone, methotrexate, nitrofurantoin, bleomycin), connective tissue disease (systemic sclerosis, rheumatoid arthritis) or occupational exposure (asbestos at the bases with pleural plaques, silica in the upper lobes with a risk of tuberculosis). Sarcoidosis appears in a young adult with bilateral hilar lymph nodes, non-caseating granulomas and sometimes hypercalcaemia; Löfgren syndrome (erythema nodosum, hilar nodes and joint pain) usually settles on its own.
Key points
- ILD: restrictive pattern, low DLCO and dry basal crackles.
- IPF: UIP pattern on HRCT, treated with nintedanib or pirfenidone, not steroids.
- Sarcoidosis: young adult, bilateral hilar nodes, non-caseating granulomas, steroids only when needed.
- Always check drugs: amiodarone, methotrexate, nitrofurantoin, bleomycin.
- Asbestos affects the bases; silica affects the upper lobes and raises the risk of tuberculosis.
Summary table
| Disease | Clinical clue | HRCT / tests | Treatment |
|---|---|---|---|
| IPF | Man over 60, former smoker, clubbing | UIP: basal subpleural reticulation, honeycombing | Nintedanib or pirfenidone; not steroids |
| Hypersensitivity pneumonitis | Exposure to birds, mould or organic dust | Upper-mid zones, mosaic pattern and air trapping | Remove the exposure; steroids as needed |
| Sarcoidosis | Young adult, bilateral hilar nodes, hypercalcaemia | Non-caseating granulomas on biopsy | Observe; prednisone for symptoms or organ involvement |
| Drug-induced ILD | Amiodarone, methotrexate, nitrofurantoin, bleomycin | Various patterns | Stop the drug ± steroids |
| Occupational disease | Asbestos (bases, pleural plaques); silica (upper lobes) | Nodes with "eggshell" calcification in silicosis | Stop exposure; in silicosis check for tuberculosis |
A free exam question
מי מבין המחלות הבאות לא נחשבת כ- smoking related interstitial lung disease ? (the question as examined, in Hebrew)
- א. Lymphoid interstitial pneumonitis (LIP)
- ב. Usual interstitial pneumonitis (UIP)
- ג. Desquamative insterstitial pneumonitis (DIP)
- ד. Respiratory bronchiolitis interstitial lung disease (RB-ILD)
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Sources
- ATS/ERS/JRS/ALAT Clinical Practice Guideline: Idiopathic Pulmonary Fibrosis and Progressive Pulmonary Fibrosis in Adults, 2022 — Diagnosis by HRCT pattern and antifibrotic treatment
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Interstitial Lung Diseases; Sarcoidosis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.