CASES AND RADIOLOGICAL REVIEW OF PNEUMONIAS

Presenters:
Dr. Eman Attaya, MD
Assistant Professor of Radiology, Texas Tech University Health Science Center
Dr. Ebtesam Islam, MD, PhD, FCCP
Assistant Professor of Pulmonology, Texas Tech University Health Science Center

Handout prepared by:

Ahmed S. Negm, MBBCh, Cairo University School of Medicine

GOALS:

 Understand which imaging modalities are used to evaluate pneumonia.

 Recognize the different radiographic signs associated with pneumonia.
 Recognize specific patterns seen with different types of pneumonia.
 Develop a differential diagnosis for pneumonia.
 Be aware of complications of pneumonia.

DEFINITION:

 Pneumonia (PNA): infection of the lower respiratory tract by various organisms which results in
consolidation of lung.

 PNA is the single largest infectious cause of death in children worldwide. For US adults, PNA is the
most common cause of hospital admissions other than women giving birth.

 Methods of spread: upper respiratory tract, aspiration, hematogenous, exogenous (ETT).

 Infection of lung  inflammatory response  alveolar edema/exudate formation  alveoli and
bronchioles fill with proteinaceous fluid, neutrophils, RBCs, fibrin, organisms  consolidation.

IMAGING MODALITIES:

CHEST X-RAY (CXR):

 Chest radiography is the imaging modality of choice in the initial evaluation of patients with
suspected PNA.
 According to the American Thoracic Society (ATS), posteroanterior and lateral (if possible) chest
radiographs should be obtained.
  Establishes the presence of PNA, determines its extent and location, assesses treatment response,
diagnoses complications such as pleural effusion, pneumothorax.

CT SCAN:

 Seldom required in initial evaluation of patients with suspected PNA.

 Recommended in patients with clinical suspicion of infection with normal or nonspecific
radiographic findings.

 Allows better depiction of pattern and distribution of PNA.

 Greater sensitivity than CXR.

 Useful in assessment of suspected complications or suspicion of an underlying lesion/neoplasm.

 Obtain in patients with PNA and persistent recurrent pulmonary opacities.

ULTRASOUND (US):

 Main role is to assess for pleural effusion/empyema and guide for aspiration/drainage.

 However studies now suggest that lung US has higher sensitivity with similar specificity compared
to chest radiography for pneumonia and other conditions such as pleural effusion, pneumothorax
and pulmonary edema.
 Advantages: performed at patient beside in ER or ICU, radiation free, portable, real-time imaging.

RADIOLOGICAL SIGNS OF INFECTIONS:

 Imaging signs of thoracic infection: can be clinically useful in suggesting a specific diagnosis and
narrowing the differential diagnosis.
 Some of these signs may also be seen with noninfectious causes.

AIR BRONCHOGRAM SIGN (CXR/CT):

• Air filled bronchi become visible when surrounded by dense, consolidated lung parenchyma.
Silhouette sign (CXR):
 Loss of normal lung-soft-tissue interface caused by mechanism that replaces air;

 Lingular PNA will obscure the left heart border.

 Middle lobe PNA will obscure right heart border.

 Lower lobe PNA will obscure diaphragm.

BULGING FISSURE SIGN (CXR): Expansile lobar consolidation causing fissural bulging;
 Seen in Klebsiella and pneumococcal pneumonia.

TREE-IN-BUD SIGN (CT):

 Small airways or terminal bronchioles become visible when filled with mucus, pus, cells forming
impactions.
 Resemble budding tree with branching nodular V and Y shaped opacities;

 Infectious bronchiolitis from bacteria, fungi, parasites, viruses.

AIR-FLUID LEVEL SIGN: seen with lung abscess or empyema.

FINGER-IN-GLOVE SIGN (CXR/CT):

 Tubular and branching opacities that appear to emanate from the hila.

 Resemble gloved fingers which represent dilated bronchi impacted with mucus.

 Most commonly seen with ABPA (allergic bronchopulmonary aspergillosis).

MILIARY PATTERN (CT):
 Multiple small (< 3 mm) pulmonary nodules of similar size that are randomly distributed
throughout both lungs;

 Hematogenous dissemination of disease.

 Classically associated with tuberculosis.
 Also seen with other infections.

 Histoplasmosis and coccidioidomycosis.

CASE 1
 CHIEF COMPLAINT: Cough and fever for four days.

 HISTORY: 63 year old man who developed a harsh, productive cough four days prior to being
seen by a physician.
 The sputum is thick and yellow with streaks of blood. He developed a fever, shaking, chills and
malaise along with the cough.

 One day ago, he developed pain in his right chest that intensifies with inspiration. The patient
lost 15 lbs. over the past few months but claims he did not lose his appetite.

 Past Medical history: mild hypertension, bronchitis.

 Past Surgical: Cholecystectomy and hemorrhoids.
 Social: He smoked 2 packs of cigarettes per day for the past 50 years, no alcohol or drug use.

 Occupation: truck driver.

  PHYSICAL EXAMINATION:
 Vital signs: BP 152/90, HR: 99/minute and regular, RR: 24/minute and somewhat
labored, temperature 102.6.

 General: Underweight Elderly man who appears tired haggard and underweight, coughs
continuously. Sitting in a chair, he leans to his right side, holding his right chest with his
left arm.

 Lungs are resonant by percussion with one exception: the right mid-anterior and right
mid-lateral lung fields are dull.

 Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath

sounds, rhonchi and late inspiratory crackles are heard in the area of the right mid-
anterior and right mid-lateral lung fields. The remainder of the lung fields is clear.

 Cardiovascular: within normal limits.

 Fingers: show clubbing.

 Abdomen: within normal limits.

 LABORATORY: WBCs 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.

 CXR: Acute pneumonia in the right middle lobe.

 The patient was treated with antibiotics as an outpatient.

DIAGNOSIS: PNEUMONIA (N.B: If a patient has recurrent pneumonia, need to work up for other causes);

BACTERIAL PNEUMONIA:

 Patterns:
 Lobar.
 Brochopneumonia.
 Aspiration.
 Round.

LOBAR PNEUMONIA:

 Homogeneous airspace consolidation involving adjacent segments of lobe;

 Alveolar spaces fill with an inflammatory exudate, with little or no tissue damage.
 Consolidation begins in periphery of lung and spreads centrally.

 Bronchi usually spared (air bronchograms).

 Unilateral.

 Most commonly caused by Streptococcus pneumoniae.

BRONCHOPNEUMONIA:
 Patchy consolidation involving single or multiple lobes;

 Infection begins in epithelium and spreads to adjacent alveoli.

  Consolidation starts in peribronchiolar region and extends to involve lobules, segments
of lung.

 Airspace nodules.

 Bronchial wall thickening.

 Cavitation is common.
 Air bronchograms are rare.

 Also seen with fungi and viruses.

CASE 2

 CHIEF COMPLAINT: Cough.

 HISTORY: A 61 year alcoholic male with a history of COPD is admitted with a three week history
of fever, generalized weakness, poor appetite, and cough productive of green, foul smelling
sputum.
 Past Medical history: COPD.

 Past Surgical: None.

 Social: 1ppd/47 years smoking, alcohol 1/5th (750mls) vodka daily for 20 years and history of
cocaine use.

 Occupation: retired.
PHYSICAL EXAMINATION:

 Vital signs: BP 120/80, HR: 96/minute and regular, RR: 20/minute and somewhat labored,
temperature 100.3 degrees.
 General: disheveled, anorexic.
  HEENT (Head, Eyes, Ears, Nose, and Throat): missing teeth with gingivitis and dental caries.
 Lungs: rales and decreased breath sounds over the right base.

 Cardiovascular: within normal limits.

 Abdomen: protuberant, soft, and nontender.

 CXR: consolidation in the superior segment of the right lower lobe.

DIAGNOSIS: ASPIRATION PNEUMONIA;

 Risk factors: alcoholism, poor oral hygiene, reduced consciousness (anesthesia, seizures,)
esophageal/swallowing disorders.

 Patchy or confluent consolidation in dependent portions of lungs (bronchopneumonia pattern).

 Right lung > left lung.

 Upright patients: basal segments of lower lobes.

 Recumbent patients: posterior segments of upper lobes, superior segments lower lobes.

ROUND PNEUMONIA:

 Most common in children.

 Majority are solitary and occur in superior segments lower lobes.
  Air bronchograms usually present.
 Streptococcus is the most common etiology.

CASE 3
 CHIEF COMPLAINT: Fever and nonproductive cough for four days.

 HISTORY: 17 year old female hay fever develops fever, headache and malaise for 4 days
followed by a nonproductive cough and scratchy throat.
 Past Medical history: none.
 Past Surgical: None.
 Social: no smoking, no alcohol or drug use.

 Occupation: student.

PHYSICAL EXAMINATION:
 Vital signs: BP 110/70, HR: 90/minute and regular, RR: 20/minute and somewhat labored,
temperature 101.

 General: within normal limits.

 Lungs: scattered rales over the left lower lung.

 Cardiovascular: within normal limits.

 Abdomen: within normal limits.

 CXR: reveals a patchy left lower lobe infiltrate. Per request, she makes a heroic effort but is unable
to produce sputum.
 DIAGNOSIS: ATYPICAL PNEUMONIA;
 Causative organisms: Mycoplasma, Chlamydia, Legionella.

 Mycoplasma is the most common cause of community acquired PNA in 5-20 years old.

 Inflammation is mainly limited to the pulmonary interstitium and the interlobular septa:
reticulonodular or patchy opacities, especially in perihilar lung.
 Subsegmental and sometimes segmental atelectasis from small airway obstruction.

 Involves lower lobes.

CASE 4

 CHIEF COMPLAINT: shortness of breath.

 HISTORY: 31 year old female presenting with cough and brownish mucus production and
wheezing.

 Past Medical history: Asthma.

 Past Surgical: none.

 Social: no smoking, no alcohol or drug use.

 Occupation: resident.
PHYSICAL EXAMINATION:
 Vital signs: BP 120/80, HR: 110/minute and regular, RR: 37/minute, SpO2: 86% on room air and
somewhat labored, temperature 101.

 General: thin.

 HEENT: sinus pressure.

 Lungs: audible wheezing.
 Cardiovascular: tachycardia.

 Abdomen: within normal limits.

 LABORATORY: WBCs 17,000/mm3; eosinophil count (>500cells/microL), elevated total serum IgE
> 1000IU/ml.

 CXR: Parenchymal opacities of upper lobes.

DIAGNOSIS: FUNGAL PNEUMONIA;

 Aspergillosis: develops in immunocompromised patients;

 Aspergilloma: upper lobe rounded mass in cavity (Air-crescent sign).

 Allergic bronchopulmonary aspergillosis (seen in asthmatics and cystic fibrosis):
bronchial dilatation with mucus impaction (Finger-in-glove sign).
 Airway invasive aspergillosis: tree-in-bud.

 Histoplasmosis/coccidiodomycosis/blastomycosis: nodules with or without calcification.

VIRAL PNEUMONIA:

 Chest X-ray: normal, unilateral or patchy bilateral areas of consolidation, nodular opacities,
bronchial wall thickening, small pleural effusions.

 Lobar consolidation is uncommon.

 CT scan:
 Parenchymal attenuation disturbances: mosaic attenuation of lungs.
 Ground glass opacity and consolidation.

 Nodules, micronodules, tree-in-bud opacities: nodules less than 10 mm likely to

represent viral infection.

 Interlobular septal thickening.

 Bronchial and bronchiolar wall thickening.
Mosaic attenuation: Ground Glass Opacities (GGOs):

Nodules: Bronchial Wall Thickening:

CASE 5
 CHIEF COMPLAINT: loss of taste and smell, shortness of breath.
 HISTORY: 47 year old Hispanic male with anosmia for 3 days presents with increasing dyspnea
on exertion.

 Past Medical history: Diabetes Mellitus (Type II).

 Past Surgical: cholecystectomy.

 Social: no smoking, no alcohol or drug use.

 Occupation: office worker.

PHYSICAL EXAMINATION:

 Vital signs: BP 87/40, HR: 110/minute and regular, RR: 37/minute, SpO2: 86% on room air and
somewhat labored, temperature 104.
 General: Obese, dehydrated.
  Lungs: scattered rales and bronchial breath sounds.
 Cardiovascular: tachycardia.

 Abdomen: within normal limits.

 CXR: bilateral “patchy” and/or “confluent, bandlike” ground glass opacity or consolidation.

 Patient is urgently intubated.

 Day 7 of vent with high peeps.

 Intern notices a decrease SpO2 on the monitor.

Physical Examination:

 Patient has decreased breath sounds on the right.

 Subcutaneous emphysema of the chest on the right and up to the neck.

 CXR: Pneumothorax & pneumomediastinum.

DIAGNOSIS: COVID-19 PNEUMONIA;

 Findings on CXR: The presence of bilateral “patchy” and/or “confluent, bandlike” ground glass
opacity (GGO) or consolidation in a peripheral and mid-to-lower lung zone distribution on a chest
radiograph obtained in the setting of pandemic COVID-19 is highly suggestive of SARS-CoV-2
infection.
IMAGING CLASSIFICATION OF CT FEATURES OF COVID-19 PNEUMONIA:

Rezvin et al, Radiographics

 Simpson S. Published Online: March 25, 2020, https://doi.org/10.1148/ryct.2020200152

TEMPORAL EVOLUTION OF COVID-19 PNEUMONIA:

 Early stage (0-5 days after symptom onset);

 Normal or mainly GGO.

 Progressive stage (5-8 days);

 Increased GGO and crazy-paving appearance.

 Peak stage (9-13 days);

 Progressive consolidation.

 Late stage (> 14 days);

 Gradual decrease of consolidation and GGO, with fibrosis (parenchymal bands,

architectural distortion, traction bronchiectasis).
MYCOBACTERIAL PNEUMONIA:
 Primary Tb: Disease that develops after initial exposure;

 Hilar or mediastinal lymphadenopathy with low density centers, patchy consolidation,

pleural effusion, and cavitation is rare.

 15% of radiographs are normal.

 Post-primary Tb: Disease that results from reactivation of a previous focus of TB or reinfection;

 Mainly apical and posterior segments upper lobes and superior segments of lower
lobes.

 Patchy consolidation, poorly defined nodules, and linear opacities.

 Cavitation is more common.

 Miliary is seen in both.

PRIMARY TB:
POST-PRIMARY TB:

DIFFERENTIAL DIAGNOSIS OF PNEUMONIA:

 Atelectasis.
 Pulmonary edema.
 Hemorrhage.
 Neoplasm.

ATELECTASIS VS PNEUMONIA:
 Both can have air bronchograms.

 Look for signs of volume loss: bronchovascular crowding, fissural displacement, mediastinal
shift, and diaphragmatic elevation.

 Atelectasis shows more enhancement with >85 HU compared to pneumonia.

LUNG CANCER VS PNEUMONIA:

 Spiculated margins, vessel sign, and pleural retraction/pleural thickening.

 Short, tortuous, and stenotic air bronchograms.

COMPLICATIONS OF PNEUMONIA:

 Lung abscess.
 Empyema.
 Septicemia.
 Necrosis.
 Pneumatoceles.
 Scarring.

Which of the following is correct:

A. Pneumonia is an infection of the upper respiratory tract.

B. Pneumonia is the single largest cause of death in children worldwide.
C. Pneumonia is the single largest cause of death in adults worldwide.
D. Hospital admissions from pneumonia are infrequent.

ANSWER: B

Concerning imaging modalities, select the best answer:

A. CT is frequently required in the initial evaluation of patients with pneumonia.

B. Chest radiography should NOT be used in the initial evaluation of patients with pneumonia.
C. Lung ultrasound has a higher sensitivity than chest radiography for the detection of pneumonia.
D. Anteroposterior radiographs should be obtained for the evaluation of pneumonia.

ANSWER: C

According to the silhouette sign, which of the following is correct:

A. Lower lobe pneumonia will obscure the hemidiaphragms.

B. Lingular pneumonia will obscure the hemidiaphragm.
C. Middle lobe pneumonia will obscure the right heart border.
D. A and C are correct.
E. B and C are correct.

ANSWER: D

Which statement is true concerning bacterial pneumonia:

A. Cavitation is common with bronchopneumonia.

 B. Staphylococcus is the most common etiology in lobar and round pneumonia.
C. Aspiration pneumonia is more common in the left lower lobe.
D. Round pneumonia is more common in adults.

ANSWER: A

Choose the correct statement:

A. The finger in glove sign is seen Mycoplasma pneumonia.

B. Aspergillosis usually develops in immunocompromised patients.
C. Lobar consolidation is common in viral pneumonia.
D. Nodules greater than 10mm are likely to be viral in etiology.

ANSWER: B

The typical appearance of COVID-19 pneumonia includes:

A. Miliary pattern of small nodules

B. Lung cavitation
C. Lobar or segmental consolidation
D. Peripheral, bilateral, multifocal groundglass rounded opacities.

ANSWER: D

The predominant finding in late stage COVID-19 pneumonia is:

A. Normal
B. Fibrosis with architectural distortion
C. Predominantly ground glass opacities
D. None of the above

ANSWER: B

Concerning Mycobacterial pneumonia, which statement is true:

A. Cavitation is more common in primary TB

B. 50% of radiographs are normal in primary TB
C. Lymphadenopathy with low density center is seen with primary TB
D. Hilar or mediastinal lymphadenopathy is more common in postprimary TB

ANSWER: C
The differential diagnosis for pneumonia includes:

A. Atelectasis
B. Edema
C. Hemorrhage
D. Neoplasm
E. All of the above

ANSWER: E

Which of the following is a reliable tool to help distinguish atelectasis from pneumonia:

A. The presence of air bronchograms

B. Signs of volume loss including diaphragmatic elevation
C. The enhancement of parenchyma greater than 85 Hounsefield Units
D. B and C.

ANSWER: D