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http://emedicine.medscape.com/article/360090-overview
Overview
Pneumonia is the sixth leading cause of death, and the number 1 cause of death from infectious disease, in the United States.[1, 2, 3, 4, 5, 6, 7] The image below depicts typical bacterial pneumonia.
Image in a 49-year-old woman with pneumococcal pneumonia. The chest radiograph reveals a left lower lobe opacity with pleural effusion.
Preferred examination
Chest radiography with posteroanterior and lateral views is the preferred imaging examination for the evaluation of typical bacterial pneumonia.[8]
Radiography
When patients present with fever, chills, or cough, pneumonia is suggested on the basis of focal or diffuse opacities. Controversy exists with regard to the time required for an opacity to appear on chest radiographs. The vast majority of opacities appear within 12 hours. When patients are referred from the community to the radiologist, adequate time has usually lapsed for its detection. However, when nosocomial pneumonia is suspected, these patients may undergo chest radiography within a few hours, when opacities may not yet be visible on radiographs.[9, 10, 11, 12, 13, 14, 15, 16, 17,
18, 19]
In immunosuppressed patients, especially those with coexistent neutropenia, diabetes, alcoholism, or uremia, the appearance of infiltrates may also be delayed. Other findings that suggest the presence of pneumonia include air bronchograms; the silhouette sign; parapneumonic effusions; and complications of pneumonia, such as lung abscesses, and atelectasis. Findings that have been associated with an increased mortality, as shown in the multicenter trial by Hasley and colleagues, are bilateral pleural effusion and multilobar pneumonia.
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S pneumoniae pneumonia
S pneumoniae causes 10-50% of all cases of community-acquired pneumonia (CAP). Radiographic consolidation of the alveoli begins in the peripheral airspaces, as in the image below. The disease usually causes a lobar or segmental pattern, and a patchy bronchopneumonic pattern involving the lower lobes is seen in the elderly. A striking characteristic of S pneumoniae infection is its tendency to involve the pleura. Parapneumonic effusions are common in pneumococcal pneumonia.[20]
Image in a 49-year-old woman with pneumococcal pneumonia. The chest radiograph reveals a left lower lobe opacity with pleural effusion.
In patients with bacteremic pneumococcal patients, 50% had clear radiographs at 9 weeks, compared with 5 weeks in nonbacteremic pneumococcal pneumonia. In patients older than 50 years with both alcoholism and COPD, 60% have an abnormal chest radiograph at 14 weeks. In patients younger than 50 years with bacteremia and no underlying illness, 40% have an abnormal chest image at 2 weeks. For the group as a whole, 37% have residual consolidation at 4 weeks, with complete resolution by 18 weeks in almost all patients. Despite therapy during the initial phase of illness, 52% of bacteremic patients compared with 26% of nonbacteremic patients had radiographs showing deterioration. Jay and colleagues recommended that an appropriate interval for serial radiographic examination is 6 weeks, unless otherwise indicated by a patient's worsening clinical status.
H influenzae pneumonia
H influenzae pneumonia, shown in the image below, is commonly seen in COPD patients who are smokers; in the elderly; and in those with alcoholism diabetes, sickle cell anemia, or immunocompromise. This organism can be present in up to 38% of outpatients and 10% of hospitalized patients with CAP.
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Image in a 48-year-old patient with Haemophilusinfluenzae pneumonia. The chest radiograph shows bilateral opacities with a predominantly peripheral distribution.
In most patients, radiographs demonstrate a patchy bronchopneumonic pattern, but segmental and lobar consolidation may be seen. Therefore, H influenzae pneumonia is indistinguishable from pneumococcal pneumonia. Pleural effusion is a common finding.Radiographs usually show a multilobar infiltrate and pleural effusions in 50% of cases. Resolution is usually slow.
S aureus pneumonia
This type of pneumonia may be seen as a complication of influenza, particularly during an epidemic. S aureus pneumonia usually begins in the peripheral airways rather than in the acini proper. In adults, patchy bronchopneumonia is more common and often bilateral, though lobar consolidation may be seen. Late development of abscesses is relatively common. When staphylococcal pneumonia occurs as a complication of influenza, it is usually rapidly progressive with extensive bilateral pneumonia that resembles pulmonary edema. In children, it is usually a lobar or multilobar consolidation, rapidly progressing with the development of pneumatoceles and/or empyema. The presence of pneumatoceles in children is virtually diagnostic of staphylococcal pneumonia. Rapid progression is seen with lobar or multilobar consolidation. Pneumatoceles may rapidly develop, and empyema is frequent.[21]
Degree of confidence
In patients with underlying structural lung disease, the appearance of the various signs of pneumonia may not be straightforward. Narrowing the differential diagnosis of pneumonia into typical and atypical forms on the basis of radiographic appearance alone is not reliable, as shown in a prospective study by Fang et al.[22]
Computed Tomography
Computed tomography (CT) scanning is increasingly used in clinical practice, but various groups have questioned its usefulness in evaluating pneumonia. Their reports have suggested that its usefulness in the diagnosis of pneumonia is limited to the following settings: Evaluation of an indistinct, abnormal opacity depicted on a chest radiograph Assessment of patchy, ground-glass, or linear/reticular opacities on chest radiographs Confirmation of pleural effusion Examination of neutropenic patients with fever of unknown origin (with the use of ultrathin-section CT scanning) In clinical practice, coinfection with multiple organisms is not rare, and underlying abnormalities of the lung parenchymal usually predispose patients to pneumonia. Hence, the overall clinical and radiologic picture must be considered.[23] CT scans of typical bacterial pneumonia are provided below.
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Image in a 49-year-old patient with pneumococcal pneumonia. This chest CT shows a left upper lobe opacity extending to the periphery.
Image in a 50-year-old patient with Haemophilus influenzaepneumonia. The chest CT shows a very dense round area of consolidation adjacent to the pleura in the left lower lobe.
Ultrasonography
The literature indicates that ultrasonography can aid in the differentiation of consolidation and effusion. Consolidated lung tissue may appear as hypoechoic areas with blurred margins. The texture varies with the amount of aeration, being more heterogeneous with aeration and homogenous with dense consolidation.[24] Ultrasonography may also help in diagnosing empyema and abscesses.
Degree of confidence
The role of ultrasonography in clinical practice is limited to the identification and quantification of parapneumonic effusions. This area can then be marked for subsequent diagnostic or therapeutic thoracentesis.
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Specialty Editor Board Satinder P Singh, MD, FCCP Professor of Radiology and Medicine, Chief of Cardiopulmonary Radiology, Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of Radiology, University of Alabama at Birmingham Disclosure: Nothing to disclose. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand Disclosure: Nothing to disclose. Eric J Stern, MD Professor of Radiology, Adjunct Professor of Medicine, Adjunct Professor of Medical Education and Biomedical Informatics, Adjunct Professor of Global Health, University of Washington School of Medicine Eric J Stern, MD is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, European Society of Radiology, Radiological Society of North America, and Society of Thoracic Radiology Disclosure: Nothing to disclose. Robert M Krasny, MD Resolution Imaging Medical Corporation Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America Disclosure: Nothing to disclose. Chief Editor Kavita Garg, MD Professor, Department of Radiology, University of Colorado Health Sciences Center Kavita Garg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Thoracic Radiology Disclosure: Nothing to disclose.
References
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10. Brolin I, Wernstedt L. Radiographic appearance of mycoplasmal pneumonai. Scand J Respir Dis. Aug 1978;59(4):179-89. [Medline]. 11. Coletta FS, Fein AM. Radiological manifestations of Legionella/Legionella-like organisms. Semin Respir Infect. Jun 1998;13(2):109-15. [Medline]. 12. Dietrich PA, Johnson RD, Fairbank JT, Walke JS. The chest radiograph in legionnaires' disease. Radiology. Jun 1978;127(3):577-82. [Medline]. 13. Foy HM, Loop J, Clarke ER, et al. Radiographic study of mycoplasma pneumoniae pneumonia. Am Rev Respir Dis. Sep 1973;108(3):469-74. [Medline]. 14. Goodman LR, Goren RA, Teplick SK. The radiographic evaluation of pulmonary infection. Med Clin North Am. May 1980;64(3):553-74. [Medline]. 15. Hasley PB, Albaum MN, Li YH, et al. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?. Arch Intern Med. Oct 28 1996;156(19):2206-12. [Medline]. 16. Lynch DA, Armstrong JD. A pattern-oriented approach to chest radiographs in atypical pneumonia syndromes. Clin Chest Med. Jun 1991;12(2):203-22. [Medline]. 17. Macfarlane JT, Miller AC, Roderick Smith WH, et al. Comparative radiographic features of community acquired Legionnaires' disease, pneumococcal pneumonia, mycoplasma pneumonia, and psittacosis. Thorax. Jan 1984;39(1):28-33. [Medline]. 18. Tew J, Calenoff L, Berlin BS. Bacterial or nonbacterial pneumonia: accuracy of radiographic diagnosis. Radiology. Sep 1977;124(3):607-12. [Medline]. 19. Zornoza J, Goldman AM, Wallace S, et al. Radiologic features of gram-negative pneumonias in the neutropenic patient. Am J Roentgenol. Dec 1976;127(6):989-96. [Medline]. 20. Jay SJ, Johanson WG, Pierce AK. The radiographic resolution of Streptococcus pneumoniae pneumonia. N Engl J Med. Oct 16 1975;293(16):798-801. [Medline]. 21. Don M, Canciani M, Korppi M. COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN: WHAT'S OLD? WHAT'S NEW?. Acta Paediatr. Jun 22 2010;[Medline]. 22. Fang GD, Fine M, Orloff J, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore). Sep 1990;69(5):307-16. [Medline]. 23. Shiley KT, Van Deerlin VM, Miller WT Jr. Chest CT features of community-acquired respiratory viral infections in adult inpatients with lower respiratory tract infections. J Thorac Imaging. Feb 2010;25(1):68-75. [Medline]. 24. Beckh S, Bolcskei PL, Lessnau KD. Real-time chest ultrasonography: a comprehensive review for the pulmonologist. Chest. Nov 2002;122(5):1759-73. [Medline]. [Full Text]. Medscape Reference 2011 WebMD, LLC
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