Eur Radiol (2003) 13:515521

DOI 10.1007/s00330-002-1490-3 CHEST

Pia Reittner Pneumonia: high-resolution CT findings

Suzanne Ward
Laura Heyneman in 114 patients
Takeshi Johkoh
Nestor L. Mller

Received: 11 September 2001
Revised: 21 March 2002
Accepted: 2 April 2001
Published online: 3 August 2002
Springer-Verlag 2002
P. Reittner () S. Ward L. Heyneman
N.L. Mller
Department of Radiology,
Vancouver Hospital
and Health Sciences Center,
855 W. 12th Ave., Vancouver, BC,
Canada V5Z 1M9
e-mail: pia-reittner@kfunigraz.ac.at
Tel.: +43-316-3852870
Fax: +43-316-3854149
P. Reittner
Department of Radiology,
Karl Franzens University
and University Hospital Graz,
Auenbruggerplatz 9, 8036 Graz, Austria
T. Johkoh
Department of Radiology,
Osaka University Medical School,
22 Yamadaoka, Suita, Osaka 5650825,
Japan
Abstract The objective of the pres-
ent study was to assess the high-reso-
lution CT appearances of different
types of pneumonia. The high-resolu-
tion CT scans obtained in 114 pa-
tients (58 immunocompetent, 59 im-
munocompromised) with bacterial,
Mycoplasma pneumoniae, viral, fun-
gal, and Pneumocystis carinii pneu-
monias were analyzed retrospectively
by two independent observers for
presence, pattern, and distribution of
abnormalities. Areas of air-space
consolidation were not detected in
patients with viral pneumonia and
were less frequently seen in patients
with Pneumocystis carinii pneumo-
nia (2 of 22 patients, 9%) than in
bacterial (30 of 35, 85%), Mycoplas-
ma pneumoniae (22 of 28, 79%), and
fungal pneumonias (15 of 20, 75%;
p<0.01). There was no significant
difference in the prevalence or distri-
bution of consolidation between bac-
terial, Mycoplasma pneumoniae, and
fungal pneumonias. Extensive sym-
metric bilateral areas of ground-glass
attenuation were present in 21 of 22
(95%) patients with Pneumocystis
carinii pneumonia and were not seen
in other pneumonias except in associ-
ation with areas of consolidation and
nodules. Centrilobular nodules were
present less commonly in bacterial
pneumonia (6 of 35 patients, 17%)
than in Mycoplasma pneumoniae
(24 of 28, 96%), viral (7 of 9, 78%),
or fungal (12 of 20, 92%) pneumonia
(p<0.01). Except for Pneumocystis
carinii pneumonia and Mycoplasma
pneumoniae pneumonia, which often
have a characteristic appearance,
high-resolution CT is of limited
value in the differential diagnosis of
the various types of infective pneu-
monia.
Keywords High-resolution CT
Pneumonias

Introduction graph provides adequate imaging information and CT is

It has been estimated that 4 million cases of pneumonia
occur each year in the United States [1, 2]. Despite the
availability of antimicrobial agents, pneumonias consti-
tute the sixth most common cause of death and are the
number one cause of death from infections [1, 2, 3, 4].
Imaging plays a crucial role in the detection and man-
agement of patients with pneumonia [5]. The chest ra-
diograph is usually the first imaging modality obtained
for the evaluation of acute respiratory symptoms. In the
majority of patients with pneumonia, the chest radio-
not warranted [4]; however, an increasing number of pa-
tients undergo CT, particularly high-resolution CT, when
there is a high clinical suspicion for pneumonia in the
presence of normal or questionable radiographic findings
[6, 7, 8, 9, 10, 11, 12]. The CT is also helpful in assess-
ing complications or evidence of mixed infections in pa-
tients with known pneumonia who are failing to respond
to appropriate therapy [13, 14, 15].
Description of the high-resolution CT findings of
pneumonia have been limited to a small number of pa-
tients and almost exclusively to pneumonia in the immu-
516
Table 1 Causative agents of
pneumonias (n=114)
Bacterial: n=35 (31)a
Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pneumoniae
Mycoplasma pneumoniae: n=28 (24)
Pneumocystis carinii: n=22 (19)
Fungal: n=20 (17)
Aspergillus fumigatus
Candida albicans
Viral: n=9 (8)
a Numbers
Cytomegalovirus
in parentheses are Epstein-Barr virus
percentages
nocompromised host [6, 7, 8, 9, 16, 17, 18, 19]. The pur-
poses of this study were to assess the high-resolution CT
findings of pneumonias in a relatively large number of
both immunocompromised and immunocompetent pa-
tients, and to determine whether the pattern of abnormal-
ities on high-resolution CT are helpful in suggesting a
specific infectious agent.
Materials and methods
The study was retrospective and included 114 patients with vari-
ous types of pneumonia, who underwent high-resolution CT at
two different academic centers. Patients were identified through a
review of patients, who had undergone chest CT for suspected
pulmonary infection. Patients with tuberculosis and non-tubercu-
lous mycobacterial infections were excluded from the study. The
study population consisted of 66 men and 48 women, ranging in
age from 8 to 87 years (mean age 45 years, SD 14 years). Fifty-
eight patients (51%) were immunocompetent and 56 (49%) immu-
nocompromised. Immunosuppression was the result of bone
marrow transplantation (n=22), hematologic malignancies such as
leukemia or lymphoma (n=17), acquired immunodeficiency syn-
drome (n=8), solid organ transplantation (n=6), chemotherapy of
tumors (n=2), and immunosuppressive treatment for systemic
lupus erythematosus (n=1).
The pneumonias were due to bacterial infection (n=35), Myco-
plasma pneumoniae (n=28), Pneumocystis carinii (n=22), fungi
(n=20), and viruses (n=9). The organisms and their relative fre-
quencies are listed in Table 1. A microbiologic diagnosis was
made in all patients. Specific diagnoses were obtained from posi-
tive culture of sputum (n=35), bronchoalveolar lavage (n=21),
open-lung biopsy (n=19), transbronchial biopsy (n=10), autopsy
(n=1), or in Mycoplasma pneumoniae pneumonia (n=28) from se-
rologic tests with elevated single titers or a fourfold rise in titer.
High-resolution CT scans were performed on a GE 9800, Hi
Speed Advantage (GE Medical Systems, Milwaukee, Wis.), or
CT-W 2000 (Hitachi Medical Corp, Tokyo, Japan) CT scanner.
The images were obtained at 10-mm intervals throughout the chest
using 1.0-mm (n=75) or 1.5-mm collimation (n=39). The scans
were reconstructed using a high spatial frequency algorithm. The
images were photographed at window settings appropriate for the
assessment of lung parenchyma (level: 600 to 700 HU; width:
10001500 HU) and mediastinum (level: 3040 HU; width:
400500 HU).
Immunocompetent Immunocompromised
patient (n=58) patient (n=56)
14 (24)a
16 (27)
3 (5)
2 (3)
28 (48)
22 (39)
15 (27)
5 (9)
7 (12)
2 (3)
The scans were interpreted independently by two radiologists
for the presence, appearance, and distribution of parenchymal, me-
diastinal, and pleural abnormalities. The patterns of parenchymal
changes were subdivided into air-space consolidation, ground-
glass attenuation, nodules, and reticulation. Ground-glass attenua-
tion was defined as an area of hazy increased attenuation without
obscuration of underlying vascular markings. Airspace consoli-
dation was considered present when the underlying vessels were
obscured. Reticulation consisted of interlobular septal thickening
or intralobular reticular opacities.
The anatomic distribution for air-space consolidation and
ground-glass attenuation was noted to be non-segmental, segmen-
tal, or lobular. A non-segmental distribution was considered pres-
ent when areas of opacification were confluent and extended be-
yond segmental boundaries [1]. A segmental distribution was con-
sidered present when the opacification was patchy, peribronchial,
or peribronchiolar, and did not cross segmental boundaries [1].
Lobular consolidation was considered present when the consolida-
tion involved entire secondary lobules but spared adjacent lobules,
regardless of whether there was a segmental or non-segmental dis-
tribution [1]. Nodules were considered either centrilobular or ran-
dom in distribution. Mediastinal compartments were evaluated for
lymph node enlargement, and the pleural spaces for the presence
of pleural fluid.
Abnormalities were classified as being distributed predomi-
nantly in the upper, middle, or lower lung zones, unilateral or
bilateral.
Agreement between the two observers for the predominant CT
findings was assessed using the kappa statistic [20]. The compari-
sons between the findings in the various types of pneumonia were
made using the chi-square test [20]. Following initial independent
analysis by the two observers, a final decision regarding the find-
ings was reached by consensus. The patterns of abnormality de-
scribed in the results section represent the conclusions reached by
consensus.
Results
Areas of air-space consolidation (Fig. 1) were detected
in patients with bacterial (30 of 35 patients, 85%), Myco-
plasma pneumoniae (22 of 28 patients, 79%), fungal (15
of 20 patients, 75%), and Pneumocystis carinii (2 of 22
patients, 9%) pneumonias, but were not identified in pa-
tients with viral pneumonias (Table 2). The presence of
 517

Table 2 Predominant high-resolution CT findings. PCP Pneumocystis carinii pneumonia

HRCT finding Bacterial Mycoplasma Viral Fungal PCP

pneumonia pneumoniae pneumonia pneumonia (n=22)
(n=35) pneumonia (n=28) (n=9) (n=20)

Air-space consolidation 30 (85)a 22 (79) 15 (75) 2 (9)

Non-segmental 24 (80) 15 (68) 6 (40) 2 (9)
Segmental 6 (20) 9 (40) 9 (60)
Lobular 11 (36) 13 (59) 3 (20)
Ground-glass attenuation 11 (31) 24 (86) 4 (44) 6 (30) 21 (95)
Non-segmental 11 (100) 13 (54) 4 (100) 6 (100) 21 (100)
Segmental
Lobular 11 (45)
Nodules 6 (17) 25 (89) 7 (78) 13 (65)
Centrilobular 6 (17) 24 (96) 7 (100) 12 (92)
Random 1 (4) 2 (15)
Reticulation 8 (22) 6 (21) 3 (33) 5 (25) 4 (18)
a Numbers in parentheses are percentages

Fig. 2 A 28-year-old man with AIDS and Pneumocystis carinii

pneumonia. High-resolution CT scan (1.5-mm collimation) reveals
extensive bilateral areas of ground-glass attenuation in a geo-
graphic distribution with sharp demarcation between normal and
abnormal lung

Mycoplasma pneumoniae, and fungal pneumonias (all

Fig. 1 A 49-year-old man with Streptococcus pneumoniae pneu-
monia. High-resolution CT scan (1-mm collimation) targeted to
the right lung reveals non-segmental air-space consolidation
involving the right lower lobe. Ground-glass attenuation is only
detected around areas of air-space consolidation (arrows)
air-space consolidation was significantly less common in
Pneumocystis carinii pneumonia (2 of 22 patients, 9%),
than in all other types of pneumonia (p<0.01, chi-square
test). There was no significant difference in the preva-
lence or in the distribution (non-segmental, segmental,
lobular) of air-space consolidation between bacterial,
p>0.10, chi-square test; Table 2).
Ground-glass attenuation (Fig. 2) was seen more
commonly in Pneumocystis carinii pneumonia (21 of 22
patients, 95%), than in fungal (6 of 20 patients, 30%)
and bacterial pneumonias (11of 35 patients, 31%;
p<0.01, chi-square test; Table 2). In patients with Pneu-
mocystis carinii pneumonia, the areas of ground-glass at-
tenuation were bilateral, symmetric, and extensive. The
other types of pneumonia were associated with more
focal areas of ground-glass attenuation, usually adjacent
to areas of air-space consolidation. There was no signifi-
cant difference in the prevalence of ground-glass attenu-
ation between bacterial, Mycoplasma pneumoniae, viral,
and fungal pneumonias (all p>0.10, chi-square test). In
518
Fig. 3 A 28-year-old woman with Mycoplasma pneumoniae pneu-
monia. High-resolution CT scan (1-mm collimation) targeted to
the right lung demonstrates poorly defined centrilobular nodules
(arrows), a focal area of air-space consolidation and lobular areas
of ground-glass attenuation. Note sharp demarcation between nor-
mal and abnormal secondary pulmonary lobules (curved arrows),
a finding characteristic for bronchopneumonia
11 of 24 (45%) patients with Mycoplasma pneumoniae
pneumonia the areas of ground-glass attenuation showed
a lobular distribution. This distribution of areas of
ground-glass attenuation was not seen in other forms of
pneumonia.
Centrilobular nodules were detected more commonly
in Mycoplasma pneumoniae pneumonias (24 of 28 pa-
tients, 86%; Fig. 3) than in bacterial pneumonias (6 of
35 patients, 17%; p<0.01, chi-square test; Fig. 4), and
were not seen in patients with Pneumocystis carinii
pneumonia (Table 2). There was no significant differ-
ence in the prevalence of nodules between Mycoplasma
pneumoniae (25 of 28 patients, 89%), viral (7 of 9 pa-
tients, 78%; Fig. 5), and fungal pneumonias (13 of
20 patients, 65%; Fig. 6; p>0.10, chi-square test). In bac-
terial pneumonias 6 of 16 patients (37%) with staphylo-
coccal infection demonstrated centrilobular nodules;
these were located adjacent to areas of patchy air-space
consolidation.
There was no significant difference in the prevalence
of reticulation between the various forms of pneumonia
(p>0.10, chi-square test; Table 2).
Fig. 4 A 38-year-old man with Staphylococcus aureus pneumo-
nia. High-resolution CT scan (1-mm collimation) targeted to the
right lung shows patchy areas of air-space consolidation, consis-
tent with bronchopneumonia
All patients with Pneumocystis carinii and viral pneu-
monia had bilateral diffuse lung involvement. Bilateral but
less extensive involvement was present in 12 of the pa-
tients (60%) with fungal, 9 (26%) with bacterial, and 6
(21%) with Mycoplasma pneumoniae pneumonia. Sixty-
four percent (18 of 28) of the patients with Mycoplasma
pneumoniae and 63% (22 of 35) with bacterial pneumo-
nias had a lower zone predominance of parenchymal ab-
normalities, whereas an upper zone predominance was
present in 10 of 20 (50%) patients with fungal pneumonia.
Cystic lesions within areas of coexistent ground-glass
attenuation were a unique finding seen in 5 of 22 (23%)
patients with Pneumocystis carinii pneumonia. Pleural
effusions were noted in 14 (40%) patients with bacterial,
in 3 (15%) with fungal, and in 2 (7%) with Mycoplasma
pneumoniae pneumonia. Mediastinal lymph node en-
largement was seen in 7 of 28 patients (25%) of Myco-
plasma pneumoniae and in 3 of 35 patients (8%) with
bacterial pneumonias.
There was fair to moderate agreement between the
observers for the assessment of the presence of air-space
consolidation (kappa statistic, 0.47), ground-glass atten-
uation (kappa statistic, 0.51), nodules (kappa statistic,
0.63), and reticulation (kappa statistic, 0.49). There was
fair agreement in the assessment of the distribution of
consolidation as being non-segmental (kappa statistic,
0.42), segmental (kappa statistic, 0.44), or lobular (kappa
statistic, 0.41).

Fig. 5 A 31-year-old woman with cytomegalovirus pneumonia
after bone marrow transplantation. High-resolution CT scan
(1.5-mm collimation) demonstrates numerous small nodules
(arrows)
Discussion
Pneumonias have been traditionally classified into lobar
pneumonias, bronchopneumonias, and interstitial pneu-
monias [1]. On chest radiographs lobar pneumonias, most
commonly caused by Streptococcus pneumoniae and
Klebsiella pneumoniae, are characterized by a non-seg-
mental distribution and often involvement of a single
lobe. Bronchopneumonias have been traditionally consid-
ered to be segmental in distribution [1]. In bronchopneu-
monias the inflammatory process typically respects inter-
lobular septal boundaries, involving some secondary pul-
monary lobules while sparing adjacent lobules; therefore,
bronchopneumonia is also known as lobular pneumonia
[1, 21]. Common causes of bronchopneumonia include
Staphylococcus aureus, gram-negative organisms, Myco-
plasma pneumoniae, and fungi. Interstitial pneumonias
are associated with a reticulonodular pattern, and are
most commonly caused by viruses [1]. In interstitial
pneumonias progression of the inflammatory process may
result in patchy or diffuse areas of air-space opacification.
519
Fig. 6 A 36-year-old man with Aspergillus fumigatus broncho-
pneumonia after bone marrow transplantation. High-resolution CT
scan (1-mm collimation) through the right lung reveals areas of
air-space consolidation in a predominantly non-segmental distri-
bution, centrilobular nodules (arrow), and areas of ground-glass
attenuation (curved arrows)
On chest radiographs, due to the summation of opacities,
the distinction between the three forms of pneumonia is
difficult. Lobar pneumonias are frequently simulated by
confluent bronchopneumonias, and both can be mimicked
by interstitial pneumonia when associated with patchy or
diffuse areas of air-space opacification [21].
In a recently published study, analyzing the high-reso-
lution CT findings in community-acquired pneumonias,
Tanaka et al. assessed the findings in 32 patients includ-
ing 18 with bacterial pneumonia and 14 with atypical
pneumonia (Mycoplasma pneumoniae pneumonia, n=12;
Chlamydia pneumonia, n=1; influenza virus pneumonia,
n=1) [22]. The main feature differentiating the two
groups was the presence of centrilobular nodules seen in
9 of 14 patients (64%) with atypical pneumonias com-
pared with 2 of 18 patients (11%) with bacterial pneumo-
nias. In the current study, similar to the results of Tanaka
et al., nodules were detected in only 6 of 35 patients
(17%) with bacterial pneumonia, but were commonly
seen in patients with Mycoplasma pneumoniae (89%),
viral (77%), and fungal (65%) pneumonia.
520

A predominantly nodular pattern of pneumonia may
be seen with various infections. Fungal pneumonia char-
acteristically manifests as multiple, ill-defined nodules
that may gradually coalesce to form a mass or an area of
air-space consolidation [19, 23]. In viral pneumonia,
nodules are typically associated with a background of
diffuse ground-glass attenuation and/or reticulation [17,
18]. In Mycoplasma pneumoniae and bacterial pneumo-
nias caused by Nocardia, Staphylococcus aureus, and
Pseudomonas aeruginosa, nodules may extend to in-
volve the entire secondary pulmonary lobule [8, 13].
The significance of ground-glass attenuation depends
on the immune status of the patient. In immunocompro-
mised patients, the presence of extensive, diffuse, bilat-
eral ground-glass attenuation is highly suggestive for
Pneumocystis carinii pneumonia [6, 25, 26]. In a study
by Hartman et al. the presence of this pattern allowed a
confident diagnosis of Pneumocystis carinii pneumonia
in 22 of 24 patients (94%) with AIDS [9]. Unusual ra-
diologic patterns in Pneumocystis carinii pneumonia
suggesting the presence of an alternative infectious agent
include focal or diffuse areas of air-space consolidation
and occasionally nodules [26, 27, 28]. In immunocom-
promised patients who do not have AIDS and in immu-
nocompetent patients with pneumonia, areas of ground-
glass attenuation are a common but non-specific finding.
Although viral pneumonia may produce extensive areas
of ground-glass attenuation, viral infections are com-
monly associated with nodules and focal or diffuse areas
of air-space consolidation [17, 18, 28]. In the current
study only 4 patients with viral pneumonia had ground-
glass attenuation, but 7 had centrilobular nodules. In
Mycoplasma pneumoniae pneumonia, focal areas of
ground-glass attenuation usually seen in association with
centrilobular nodules may be present. These focal areas
of ground-glass attenuation often have a lobular distribu-
tion [13, 22]. In bacterial and fungal pneumonias areas
of ground-glass attenuation tend to be minor findings ad-
jacent to areas of air-space consolidation and nodules
[22, 23].
Reticulation was a non-specific feature in all groups
of pneumonias, and was associated with air-space con-
solidation, ground-glass attenuation, and nodules.
Our study has several limitations. It is retrospective
and includes a limited number of patients in each group
of pneumonia, especially viral pneumonia. Only a small
number of patients with pneumonia undergo CT; there-
fore, it is possible that the study was biased toward pa-
tients with more extensive abnormalities or atypical pre-
sentations. Furthermore, the study did not compare the
findings of CT with those seen on the radiograph.
Conclusion
In conclusion, there is considerable overlap between the
high-resolution CT features of the various types of pneu-
monia. The presence of extensive areas of ground-glass
attenuation with absence of air-space consolidation is
highly suggestive of Pneumocystis carinii pneumonia
and the combination of centrilobular nodules and lobular
areas of ground-glass attenuation is most suggestive of
Mycoplasma pneumoniae pneumonia. In the current
study, the other causes of pneumonia could not be distin-
guished on the basis of pattern or distribution of abnor-
malities on high-resolution CT.

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