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Abstract
Bacterial pneumonia is commonly encountered in clinical practice. Radiology plays a prominent role in the evaluation of pneumonia. Chest
radiography is the most commonly used imaging tool in pneumonias due to its availability and excellent cost benefit ratio. CT should be
used in unresolved cases or when complications of pneumonia are suspected. The main applications of radiology in pneumonia are oriented
to detection, characterisation and follow-up, especially regarding complications. The classical classification of pneumonias into lobar and
bronchial pneumonia has been abandoned for a more clinical classification. Thus, bacterial pneumonias are typified into three main groups:
Community acquired pneumonia (CAD), Aspiration pneumonia and Nosocomial pneumonia (NP).The usual pattern of CAD is that of the
previously called lobar pneumonia; an air-space consolidation limited to one lobe or segment. Nevertheless, the radiographic patterns of CAD
may be variable and are often related to the causative agent. Aspiration pneumonia generally involves the lower lobes with bilateral multicentric
opacities. Nosocomial Pneumonia (NP) occurs in hospitalised patients. The importance of NP is related to its high mortality and, thus, the need
to obtain a prompt diagnosis. The role of imaging in NP is limited but decisive. The most valuable information is when the chest radiographs are
negative and rule out pneumonia. The radiographic patterns of NP are very variable, most commonly showing diffuse multifocal involvement
and pleural effusion. Imaging plays also an important role in the detection and evaluation of complications of bacterial pneumonias. In many
of these cases, especially in hospitalised patients, chest CT must be obtained in order to better depict these associate findings.
2004 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pneumonia; Bacterial pneumonia; Pulmonary CT; Nosocomial pneumonia
1. Introduction
Bacterial pneumonias account for a large percentage of
all pneumonias. They have been classified into three main
groups: lobar pneumonia, bronchopneumonia and acute interstitial pneumonia [1]. Lobar pneumonias are characterised
by confluent areas of focal airspace disease, usually limited
to one lobe or segment. Bronchopneumonia has a multifocal distribution with nodules that tend to join producing
air-space consolidations affecting one or more lobes. Acute
interstitial pneumonias are produced by involvement of the
bronchial and bronchiolar wall, and of the pulmonary interstitium, and are most commonly caused by viral organisms
and Mycoplasma pneumoniae.
This classic morphologic classification is of limited usefulness because the radiographic pattern often cannot be
used to predict the causative organism. The appearance of
new infective organisms, the increasing age of the population and the wide use of antibiotics have changed the pat
Corresponding author.
E-mail address: vilar jlu@gva.es (J. Vilar).
2. Imaging pneumonia
In patients with suspected pneumonia, imaging plays a
major role in the detection, characterisation and follow-up
of the disease.
0720-048X/$ see front matter 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2004.03.010
2.1. Detection
The basic and most diffused imaging tool to diagnose
pneumonia remains the chest radiograph. Indeed pulmonary
infections are the most common reason for obtaining an
emergency chest film. Pneumonia may present with a
wide spectrum of symptoms and often the initial clinical
manifestations are clear. Although the chest radiograph is
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Fig. 1. Additional value of CT: CAP (a) chest radiograph: there is a paratracheal opacity in the right upper lobe. (b) CT of the same patient shows
clearly the opacity due an air-space consolidation.
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recommended in cases uncertain to the chest film, complications of pneumonia or suspicion of an underlying additional
lesion such as bronchogenic carcinoma.
Magnetic resonance imaging (MRI) can demonstrate pulmonary consolidations. It can be used as an alternative to CT
in patients who should not be exposed to ionising radiation.
2.2. Characterisation
Is imaging reliable for distinguishing the infective organism? Tew et al. [5] reviewed 31 patients with bacterial and non-bacterial pneumonias. The diagnostic accuracy
was 67% for bacterial pneumonia and 65% for non-bacterial
pneumonia. The authors concluded that radiology alone was
unable to distinguish bacterial from non-bacterial pneumonias. In a review of 114 cases of pneumonia, Reittner et al.
concluded that CT is also unable to differentiate the aetiology of various types of pneumonia except Pneumocystis
carinii [6]. The characterisation of some NP may be quite
difficult, especially in patients with assisted ventilation when
other pulmonary conditions may coincide [7]. Despite these
limitations, imaging may be of great help in detecting the associated findings. A study by Albaum et al. [3] showed that
the chest radiograph reliability for detecting pleural fluid and
multiple infiltrates was good. This is important since both
findings are related to a worse prognosis.
2.3. Follow-up
Most pnemonias will resolve in 1 or 2 weeks. Slow resolution can occur when there are certain associated conditions
such as chronic obstructive pulmonary disease, alcoholism,
diabetes and immune-deficiency. Otherwise, if the pneumonia does not resolve, an underlying pathology should be suspected, especially bronchogenic carcinoma. In these cases,
as mentioned previously, CT is recommended [8,9].
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Fig. 3. PA chest radiograph shows an alveolar consolidation involving the right and left lower lobes in a patient infected by Streptococcus pneumoniae.
Fig. 4. Mycoplasma pneumonia: chest radiograph. There is a diffuse peripheral and bilateral interstitial involvement.
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Fig. 5. (a) Legionella pneumonia: chest radiograph of a patient with fever, dyspnea and myalgias. There is a smooth bilateral perihilar consolidation. (b)
Chest radiograph obtained 48 h later, notice the rapid extension of the consolidation. (c) and (d) On CT, the consolidations are multiple and bilateral.
Fig. 5. (Continued ).
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that the patterns of lobar pneumonia and bronchopneumonia were equally frequent in Pneumococcal pneumonia. Another common finding in Pneumococcal pneumonia is the
presence of small pleural effusions that are usually reactive.
3.2. Mycoplasma pneumonia
The incidence of Mycoplasma infection is variable according to different series and may be influenced by epidemics. Every 48 years, the incidence may reach up to
50%. This is a pneumonia of children, adolescents and
adults below 40 years of age [13]. Mycoplasma pneumonia has variable radiographic appearances. In 1975, Putnan
et al. [14] identified two main clinical and radiographic
groups: one group had unilateral or bilateral air-space disease with a lobar or segmental distribution, while the other
with a longer duration of symptoms, had a diffuse bilateral
reticulo-nodular pattern (Fig. 4). A review of 31 cases of M.
pneumoniae in outpatients revealed no predominant radiographic pattern (interstitial or alveolar) with more frequent
involvement of the lung bases [15].
3.3. Chlamydia pneumonia
The radiographic appearance of C. pneumoniae is similar
to that of M. pneumoniae, most commonly as a localised
area of consolidation which may be patchy or homogeneous.
Chlamydia and Mycoplasma often coexist [1].
4. Aspiration pneumonia
3.4. Legionella pneumonia
Legionnella pneumophila is responsible for Legionnella
pneumonia or Legionnaires disease. These infections are
acquired by breathing droplets of contaminated water. The
disease may be sporadic or may occur in outbreaks, most
frequently in places where the population is exposed to air
conditioning towers, water distribution systems and humidifiers colonised by the germ [16]. The clinical features of
Legionella pneumonia are typical, consisting in diarrhoea,
headache, myalgias, dyspnea and cough. The radiographic
findings are often those of segmental peripheral consolidations that spread rapidly producing opacification of one or
more lobes (Fig. 5). They become bilateral in half of the
cases [17].
3.5. Unusual patterns of CAP
3.5.1. Round pneumonia (Fig. 6)
It was described in children but occasionally it may happen in adults. In the presence of a pulmonary nodule, round
pneumonia should be suspected especially if no previous
films are available, a rapid growth is observed or there are
signs of infection [18]. A variant of this could be the cases
described in screening for lung cancer where some small
pulmonary nodules detected will disappear after the antibiotic treatment [19].
Aspiration is the inhalation of orofaringeal or gastric contents into the larynx and lower respiratory tract. If the inhalation is of regurgitated sterile gastric contents, aspiration
pneumonitis is caused; and if it is of colonised oropharingeal
material, aspiration pneumonia occurs [20].
Factors that predispose to aspiration pneumonitis are
those that produce disturbance of consciousness such as
drug abuse, seizures, massive cerebrovascular accident, or
the use of anaesthesia. Aspiration pneumonia is conditioned
by neurologic disphagia, anatomic abnormalities of the upper aerodigestive tract, gastroesophageal reflux in elderly
persons, or poor oral care.
The radiographic appearance of aspiration pneumonia and
pneumonitis is variable [21] but the most common pattern
is that of bilateral and multicentric opacities, particularly
in the right lung, with a perihilar and basal distribution
(Fig. 8).
5. Nosocomial pneumonias
Nosocomial pneumonia or hospital acquired pneumonia
is defined as a pneumonia occurring 48 h after hospital admission, excluding any infection that is incubating at the
time of hospital admission, and also a pneumonia which
occurs within 48 h after discharge from the hospital [22].
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Fig. 7. (a) Chest radiograph of a patient with bullous emphysema. (b) The same patient with pneumonia in the left upper lobe. An airfluid level (arrows)
within the bullae mimics cavitation. (c) CT of this area showing the fluid filled bulla.
According to the literature, the incidence of NP is variable, probably because the groups of patients studied differ
and the diagnostic criteria vary. These variations depend
greatly on the type of hospitalisation and wards (surgical or
medical).
Risk factors involved in NP are the previous condition of
the patient, age, severity of the underlying disease, the length
of hospitalisation and the instrumentation used in invasive
techniques. The most common micro-organisms responsible
for NP are aerobic Gram-negative bacilli (Enterobacteriae,
E. coli, Pseudomona aeruginosa), and some Gram-positive
cocci such as S. aureus and S. pneumoniae. Anaerobic organisms are less common. Quite often, multiple different
germs are found [23].
In patients hospitalised in Intensive Care Units, these
pneumonias are more frequent, and the mortality is very
high (1050%). Mechanical ventilation constitutes a great
risk factor for NP since it can facilitate the growth and
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Fig. 9. Ventilator assisted pneumonia: chest radiograph of a patient obtained after 5 days of mechanical ventilation. There is a right perihilar consolidation.
Acinetobacter was obtained from bronchoaspirate cultures.
dissemination of germs and the cough mechanism is reduced. This has been denominated as ventilator associated
pneumonia (VAP). Nevertheless, NP in the Intensive Care
Units may also occur in non-ventilated patients. Thus NP
has been classified in two groups: ventilator associated
pneumonia and pneumonia in non-ventilated patients [24].
The incidence and mortality of the former is much higher
Fig. 10. Nosocomial pneumonia: chest radiograph shows patchy and peripheral areas of consolidation in a hospitalised non-ventilated patient under a
long-term treatment with steroids. The responsible organism was Pseudomona aeruginosa.
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6. Complications
All pneumonias, CAP and nosocomial may complicate.
Complications are more common in inmunodepressed patients and in nosocomial pneumonias.
Fig. 12. (a) Chest radiograph of a 12 months old child, with a consolidation
in left lower lobe. (b) Chest radiograph obtained 4 weeks later. A cystic
space has developed in the area of previous pneumonia, corresponding to
a pneumatocele (arrows).
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7. Conclusions
Pneumonias can be classified in three main groups: community acquired pneumonia, nosocomial pneumonia and
aspiration pneumonia. The role of the radiologist is to be
decisive in their diagnosis and follow-up. The chest radiograph remains a basic tool for this purpose. CT is used as a
complement to plain films and especially in the evaluation
of complications or unfavourable resolution of a pulmonary
infiltrate. The role of radiology in the intensive care unit
patient is more limited since there is a great overlap of
pathologies that can have similar radiographic signs. Close
follow-up of these patients and adequate clinical correlation is mandatory. CT in these cases can add significant
information when portable films are inconclusive.
References
Fig. 13. Loefflers pneumonia: (a) the chest radiograph shows an opacity
in the left upper lobe. (b) Lateral chest radiograph showing posterior
displacement of the major fissure due to abundant exudate by Klebsiella
pneumoniae.
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