RADIOLOGY:

CHEST INFECTIONS
JI MARQUEZ, JUAN KARLO L.
MECHANISMS OF DISEASE
3 POTENTIAL ROUTES:
• Via the tracheobronchial tree
• Via the pulmonary vasculature
• Via direct spread from infection in the mediastinum, chest
wall, or upper abdomen
 INFECTION VIA THE
TRACHEOBRONCHIAL TREE
3 SUBTYPES
1. Lobar Pneumonia
• Pneumococcal
• Inflammatory exudate begins
within the distal airspaces
• Spreads via the pores of
Kohn and canals of Lambert
producing nonsegmental
consolidation
• May involve the entire lobe
• Air bronchograms are
common and significant
volume loss is unusual
 INFECTION VIA THE
TRACHEOBRONCHIAL TREE
3 SUBTYPES
2. Lobular or bronchopneumonia
• Staphylococcal – most common
• Early stages: centered primarily
in and around lobular bronchi
• Exudative fluid extends
peripherally along the bronchus
to involve the entire pulmonary
lobule
• “Patchwork quilt” – multifocal
opacities roughly lobular in
configuration
 INFECTION VIA THE
TRACHEOBRONCHIAL TREE
3 SUBTYPES
3. Interstitial pneumonia
• Viral and mycoplasma infection
• Inflammatory thickening of
bronchial and bronchiolar walls
and pulmonary interstitium
• Radiographic pattern of airway
thickening and reticulonodular
opacities
• No air bronchograms because
alveolar spaces remain aerated
BACTERIAL
 BACTERIAL PNEUMONIA
Gram-positive bacteria
1. Streptococcus pneumoniae
• Tends to begin in the
lower lobe or the
posterior segments of the
upper lobe
• Radiographic
appearance:
• Lobar consolidation,
• Air bronchograms are
usually evident
 BACTERIAL PNEUMONIA
Gram-positive bacteria
2. Staphylococcus aureus
• Most common in hospitalized and debilitated patients
• Produces a bronchopneumonia – patchy opacities
• No air bronchogram
• Rapid spread
 BACTERIAL PNEUMONIA
Gram-positive bacteria
2. Staphylococcus aureus
 BACTERIAL PNEUMONIA
Gram-negative bacteria
2. Klebsiella pneumoniae
• Homogenous lobar
opacification containing air
bronchograms
• 3 features to distinguish from
pneumococcal
• Volume of the involved lobe may
be increased by the exuberant
inflammatory exudate - Bulging
interlobar fissure
• Abscess
• Pleural effusion or empyema
 BACTERIAL PNEUMONIA
Anaerobic bacterial infections
• Majority arise from aspiration of infected
oropharyngeal contents
• Bacteroides and Fusobacterium
• Peripheral lobular and segmental
airspace opacities
• Distribution of parenchymal opacities
reflects the gravitational flow of
aspirated material
• Supine: posterior segments of the upper
lobe and superior segments of the lower
lobe
• Erect: basal segments of lower lobe
 BACTERIAL PNEUMONIA
Mycobacterial infections
• Primary TB and Reactivation
or postprimary TB
• Primary TB
• Most patients are
asymptomatic and have no
radiographic sequelae
• If symptomatic, a nonspecific
focal pneumonitis occurs and
is seen as small, ill-defined
areas of segmental or lobar
opacification
 BACTERIAL PNEUMONIA
Mycobacterial infections
• Reactivation/Post-primary TB
• Tends to occur in the apical
and posterior segments of
the upper lobes and
superior segments of the
lower lobes
• Ill-defined patchy and
nodular opacities
• Cavitation – indicates
active and transmissible
disease
 BACTERIAL PNEUMONIA
Mycobacterial infections
• Miliary TB
• Complicate either primary
or reactivation disease
• Hematogenous
dissemination of
tuberculous bacilli
• Diffuse bilateral 2-3mm
pulmonary nodules
VIRAL
VIRAL PNEUMONIA
• Relatively uncommon
• Diagnosis of exclusion
• Radiographic features are nonspecific and usually
demonstrate a pattern of bronchopneumonia or interstitial
opacities
VIRAL PNEUMONIA

• Influenza – bilateral lower lobe

patchy airspace opacification
(adults); diffuse interstitial
reticulonodular pattern (children)
VIRAL PNEUMONIA

• RSV – patchy airspace opacities

VIRAL PNEUMONIA

• Varicella-zoster virus – diffuse

bilateral ill-defined nodular
opacities 5-10mm in diameter
VIRAL PNEUMONIA

• Adenovirus - overinflation and

bronchopneumonia accompanied
by lobar atelectasis; in children,
lobar or segmental consolidation
FUNGAL
FUNGAL PNEUMONIA
• COCCIDIOIDOMYCOSIS
• C. immitis
• Acute – normal or show focal or multifocal
segmental airspace opacities that resolve
over several months
• Persistent – coccidioidal nodules or
masses (subpleural regions of the upper
lobes), areas of consolidation, miliary
nodules
• Chronic progressive – upper lobe
fibrocavitary disease
FUNGAL PNEUMONIA
• ASPERGILLUS
• Aspergilloma formation;
aspergillosis
• Aspergilloma – ball of hyphae,
mucus, and cellular debris that
colonizes a preexisting bulla or
parenchymal cavity created by
some other pathogen
• Solid round mass within an upper
lobe cavity with a air crescent
separating the mycetoma from
the cavity wall
REFERENCES
• Brant, William E., and Clyde A. Helms, eds. Fundamentals of
diagnostic radiology. Lippincott Williams & Wilkins, 2012.
• Koo, H. J., Lim, S., Choe, J., Choi, S. H., Sung, H., & Do, K. H.
(2018). Radiographic and CT features of viral
pneumonia. Radiographics, 38(3), 719-739.