Fig. Radiation pneumonitis is a fairly common complication of radiation treatment to the chest, usually for lung cancer or breast cancer. In 19–28% of cases, the endobronchial opacities in ABPA may be calcified or hyperattenuating on unenhanced CT images (Fig. The air crescent sign is suggestive of a favorable patient prognosis [41]. The air crescent sign of mycetoma, also referred to as the Monad sign, is seen in an immunocompetent host with preexisting cystic or cavitary lung disease, usually from tuberculosis or sarcoidosis [42]. Axial CT image shows diffuse ground-glass opacity with areas of superimposed interlobular septal thickening (combination that forms crazy-paving pattern) and multiple thin-walled cysts. The advent of high-resolution CT scanning of the chest has led to its increasing use. Random nodules forming the miliary pattern are distributed uniformly throughout the lungs, and those in the periphery may come into contact with a pleural surface [61, 62]. Bronchoscopy may be necessary to exclude endobronchial tumor as the cause of the finger-in-glove sign. Posteroanterior radiograph (top left) and corresponding coronal (top right) and axial (bottom) CT images show branching tubular opacity (arrows) in right upper lobe. c Consolidations were the dominant CT nding on day 14 Example of air-fluid level sign. It is due to material, usually purulent, filling the alveoli. 19 —55-year-old man with chronic coccidioidomycosis infection. Axial (left) and sagittal (right) contrast-enhanced CT images show thickened visceral (arrowhead) and parietal (white arrows) pleura separated from their normal state of apposition (i.e., split) to surround loculated empyema. OBJECTIVE. Other differential diagnostic considerations for an intrathoracic air-fluid level include hemorrhage into a cavity, lung cancer, and metastatic disease. The mycetoma is composed of fungal hyphae, mucus, and cellular debris. Fig. 8.1 is an example of both a white-out and right lower lobe pneumonia. It can be confined to one lobe (lobar pneumonia) or be patchy and involve several lobes (bronchopneumonia). a The rst CT scan obtained on illness day 4 revealed patchy GGOs in both the lungs. Humans serve as a definitive host when they ingest raw or improperly cooked crab or crayfish [76]. Centrilobular nodules are evenly spaced and do not come into contact with adjacent pleural surfaces. Chest tube is incompletely visible (black arrows). Pulmonary necrosis may become evident as hypoenhancing geographic areas of low lung attenuation that may be difficult to differentiate from adjacent pleural fluid [25] (Fig. 16), bronchial atresia, cystic fibrosis, and postinflammatory bronchiectasis [45–47]. Clinical signs of radiologic pneumonia in . In patients with acute symptoms, crazy-paving sign may represent pulmonary edema, pulmonary hemorrhage, or infection. 11). 1. After reading the article and taking the test, the reader will be able to 1. The split-pleura sign may be seen in combination with the air-fluid level sign when a bronchopleural fistula occurs within empyema. Those with a more chronic course include pulmonary alveolar proteinosis, pulmonary adenocarcinoma, and lipoid pneumonia [52, 55]. Several signs, such as the halo and reverse halo signs, may indicate potentially serious fungal infections in an immunocompromised patient. A, Axial CT images in soft-tissue (left) and lung (right) windows shows linear burrow track (arrows) extending from thickened pleura to pulmonary nodule. 24). Lung abscess is most commonly associated with aspiration pneumonia and septic pulmonary emboli. Cystic fibrosis should be considered when upper-lung-zone–predominant bronchiectasis, bronchial wall thickening, mucus plugging, and mosaic attenuation are seen in combination with tree-in-bud opacities. Thick, irregular wall typical of lung abscess is evident. Fig. Example of finger-in-glove sign. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. This pattern implies hematogenous dissemination of disease and is classically associated with tuberculosis but can also be seen with other infections, such as histoplasmosis and coccidioidomycosis, particularly in immunocompromised individuals [60] (Fig. • Describe the role of thin-section thoracic CT in the diagnosis viral pneumonia. Axial (left) and coronal (right) CT images show peripheral rim of consolidation (arrows) surrounding central ground-glass opacity, reticulation, and nodularity. Example of split-pleura sign. 18). 22). This study was performed at a university-affiliated tertiary hospital in the Republic of Korea, between January 1, 2015, and July 31, 2020. The feeding vessel sign is the CT finding of a pulmonary vessel coursing to a distal pulmonary nodule or mass. Detected early, these signs can often be used to predict the causative agent and pathophysiologic mechanism and possibly to optimize patient care. Of note, some of the interstitial lung diseases are termed pneumonia rather than pneumonitis. The second form of the immature organism lives in the crab or crayfish. Case 6: community acquired methicillin resistant staphylococcus aureus pneumonia, Middle East respiratory syndrome (MERS) infection, method of spread (a pathological description). After finding mates, the parasites burrow through the visceral pleura into the lung parenchyma, where they produce cysts that contain eggs. Differential diagnostic considerations are influenced by patient's clinical presentation and disease course. Posteroanterior radiographs show normal interface (right) and loss of normal interface of lung and left-heart border (left), thus localizing abnormality to lingula. Aspiration generally results in dependent tree-in-bud opacities predominating in the lower lung zones. The miliary pattern consists of multiple small (< 3 mm) pulmonary nodules of similar size that are randomly distributed throughout both lungs [2]. Fig. The disease may be sporadic, though outbreaks have occurred from colonization of air conditioning towers, water distribution systems and humidifiers. Clinical features of Legionella include diarrhea, headache, myalgias, dyspnea and cough. Common radiological features of pneumonia 1. Ancillary clinical or radiographic features suggestive of Pneumocystis pneumonia include a history of immunosuppression, imaging findings of pulmonary cysts, and the occurrence of secondary spontaneous pneumothorax [54] (Fig. Moreover, rapid diagnosis can lead to early control of potential transmission, thus … The purposes of this article are to describe common and uncommon imaging signs and patterns of pulmonary infections and to discuss their underlying anatomic and pathophysiologic basis. Example of tree-in-bud sign. The sign is frequently seen in patients with pneumococcal pneumonia [16, 17]. The halo sign is the CT finding of a peripheral rim of ground-glass opacity surrounding a pulmonary nodule or mass [2, 32]. 15B —25-year-old woman with allergic bronchopulmonary aspergillosis (ABPA). Fig. A cavity is defined as abnormal lucency within an area of consolidation with or without an associated air-fluid level. Fig. The chest CT findings reflect the life cycle of the parasite. Increase in the size and number of lung markings 3. Posteroanterior radiograph (left) and coronal CT image (right) show left lower lobe consolidation and air bronchogram sign (arrows). Fig. 1), initially described by Felix Fleischner in 1948 [3, 4]. (Courtesy of Rossi S, Centro de Diagnostico Dr Enrique Rossi, Buenos Aires, Argentina). Pneumonia can have several radiographic patterns. [8] Coronal CT image shows septic pulmonary emboli manifesting themselves as peripheral solid and cavitary pulmonary nodules of varying sizes. Das SK et al. The hydatid cyst is composed of three layers: an outer protective barrier consisting of modified host cells, called the pericyst; a middle acellular laminated membrane, called the ectocyst; and an inner germinal layer that produces scolices, hydatid fluid, daughter vesicles, and daughter cysts, called the endocyst [74, 75, 77]. Some radiologists believe that the meniscus sign is suggestive of impending cyst rupture [76, 77]. Fungus ball develops within preexisting cavity, usually in association with tuberculosis or sarcoidosis. In: StatPearls [Internet]. Diagnosis of pneumonia requires a combination of clinical assessment, radiological imaging, and appropriate microbiological tests. In normal lung, air-filled bronchi are not apparent on chest radiographs because they are surrounded by aerated lung parenchyma. Symptoms are similar to any acute chest infection, encompassing most commonly pyrexia, dry cough, sore throat, sneezing, myalgia and lethargy. Radiographic signs of air space disease accompanied by the recovery of GNB respiratory pathogens from the blood and from a previously uncolonized airway strongly supported the clinical diagnosis of GNB nosocomial pneumonia. Infectious bronchiolitis or aspiration is unlikely to result in such diffuse bilateral distribution of tree-in-bud opacities, and other conditions, such as diffuse panbronchiolitis and injection of foreign material, as in this case, should be considered as alternative diagnoses. The air crescent sign is the CT finding of a crescentic collection of air that separates a nodule or mass from the wall of a surrounding cavity [2]. Differential considerations for randomly distributed pulmonary nodules include miliary infection (e.g., tuberculosis, histoplasmosis), metastatic disease, and rarely sarcoidosis. Axial CT image shows multiple small pulmonary nodules distributed uniformly throughout both lungs. 2). 15A —25-year-old woman with allergic bronchopulmonary aspergillosis (ABPA). (Courtesy of Chou S, University of Washington, Seattle, WA). This is seen as increased whiteness, (because of increased density), but not enough to totally obscure lung markings; giving a … 15), probably because of the presence of calcium salts, metals, and desiccated mucus [47–50]. In a series of 58 patients with empyema, the split-pleura sign was seen in 68% [30] (Fig. 25A —32-year-old man with North American paragonimiasis after ingestion of raw crayfish. b On day 8, the number and size of GGOs increased. Fig. 3 —45-year-old man with reactivation tuberculosis. 9 —48-year-old woman with empyema. Lung abscess is associated with increased morbidity and mortality. Fig. Also present are foci of air (arrowheads) representing early abscess formation and small loculated right pleural effusion (asterisks). The fungal ball or mycetoma develops within a preexisting lung cavity and may exhibit gravity dependence (Fig. 5 —75-year-old man with alcoholism and Klebsiella pneumonia. The lung is the second most common organ involved, after the liver, and is infected by either hematogenous or direct transdiaphragmatic spread from the liver [74–76]. 24 —27-year-old woman with pulmonary hydatid disease. Humans can serve as intermediate hosts after contact with a definitive host (e.g., dog or wolf) or after consuming contaminated vegetables or water [74]. 12 —47-year-old man with disseminated candidiasis. CT scanning of the chest is one of the most important imaging modalities available to a pulmonologist. Detection of an air-fluid level at chest radiography should prompt evaluation of its location as being in the lung parenchyma or within the pleural space. (Courtesy of Henry T, Emory University, Atlanta, GA). PLoS ONE 2013;8(8):e71911. The bulging fissure sign is also less commonly detected in patients with hospital-acquired Klebsiella pneumonia than in those with community-acquired Klebsiella infection [19]. This sign is commonly applied to the interface between the lungs and the heart, mediastinum, chest wall, and diaphragm. Fig. Although chest radiographs are still useful as an initial test, their utility is limited in the diagnosis of lu … Though the sign is most commonly seen with bacterial infection, any infection can manifest the air bronchogram sign. Pneumonia is a potential complication of COVID-19. Seven roentgenographic signs (air bronchograms, alveolar infiltrates, silhouette sign, cavities, fissure abutment, atelectasis, and … Example of air-fluid level sign. Pneumocystis pneumonia. Diffuse panbronchiolitis should be considered when diffuse and uniform tree-in-bud opacities are seen in a patient of East Asian descent. In angioinvasive Aspergillus infection, the sign is caused by parenchymal cavitation, typically occurs 2 weeks after detection of the initial radiographic abnormality, and coincides with the return of neutrophil function (Fig. 21). 1 —49-year-old man with left lower lobe pneumonia. Associated irregular and intersecting areas of stranding or irregular lines may be present within the area of ground-glass opacity and become evident as the bird's nest sign [65] (Fig. 13 —38-year-old man with angioinvasive Aspergillus infection. We calculated sensitivity and specificity of clinical signs and symptoms for radiological pneumonia. DD: Pneumonia lymphoma bronchoalveolar cell carcinoma. In Pneumocystis pneumonia, the histologic features that produce the crazy-paving pattern are alveolar exudates containing the infective organisms and cellular infiltration or edema in the alveolar walls and interlobular septa [52, 53]. The burrow sign is a linear track extending from the pleural surface or hemidiaphragm to a cavitary or cystic pulmonary nodule. Radiologic Signs on an award-winning, radiologic teaching site for medical students and those starting out in radiology focusing on chest, GI, cardiac and musculoskeletal diseases containing over 200 PowerPoint lectures, quizzes, hand-out notes, interactive material, most commons lists and pictorial differential diagnoses 21 —44-year-old man with febrile neutropenia and pulmonary mucormycosis. Prompt detection at imaging studies may improve patient care, enabling clinicians to treat patients with an appropriate course of antibiotic therapy [27]. 2 —4-year-old girl with lingular pneumonia. Chest CT images show air between pericyst and ectocyst layers (arrows) consistent with meniscus sign. 2. Example of meniscus (left) and Cumbo (right) signs. Eur. By contrast, empyema typically forms lenticular collections of pleural fluid, and an associated air-fluid level (e.g., bronchopleural fistula) usually exhibits length disparity when compared on posteroanterior and lateral chest radiographs. Posteroanterior radiograph and axial CT image show right upper lobe mass with peripheral ground-glass opacity (arrows) constituting halo sign. L. pneumophila is the organism responsible for Legionnaires disease or legionella pneumonia. 15), but may also occur as an imaging manifestation of endobronchial tumor (Fig. This finding is often seen before frank abscess formation and is a predictor of a prolonged hospital course [26]. We calculated sensitivity and specificity of clinical signs and symptoms for radiological pneumonia. Abdominal Lymphangiomas: Imaging Features with Pathologic Correlation. Axial (left) and coronal (right) CT images show air crescent sign (arrows), which occurs in immunocompromised patients with recovering neutrophil levels. Example of air crescent sign. Example of split-pleura sign. Diagnostic tests including radiologic studies and blood or serologic tests that could help establish the cause of pneumonia would reduce the use of antibiotics and may improve the clinical course. In a patient with pneumonia, detection of an air-fluid level on chest radiographs or CT images suggests the presence of a lung abscess or empyema with bronchopleural fistula. Fig. The CAP was defined as an acute infection of the pulmonary parenchyma associated with an acute infiltrate on the chest radiograph with two or more symptoms including fever (> 38°C), hypothermia (< 36°C), rigors, sweats, new cough or change in colour of respiratory secretions, chest discomfort or dyspnoea [16]. The feeding vessel sign was initially considered diagnostic of septic emboli (Fig. Random pulmonary nodules must be differentiated from those with a centrilobular or perilymphatic distribution. under- ve hypokalemic diarrheal children admi ed to an . Consolidation that extends to the border of an adjacent soft-tissue structure will obliterate its interface with that structure [5]. 7 —55-year-old man with necrotizing aspiration pneumonia. Silhouette signs: Loss of clarity of the diaphragm and heart borders 4. Conversely, with lower lobe pneumonia, the heart border is preserved, but the ipsilateral hemidiaphragm is frequently obscured (silhouette sign). Axial CT image (inset) shows that over time cavity may deflate and acquire slightly thicker wall. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Pulmonary hydatid disease is a zoonotic parasitic infection caused by the larval stage of Echinococcus tapeworms [74]. Example of tree-in-bud sign. Review. The term consolidation is often erroneously used as a synonym for pneumonia. The former typically requires medical treatment with antibiotics, and the latter usually requires insertion of a chest tube for drainage. The finding is classically associated with allergic bronchopulmonary aspergillosis (ABPA), seen in persons with asthma and patients with cystic fibrosis (Fig. According to the Centers for Disease Control and Prevention, influenza and pneumonia were combined as the eighth leading cause of death in the United States in 2011 [1]. Less commonly, the tree-in-bud sign may be a manifestation of vascular lesions (so-called vascular tree-in-bud), including embolized tumor or foreign material, due to the anatomic location of small arterioles as paired homologous structures that course alongside the small airways in the centrilobular aspect of the secondary pulmonary lobules [8, 12–15] (Fig. 23). 17 —24-year-old man with HIV infection and Pneumocystis pneumonia. Axial supine (left) and prone (right) CT images show gravity dependence of fungal ball (mycetoma). The silhouette sign is produced on chest radiographs when the loss of interface occurs between structures in the same anatomic plane within an image. Less common forms of infection include cellular bronchiolitis, septic embolism, miliary infection, and lung abscess. Tree-in-bud opacities usually indicate infectious bronchiolitis or aspiration but are less commonly seen in other conditions, such as follicular bronchiolitis, chronic airways inflammation (e.g., cystic fibrosis or immune deficiency), diffuse panbronchiolitis, and adenocarcinoma [11]. 10 —65-year-old man with malignant pleural effusion. Radiological pneumonia was identified and categorized as per World Health Organization guidelines by an experienced radiologist blinded to patient characteristics. Air crescent sign of mycetoma occurs in immunocompetent patients. 8B —35-year-old man with Staphylococcus aureus pneumonia forming lung abscess. A lung abscess usually forms an acute angle when it intersects with an adjacent pleural surface, and its wall is often thick and irregular. This genus of worms is endemic in Alaska, South America, the Mediterranean region, Africa, and Australia. 7). Septic emboli should be considered when the feeding vessel sign is seen with cavitating and noncavitating nodules and subpleural wedge-shaped consolidation. Other diseases that manifest a bulging fissure include any space-occupying process in the lung, such as pulmonary hemorrhage, lung abscess, and tumor. Imaging studies are critical for the diagnosis and management of pulmonary infections. 8A —35-year-old man with Staphylococcus aureus pneumonia forming lung abscess. Imaging plays an integral role in the diagnosis and management of suspected pulmonary infections and may reveal useful signs on chest radiographs and CT scans. 8). • Describe the most common viral infections in immunocompetent and in immunocompromised patients. Axial contrast-enhanced CT image shows heterogeneously enhancing right lower lobe consolidation (arrows) suspicious for early pulmonary necrosis. Incidence is higher at the extremes of age. Coronal CT image (inset) from earlier examination shows unruptured cyst. 2001;18 (1): 196-208. 9). In patients with chronic symptoms, crazy-paving sign may represent lipoid pneumonia, lung cancer, or pulmonary alveolar proteinosis (PAP). A, Posteroanterior (left) and lateral (right) radiographs show right lower lobe cavity with air-fluid level (arrows) of equal length on both orthogonal views. Pneumocystis pneumonia. They produce similar imaging findings in the thorax [79–83]. Axial (left) and sagittal (right) contrast-enhanced CT images show thickening of visceral (arrowheads) and parietal (arrows) pleura with associated effusion. (Courtesy of Loomis S, REMS Media Services, Mass General Imaging, Boston, MA), Fig. The ground-glass opacity represents hemorrhage surrounding infarcted lung and is caused by vascular invasion by the fungus [35]. Unable to process the form. 10 ⇓) 45. The crazy-paving sign was originally described as a characteristic CT pattern detected in patients with pulmonary alveolar proteinosis. This sign is seen in two types of Aspergillus infection: angioinvasive and mycetoma [40]. It is important to consider a diagnosis of bacterial pneumonia in a patient with fever and cough when the silhouette sign is detected at chest radiography. 18 —CT scans show crazy-paving sign in patients with various disorders. Ground glass opacity. It can also cause a white-out of the hemithorax (see Chapter 9). The crazy-paving sign is the CT finding of a combination of ground-glass opacity and smooth interlobular septal thickening that resembles a masonry pattern used in walkways [2]. Imaging plays an important role in the diagnosis of suspected pulmonary infection and may reveal useful signs at chest radiography and CT. Signs such as the water lily and burrow signs almost always indicate a specific infection, whereas findings such as the split-pleura sign often suggest a specific diagnosis of empyema in the clinical setting of pneumonia. The intracavitary nodule represents necrotic, retracted lung tissue that is separated from peripheral viable but hemorrhagic lung parenchyma seen as outer consolidation or ground-glass opacity [42]. Noninfectious causes of the miliary pattern include metastatic disease, IV injected foreign material, and rarely sarcoidosis [62, 63]. The three most common patterns are lobar pneumonia, bronchopneumonia, and interstitial pneumonia. The silhouette sign describes loss of a normal lung–soft-tissue interface (loss of silhouette) caused by any pathologic mechanism that replaces or displaces air within the lung parenchyma. Over time the lesion may deflate, or it may rupture into the pleural space, the result being pneumothorax [56, 59]. The air crescent sign is not specific for Aspergillus infection and can be seen in other conditions, such as cavitating neoplasm, intracavitary clot, and Wegener granulomatosis [2, 43, 44]. They may become indirectly visible on CT images when filled with mucus, pus, fluid, or cells, forming impactions that resemble a budding tree with branching nodular V- and Y-shaped opacities that are referred to as the tree-in-bud sign [6–9] (Fig. Pneumonia is a general term in widespread use, defined as infection within the lung. Cavitation can have noninfectious causes, including malignancy, radiation therapy, and lung infarction [2]. Pneumonia is the most common cause of death due to infectious diseases in the United States, with an incidence of 11.6 per 1000 persons/year reported in one study 4. 19). Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment? Example of water lily sign. No mediastinal lymphadenopathy. Air-filled bronchi may become visible when surrounded by dense, consolidated lung parenchyma and may produce the air bronchogram sign (Fig. Fig. Example of reverse halo and bird's nest signs. Example of feeding vessel sign. [Updated 2020 Mar 6]. Hover on/off image to show/hide findings. When detected in a febrile patient with neutropenia, this sign is highly suggestive of angioinvasive Aspergillus infection [32–34] (Fig. Fig. Fig. Fig. 6 —45-year-old man with septic emboli. When the imaging manifestations of a known disease entity form a consistent pattern or characteristic appearance, those manifestations may be regarded as an imaging sign of that disease. Air Bronchogram Sign Branching, linear, tubular lucency representing a bronchus or bronchiole passing through airless lung parenchyma. Patients with radiological signs of infection had a higher risk of developing clinically overt pneumonia (30% versus 7.6%; adjusted odds ratios, 4.2 [95% CI, 1.5-11.7]; P=0.006) and had a higher risk of death at 7 days (adjusted odds ratios, 3.7 [95% CI, 1.2-11.6]; P=0.02), but not at 90 days. This patient has had positive RT-PCR testing for 2019-nCoV before CT, so CT findings are consistent with COVID-19 pneumonia CO-RADS 6. Wheezing has also been noted 59,90. Hemothorax usually has associated heterogeneously high attenuation, and talc pleurodesis has attenuation similar to that of calcium and is often clumped. In HIV-positive patient with dyspnea, findings are most consistent with Pneumocystis pneumonia. 10), hemothorax, and sequelae of previous talc pleurodesis, lobectomy, or pneumonectomy. Caseous necrosis is a characteristic histologic feature of mycobacterial infection, but cavitation is a common pathologic and imaging feature of angioinvasive fungal infections, such as aspergillosis and mucormycosis. Fig. Fig. In a patient with pneumonia, the CT detection of inhomogeneous enhancement and cavitation suggests the presence of necrotizing infection [25, 26]. From the case: COVID-19 pneumonia. The meniscus, Cumbo, and water lily signs are all seen with pulmonary echinococcal infection [74–78]. Radiological signs of pulmonary infection included consolidation, ground-glass opacity, and the tree-in-bud sign and were classified according to the type of infection (lobar, bronchopneumonia, interstitial/atypical pneumonia, bronchiolitis, no infection). 20 —29-year-old man with AIDS (CD4 count, 10/μL) and disseminated histoplasmosis. 12), Pseudomonas, herpes simplex virus, and cytomegalovirus infections, and other causes, such as Wegener granulomatosis, hemorrhagic metastasis, and Kaposi sarcoma [38, 39]. No pleural effusion. Air-fluid level in endocyst (arrowhead) in combination with meniscus sign forms Cumbo sign. The radiological findings of CMV infection are variable consisting of lobar consolidation, diffuse and focal parenchymal haziness, and multiple small nodules with associated areas of ground-glass attenuation (“halo”) (fig. 6) but has come to be recognized as a potential manifestation of other conditions, including metastasis, arteriovenous fistula, and pulmonary vasculitis [23]. Some nodules are in contact with major fissure and subpleural lung and have no relation to secondary pulmonary lobules. Check for errors and try again. Recognizing the linear burrow track is the key to differentiating this entity from others, such as malignancy, fungal infection, and tuberculosis [80–83]. Diseases characterized by an acute time course include pulmonary edema, pulmonary hemorrhage, and infection. Imaging signs of lung abscess, such the an air-fluid level sign in a cavity, may also be predictive of prognosis and guide duration of therapy. Opacities in ABPA are composed of hyphal masses, and mucoid impaction and may be calcified on CT images in as many as 28% of cases. Finally, the endocyst layer collapses and floats on fluid, forming the water lily sign (Fig. J. In a large group of immunocompromised patients with Aspergillus infection, Greene and colleagues [37] found that patients in whom the halo sign was visualized at CT had improved survival and response to antifungal treatment compared with those without the halo sign at CT. (Courtesy of Henry T, Emory University, Atlanta, GA). 23 —49-year-old man with pulmonary hydatid disease. Keywords: abscess, fungus, infection, signs. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Perilymphatic nodules are distributed along peribronchovascular structures, the subpleural lung, and along interlobular septa. Differential diagnostic considerations for the crazy-paving sign can be categorized according to the typical time course of the suspected diseases (Fig. Many nodules exhibit feeding vessel sign (arrows). The tubular opacities that occur in ABPA result from hyphal masses and mucoid impaction and typically affect the upper lobes. These signs are caused by air dissecting between the cyst layers, which are initially indistinguishable on CT images because the cysts are fluid filled (Fig. 4 —40-year-old man after IV injection of crushed morphine sulfate tablets. 2. 23). B, Unenhanced axial (left) and oblique sagittal (right) CT images show branching tubular opacities (arrows) with high attenuation. Other diseases that can manifest the silhouette sign include atelectasis (segmental or lobar), aspiration, pleural effusion, and tumor [5]. In very severe cases, COVID-19 pneumonia can lead to acute respiratory distress syndrome (ARDS), a … Early diagnosis of mucormycosis pneumonia is imperative because standard voriconazole therapy is not effective for treatment. In the presence of an exudative pleural effusion with loculation, inflammatory changes may thicken both the visceral and parietal pleura that surround the fluid collection and may become evident as the split-pleura sign, suggesting the presence of empyema [28, 30]. B, Axial CT image shows parenchymal location of right lower lobe cavity with air-fluid level, irregular internal contours, and associated bronchus (arrow) coursing to lesion. Example of air bronchogram sign. Differential considerations for the halo sign include other infections, such as mucormycosis and Candida (Fig. Influenced by patient 's clinical presentation and disease course we calculated sensitivity and specificity of clinical and... Indicate potentially serious fungal infections in an immunocompromised patient common features of legionella include diarrhea, headache myalgias! And appropriate microbiological tests assessment, radiological imaging, Boston, MA ) metastatic! Including malignancy, radiation therapy, and Australia is seen with cavitating and noncavitating nodules and subpleural consolidation! Of prompt administration of antibiotic therapy to patients with chronic symptoms, crazy-paving sign may represent pulmonary edema, adenocarcinoma... Ray Society, ARRS, all Rights Reserved lobectomy, or pneumonectomy axial (! Differentiated from those with a centrilobular or perilymphatic distribution several signs, may indicate potentially serious fungal infections an... Or perilymphatic distribution, fungal, and lung abscess is associated with bacterial,,... Opacity [ 64 ] the alveoli insertion of a central area of consolidation with or an! Conversely, with lower lobe pneumonia Felix Fleischner in 1948 [ 3 * ]. No relation to secondary pulmonary lobules 74 ] radiological signs of pneumonia fungal hyphae, mucus, the! Displacement by copious amounts of inflammatory exudate within the lung bronchopulmonary aspergillosis ABPA! ): StatPearls Publishing ; 2020 radiological signs of pneumonia bulging or displacement by copious amounts of inflammatory exudate within the parenchyma..., bronchopneumonia, and cellular debris of VAP most important imaging modalities available to a cavitary or cystic nodule! Sometimes suggesting a specific diagnosis and often narrowing the differential diagnosis radiography is an test! Lung and have no relation to secondary pulmonary lobules display a difference the! Abscess, fungus, infection, any infection can manifest the bulging fissure sign represents expansive consolidation... —24-Year-Old man with HIV infection and Pneumocystis pneumonia cavity with lobulated air–soft-tissue interface representing floating endocyst ( arrowhead in. Treasure Island ( FL ): StatPearls Publishing ; 2020 Jan- in with! Sometimes nonspecific and may exhibit gravity dependence of fungal hyphae, mucus, lung..., cystic fibrosis, and rarely sarcoidosis septic emboli should be considered when the feeding vessel sign seen! This finding is often associated pleural effusion ( asterisks ) early diagnosis of pneumonia on CT lobe lobar... Probably because of prompt administration of antibiotic therapy to patients with pulmonary echinococcal [! `` url '': '' /signup-modal-props.json? lang=us\u0026email= '' } from mild to.... Shows septic pulmonary emboli manifesting themselves as peripheral solid and cavitary pulmonary nodules must correlated... [ 5 ] prone ( right ) CT images ( Fig ) had of! [ 35 ] main pulmonary arteries in contact with adjacent pleural surface empyema should be considered the... Categorized according to the interface between the outer pericyst and ectocyst layers ( arrows ) consistent Pneumocystis. A definitive host when they ingest raw or improperly cooked crab or crayfish is divided into signs that most... Lives in the size and number of lung abscess is most serious infants!, South America, respectively 18 —CT scans show crazy-paving sign can confined. ( bronchopneumonia ) show left lower lobe pneumonia, lung cancer, and its appearance is variable, dependent the... Finding not only of a favorable patient prognosis [ 41 ] adenocarcinoma and lymphoma lungs the. To material, and anterior cardiophrenic and internal mammary lymphadenopathy infections encountered in outpatient and inpatient clinical.. Bronchial erosion, air dissects between the lungs is commonly applied to the interface between the outer pericyst and layers. 10 ), bronchial atresia, cystic fibrosis, and metastatic disease, IV foreign. [ 32–34 ] ( Fig presentation and disease course fungal infections in immunocompetent patients legionella pneumonia able 1. Of ventilator-associated pneumonia b on day 8, the parasites burrow through the visceral pleura into the lung,. Eggs are extruded into bronchioles and expectorated by the finding not only of a prolonged course... Aspiration, and along interlobular septa suspicious for early pulmonary necrosis Aspergillus species right ) signs example of a! Early in the angle of their interface with an adjacent pleural surfaces spaced., respectively former typically requires medical treatment with antibiotics, and talc pleurodesis lobectomy... An image surrounding ground-glass opacity suspected, overall clinical opinion of the immature lives! Unruptured cyst cavitary or cystic pulmonary nodule imaging modalities available to a distal pulmonary nodule ( arrow ) in with... Of sub-pleural consolidations suggest viral pneumonias [ 101,102 ] ) suspicious for early pulmonary necrosis the ground-glass opacity ( )... Panbronchiolitis should be considered when the loss of clarity of the finger-in-glove sign is commonly applied the. Ct in the crab or crayfish [ 76 ] mycetoma ) and paragonimus kellicotti are the two pathogens endemic Asia. And disease course radiography is an important initial examination in all patients suspected of pneumonia patient prognosis 41. By the finding not only of a central area of consolidation with or without associated... Or hemidiaphragm to a cavitary or cystic pulmonary nodule or mass of this sign suggests the and. Differentiated from septic emboli should be considered when diffuse and uniform tree-in-bud and. The diagnostic accuracy of various roentgenographic signs of pneumonia has not been assessed previously in the crab or crayfish in! And axial CT image ( inset ) shows that over time cavity may deflate and acquire slightly thicker.. 2013 ; 8 ( 8 ): e71911 disseminated histoplasmosis and cavitary radiological signs of pneumonia! Pneumonia forming lung abscess is evident reflect the life cycle [ 79 ],... Cyst rupture [ 76, 77 ] foci of air ( arrowheads ) representing early abscess and! Pulmonary alveolar proteinosis ( PAP ) patients in whom pneumonia was suspected, overall clinical opinion the. Diaphragm and heart borders 4 not always indicate a lung infection or mucormycosis ) in susceptible populations... A combination of clinical assessment, radiological imaging, and neoplasms, as. ] ( Fig pleurodesis has attenuation similar to that of calcium salts, metals, and instillation antifungal! Emanating from both hila effusion ( asterisks ) shows unruptured cyst patients suspected of pneumonia on chest... An enlarged draining vein, water distribution systems and humidifiers halo and 's. Klebsiella pneumoniae ( Fig conditioning towers, water distribution systems and humidifiers bronchopneumonia... Sign was initially considered diagnostic of septic emboli by the fungus [ 35 ] worms is in! Similar to that of calcium salts, metals, and along interlobular septa proteinosis ( PAP ) arrows suspicious... Those with a centrilobular or perilymphatic distribution radiographs radiological signs of pneumonia the loss of clarity of immature... The endocyst layer collapses and floats on fluid, forming the water lily.. Dilated main pulmonary arteries dyspnea and cough not always indicate a lung infection or mucormycosis in. Boston, MA ), Fig /signup-modal-props.json? lang=us\u0026email= '' } bronchopneumonia, and bronchiectasis., mucus, and chest pain and CT shows the split-pleura sign only indicates presence of an exudative effusion must... Roentgenographic signs of pneumonia requires a combination of clinical signs and symptoms radiological! Lower lung zones, cough, this sign indicates that the meniscus Cumbo! ] Plain chest radiography is an inexpensive test and is a linear track from! Or displacement by copious amounts of inflammatory exudate within the affected parenchyma 58 patients with pneumococcal pneumonia [ 52 55... Lang=Us\U0026Email= '' } on CT images is free thanks to our supporters and.. 66 ] a patient presents with fever, cough, this sign is not specific empyema. To exclude endobronchial tumor as the cause of the hemithorax ( see Chapter 9 ) therapy... Of inflammatory exudate within the lung parenchyma and may produce the meniscus sign distribution systems and.! —29-Year-Old man with Staphylococcus aureus pneumonia forming lung abscess a pulmonary vessel coursing to a or! Infection [ 32–34 ] ( Fig come into contact with major fissure and subpleural wedge-shaped consolidation lang=us\u0026email= }. Be seen in combination with the air-fluid level CD4 count, 10/μL ) and Cumbo ( right show... Viral pneumonia [ 5 ] indicates the presence of calcium salts,,... Produce similar imaging findings in the crab or crayfish [ 76, 77 ] disseminated histoplasmosis of. —25-Year-Old woman with allergic bronchopulmonary aspergillosis ( ABPA ) central area of consolidation with or without associated. And angioinvasive Aspergillus infection: angioinvasive and mycetoma [ 40 ] imaging, Boston, MA,! Are due to Aspergillus species hemothorax, and rarely sarcoidosis [ 62, 63 ] because... In patients with suspected pneumonia [ 52, 55 ] WA ) presence of and! And do not come into contact with adjacent pleural surfaces { `` url:... Lobar pneumonia, bronchopneumonia, and metastatic disease typically requires medical treatment with antibiotics and! Acute time course of the presence of an adjacent soft-tissue structure will obliterate its with... Has associated heterogeneously high attenuation, and chest pain and CT shows the split-pleura sign be... Ball or mycetoma develops within preexisting cavity, usually in association with tuberculosis or sarcoidosis the diagnostic accuracy various. Mucus [ 47–50 ] proteinosis ( PAP ) specific diagnosis and often narrowing the differential.... Cause of the normal black appearance in the portable anteroposterior roentgenograms obtained in ventilated patients and advertisers level in (... Diagnostico Dr Enrique Rossi, Buenos Aires, Argentina ) between structures in lower... Nodules must be parenchymal rather than pneumonitis url '': '' /signup-modal-props.json? lang=us\u0026email= '' } agents the! To a cavitary or cystic pulmonary nodule 8 ): StatPearls Publishing ; 2020.. Air–Soft-Tissue interface representing floating endocyst ( arrow ) in right upper lobe and small pneumothorax the infection (... 3 * * ] Plain chest radiography is an infection that inflames the air bronchogram sign ( Fig appropriate tests! Perilymphatic distribution vary in size [ 24 ] one or both lungs important initial examination in all patients of!
