The Chest Xray:

Part Three:

The Lungs

MDFMR/UNECOM

August 12, 2009

A lot to cover today, so no segues.

A Normal PA view

So, on to the lungs

A Normal Lateral View

An Approach toPneumonias

1. Lobar PneumoniasA lobe, or lobes, are

consolidated

Radiological criteria for calling a shadow in CXR as consolidation are:

1.Lobar or Segmental Density The density should either correspond to lobe or segment of Lung.

2.Air Bronchogram presence of air bronchogram would confirm that it is an alveolar process.

3.No Loss of Lung Volume In early stages of consolidation the volume of lung increases. In later stages there can be some amount of loss of lung volume due to secretions obstructing airways.

As a general rule there is no significant loss of lung volume in consolidation

Consolidation

The silhouette sign :

An intra-thoracic radio-opacity, if in anatomic contact with a border of heart or aorta, will obscure that

border. An intra-thoracic lesion not anatomically contiguous with a

border or a normal structure will not obliterate that border.

In the case of middle lobe disease (collapse), the right heart margin is lost.

Right lower lobe pneumonia will blur the diaphragm on the right side. The right heart

margin remains distinct. The view shows air in the bronchi of the consolidated lobe and

beginning abcess formation.

•Haziness in the right mid lung field.  •Right heart margin slightly hazy with intact silhouette of right diaphragm •Middle lobe density in lateral •No significant loss of lung volume in lateral •Air bronchogram in lateral

RLLentire consolidation

•Density in the left upper lung field •Loss of silhouette of left heart margin •Density in the projection of LUL in lateral view •Air bronchogram in PA view •No significant loss of lung volume

•Haziness in the left lower lung field •Blunting of left costophrenic angle •Loss of silhouette of left heart margin •Density in the projection of lingula in lateral view •Air bronchogram in lateral •No significant loss of lung volume

Another lingular pneumonia

One whole lobe is consolidated with decreased crepitation. The size of the affected lobe is normal. However, the color is dark red. The cut surface may ooze fluid, which may be hemorrhagic or purulent. Airways of the affected lobe may

contain pus. This gross photograph of a cut lung shows consolidation and discoloration of most of the lower lobe .

This low power photomicrograph shows many alveolar spaces filled with inflammatory infiltrate. This high power photomicrograph shows the infiltrate to be composed of neutrophils. Note that the alveolar septa are relatively normal.  After complete resolution, the underlying lung

architecture is preserved.

Lobar Pneumonia :

Most common causes for lobar pneumonia are:

1.Pneumococcus2.Mycoplasma3.Gram negative organisms4.Legionella

2. Bronchopneumonias

pneumonia that is localized, often to the

bronchioles and surrounding alveoli

•Histopathology

•Patchy distribution in and around small airways

•Dense acute inflammatory exudate of PMNs, fibrin and blood in bronchi, bronchioles and adjacent alveoli.

•FOCAL destruction of alveolar walls (you can see normal parenchyma in other

areas adjacent)

Bronchopneumonias

Comparison of bronchopneumonia vs. lobar pneumonia

bronchopneumonia Lobar pneumonia

Most common causes for bronchopneumonia are:

1.Streptococcus2.Viral3.Staph

Some selected bronchopneumonias follow...

Bilateral bronchopneumonia(which lobes, eager young minds?)

The gross pathology

Bronchopneumonia is a very common form of pneumonia. It presents differently from lobar pneumonia on the chest film.

Lobar pneumonia tends to start at the periphery and involve a single lobe of the lung. However, bronchopneumonia starts

centrally in the bronchi and may cause peripheral consolidation which is due either to infection or to atelectasis.

Thus, a bronchopneumonia tends to be bilateral. There is associated peribronchial thickening and there are patchy areas of consolidation which involve both lungs. This consolidation

is asymmetrical. It may involve a segment of the RUL and another in the lingula.

The commonest organism to cause bronchopneumonia is staph aureus. Bronchopneumonias are also very common in

children.

This case shows a woman with bronchopneumonia. Note that there is bilateral patchy consolidation with obliteration of the apex of the heart and portions of the right and left diaphragm on the PA view. Areas of increased density can be seen in the right upper lobe, right lower lobe and in the left lower lobe. These should represent areas of consolidation.

On the lateral view portions of the left and right hemidiaphragm are incompletely seen and there is increased density in the region of the middle lobe.

Additionally, the major fissure is very prominent and consolidation can be seen adjacent to this fissure on

the lateral view. This likely represents a consolidation in the right upper lobe. This

appearance is typical for a bronchopneumonia. Usually there is discrete peribronchial cuffing in the

hilar region as well. We do not see this on these films.

This next patient had a head and neck cancer (notice bilateral apical fibrosis secondary to radiation therapy) and

developed a lung abscess in the left lower lobe superior segment secondary to

aspiration pneumonia. The first film shows an infiltrate in the left lower lobe extending

from the hilum to the retrocardiac and midlung zones. The midlung zone opacity is

more prominent and has a more or less rounded, but poorly marginated contour suggesting the possibility of an abscess.

A film taken 8 days later shows a large lucency replacing the opacity in the midlung zone. This occurs when the

abscess communicates with an airway. An air fluid level is seen in the cavity. The surrounding infiltrates have improved. This case illustrates a classic location of lung abscess and aspiration pneumonia,

the superior segment of either lower lobe. Patients with swallowing difficulty and impaired consciousness are particularly

susceptible.

One last bronchopneumonia:this is an aspiration pneumonia such as we commonly see in

the ICU following drug O.D.

Okay, we’ve done lobar pneumonias, and

bronchopneumonias. Now, how about:

3. Necrotizing Pneumonias

Most common causes for Necrotizing pneumonia are:

•Staphylococcal•Anaerobic infection

•Gram negative organisms

But this one was caused by pneumococcus

...which lobe?

This one, gram negative anaerobes

This, staph, in the lingula

Staph, again

This is why antibiotics may not be sufficient:

Segmental PneumoniaAspiration Pneumonia•Superior segment of RLL

This is a segmental (basal segment, RLL) post-obstructive pneumonia

So, here is a segmental pneumonia involving the posterior segment of the RUL

One worries about obstructing neoplasmOr aspirated foreign body

Round Pneumonia

Most common causes for round pneumonia are:

1.Fungal2.Tuberculous

Aspergillus Pneumonia developed while on steroids.

This is a case of blastomycosis.

Blastomycosis•Round pneumonia

•"Mass" like density with air bronchogram 

Tuberculosis•RUL cavity

•Posterior segment

Close-up of previous film

TuberculosisLUL cavity

•Cavity behind clavicle - note increased density of clavicle in the region over lying cavity

Tuberculosis•Note RUL cavitating infiltrate progressing to scarring

•Right hilum is pulled up

Here’s a round ‘something’

A branchial cyst, lower down than usual

Acute fire-eater pneumonia in a 21-year-old man who had aspirated petroleum during a performance. Posteroanterior chest radiograph shows ill-defined nodular areas of increased opacity in

both lower lobes (arrows).

Caveat Ultissimo Magnum Alertorum!

All that is round is not a round pneumonia!

Here is a lung cancer. Can you see it?

Another lung CA. Where?

Just how sharp are you? Where is the tip-offthat this is badness?

The right pedicle of T-7 is missing

New patient. What do you see?

Yes, that LLL nodule was most obvious to me. Now let’s bright-light the RLL...

Here is an obvious nodule

And the same patient 11 mos. later

This is metastaticbreast cancer

Metastatic renal cell CA

Two cases with neurofibromas

subtleobvious

Two different patients with very obvious, and asymptomatic lung cancers

This patient c/o flushing, wheezing, and urticaria. Where is the lesion and what is the DX?

Large cell CA of lung

squamous cell CA of lung

Ssshhh! Keep it to yourself! What do you see?

Yes, there are bilateral LL nodules. This is metastatic Ewing’s Sarcoma

Remember, old films can help:

This is the old film:

now

then

Not everything round is a round pneumonia or cancer. These are septic pulmonary emboli.

This is a pulmonary infarct

This is a pulmonary A-V fistula

And this is a pseudotumor, or so-called phantom tumor

Now, back to pneumonias, and on to

Diffuse Alveolar Pneumonia

Most common causes for diffuse alveolar pneumonia are:1.Pneumocystis

2.Cytomegalovirus

Patient with Pneumocystis Carinii pneumonia

Post-lung transplant, CMV pneumonia

Diffuse Interstitial Pneumonia

Most common causes for diffuse interstitial pneumonia are:

1.Viral2.Chickenpox

Some viral pneumonias follow:

Here is a viral, interstitial pneumonia with some extension into the alveolar spaces (more about this later)

It’s helpful to think histologically when looking at chest films of

pneumonia:

Here is normal lung

Lobar PneumoniaRemember that bacteria (as a rule of thumb) elicit a

neutrophilic inflammatory response. Here you can see the alveolar air spaces are full of PMNs as well of

exsanguinated RBCs. It shouldn't surprise you then that hemoptysis (coughing up blood) can be a symptom of

pneumonia. Notice that the interstitial space is left relatively normal.

Lobar PneumoniaPMNs only live for 2 or 3 days. So (although you may not be able to make the distinction at this magnification) macrophages have replaced the PMNs. At the same time, the alveolar exudate has become fibrotic. This complication of lobar pneumonia is called "organizing pneumonia."

Interstitial PneumoniaViral pneumonias manifest themselves in the

interstitium rather than the alveolar air spaces. Notice that the interstitial space is greatly

expanded with lymphocytes while the alveolar spaces are relatively normal. Does it make sense

to you that viral pneumonias are usually less problematic than bacterial pneumonias? A common complication of viral pneumonia,

however, is a secondary bacterial superinfection.

And then the chest film gets more confusing, and the patient, sicker:

Or, as in this case:

Really advanced stuff:•With viral pneumonias, chest radiographic findings

usually are nonspecific-they cause an interstitial infiltrate, but some features are characteristic of individual viruses.

•HSV can produce focal lesions on chest x-ray that begin as small nodules in the periphery. As the disease

progresses, the nodules coalesce to form extensive infiltrates.

Usually see this in newborns, or in immunocompromised patients.

.•In influenza pneumonia, radiographic findings are similar to those described for other respiratory viral infections. Perihilar and

peribronchial infiltrates occur commonly, while progression to diffuse interstitial infiltrates is

observed with severe disease. Other findings of influenza pneumonia include hyperexpansion of the lungs, subsegmental atelectasis of multiple lobes, and lobar atelectasis, particularly of the

right-upper or right-middle lobe

.•In CMV pneumonia, chest radiographs show interstitial infiltrates predominantly in the lower lobes. Advancement to diffuse interstitial

infiltrates is observed in patients with organ transplant.

•In RSV, chest radiographs show bilateral interstitial or patchy infiltrates. Lobar consolidation and pleural effusions are present in 25% and 5% of

cases, respectively. Here’s an infant with RSV pneumonia:

•In PIV, chest radiographs may reveal findings ranging from

focal infection to diffuse interstitial infiltrates or diffuse

mixed alveolar-interstitial infiltrates consistent with acute

lung injury

.•In varicella pneumonia, radiographic findings are diffuse, fluffy, reticular or nodular infiltrates that can be rapidly progressive. Pleural effusion and peripheral adenopathy can occur. Radiographic abnormalities are more prominent during the peak of the rash and resolve rapidly with clinical

improvement. Long-term respiratory sequelae are infrequent in survivors, although small, diffusely scattered, punctate lung calcifications may

persist on chest films

An early varicella pneumonia

.•Hantavirus infection may result in normal chest radiograph findings during early disease. This is followed by signs of interstitial edema, Kerley

B lines, peribronchial cuffing, and indistinct hila. Progression to the pulmonary edema phase over the subsequent 48 hours is indicated by centrally located dense alveolar infiltrates unlike the more peripheral

infiltrates of adult respiratory distress syndrome from other causes. With further progression, pleural effusions also may develop.

Here is a tricky interstitial pneumonia:

The history helps us here (as it always does: sick for months,

with weight loss, and oh yes, just arrived from the Third World

So, we look more closely, and see the interstitial nodularity of miliary TB

Let’s review:

Lobar Pneumonia :

Most common causes for lobar pneumonia are:

1.Pneumococcus2.Mycoplasma3.Gram negative organisms4.Legionella

RLLentire consolidation

Bronchopneumonias

pneumonia that is localized, often to the bronchioles and

surrounding alveoli

Most common causes for bronchopneumonia are:

1.Streptococcus2.Viral3.Staph

Bilateral bronchopneumonias- note the patchy consolidation

Segmental Pneumonias involve part of one lobe, i.e. are “sub-

lobar”

Most common causes for segmental pneumonia are:

1.Post obstructive

2.Aspiration

A patient with aspiration pneumoniaIf the organism necrotizes tissue, this could

develop into a necrotizing segmental pneumonia, aka lung abscess

Necrotizing pneumonias ‘eat’ away at the lung parenchyma

because of the causative organism’s propensity for doing

so. They may start as lobar, segmental, or

bronchopneumonias.

¿Claro?

Most common causes for Necrotizing pneumonia are:

•Staphylococcal•Anaerobic infection

•Gram negative organisms

These pneumonias, as well as the round pneumonias we just saw, involve the alveolar spaces in a more or less focal manner, as

opposed to the diffuse alveolar pneumonias seen with CMV and

pneumocystis

Patient with Pneumocystis Carinii pneumonia

But remember!

The alveolar spaces can be filled with water, pus, or blood, and on a single film, without any history,

you can’t tell them apart.

Here is water...

ARDS

Another case of ARDS (post-viral pneumonia!)

Here is pus...

Varicella pneumonia, interstitial progressing To alveolar, as seen previously

More pus...another PCP pneumonia

...and here is blood

SLE-microangiitis leading toPulmonary hemorrhage

And another patient with diffuse alveolar hemorrhage, in this case a marrow transplant patient with no platelets

Finally, the alveolar spaces may not be infected all, at least not initially, as with most

viral (interstitial) pneumonias

Finally, we should talk about Bronchiolitis obliterans organizing pneumonia or:

BOOP

Patients with BOOP are usually between the ages of 40-70, and present with a history of dry cough and SOB of two

weeks to two months in duration. These symptoms persist despite antibiotic therapy. On auscultation of the lungs

late inspiratory crackles are heard. The patient often has an elevated ESR, and PFTs demonstrate a decreased

diffusion capacity and a restrictive pattern (diminished FC and TLC with a normal FEV/FV ratio).

The etiology of BOOP may be idiopathic or secondary to viral illness (RSV, adenovirus), collagen vascular disease,

(RA, SLE), caustic inhalation (sulfur dioxide, chlorine), heart-lung transplant and chronic aspiration..

The diagnosis is made histologically, via open lung biopsy since transbronchial biopsy frequently yields inadequate

tissue specimens. Fibrous plugs and granulation tissue are present within

terminal bronchioles as well as alveolar ducts and alveoli.

In addition, perivascular mononuclear cell infiltrates are also seen.

The interstitium is commonly involved, distinguishing BOOP from pulmonary fibrosis.

The most common chest x-ray finding is bilateral, patchy subpleural air-space opacities (69%), which can mimic lung masses. Pleural effusions and cavitations are rare. Similar

radiographic appearances are typical for eosinophilic pneumonia, PE, septic emboli, bronchoalveolar carcinoma,

metastatic disease and sarcoidosis

BOOP

Open lung biopsy of patient with BOOP

And we are finished