Clinico Radiological Series: Imaging of Chest Infections Randeep Guleria, Ashu Seith Bhalla, Manisha Jana, Priyanka Naranje, GC Khilnani
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdominal situs inversus, complete 286f
Abscess
ruptured 332
unruptured 332
Acid-fast
bacilli 143, 149
stain 38
Acinar nodules 270, 366
Acinetobacter baumannii 54, 175, 176, 178, 299, 369
pneumonia 169f
Acquired immunodeficiency syndrome 4, 97, 148, 183, 240t, 245b, 246, 249t
Actinomyces israelii 26
Actinomycosis 399
Active nodal disease, signs of 134
Active pulmonary disease, signs of 132
Adenocarcinoma 246, 347, 352f, 357
Adenoid hypertrophy 273
Adenopathy 262
mediastinal 262
Adenosine deaminase deficiency 192
Adenovirus 61
pneumonia 66
Adult respiratory distress virus, revere 67
Air leaks, ventilation-associated 182
Air-bronchogram 16, 209f, 216f, 222f, 296, 352, 357f
irregular 352f
sign 163f
Air-bubble 115f
sign 113
Air-crescent sign 74, 376, 378f
Air-fluid level 113
Airspace nodules 55f, 119
Airway 440, 442
colonization 225
complications 303
disease, small 250f
fungal infections, patterns of 210f
infections 418, 419
chronic sequelae of 429, 430t
classification 418
invasive aspergillosis 77, 77f, 78f, 212f, 226f
obstruction 275
pathology, upper 273
Albendazole 333
Albert's stain 33, 34
Allergic bronchopulmonary aspergillosis 85, 87f, 89t, 269, 282, 276, 284
treatment of 89
Alveolar echinococcosis 118
Alveolar hemorrhage, diffuse 206f, 211, 215, 231, 306, 447f
Alveolar hydatidosis 119f
Alveolar interstitial syndrome 17f
Alveolar pneumonia 179f
Alveoli 65
Amebiasis 107, 108
Amebic liver abscess
rupture of 109f
transdiaphragmatic rupture of 108f
American College of Chest Physicians 395t
American Thoracic Society 146
Amoebiasis 391
Anaerobic bacteria 56
Anaerobic infections 56f, 241f
Angioinvasive aspergillosis 74, 196f, 226f, 306
Angioinvasive fungal infections 180
patterns of 209f
Angioinvasive infections 306
Antineutrophil cytoplasmic antibodies 372
Antiretroviral therapy 250
Antithymocyte globulin 202
Antitubercular treatment 407
Aorta 310f, 413
Aortic arch
anomalies 198
right-sided 286f
Aortic pseudoaneurysms 309
Arterial hypertension, pulmonary 239, 250
Artery
nonbronchial 440, 450
small left pulmonary 283
Ascariasis 107, 118
life cycle of 119f
Ascaris lumbricoides infection 118
Aspergilloma 269, 327f, 331, 333, 333f, 377, 377t
complex 81
simple 80, 81f
Aspergillosis 73, 216f
Aspergillus 41, 74, 220, 224, 239, 376, 382
colonization 225
flavus 73, 354f
fumigatus 73, 85, 89, 210, 216f, 225, 245
induced asthma 89
infection 358
niger 73
nodule 83
pneumonia 206f
related lung disease 73
specific antibody 85
terreus 73
ustus 73
Aspiration 357
pneumonia 169, 170f
Asthma 284
Atelectasis 230, 264, 333
nonobstructive 357
Atoll sign 358, 369
Atresia
pulmonary venous 281
venous 283
Autoimmune disorders 189
Autoimmune malignancies 189
Avian flu 65
B
B cell
disorders 186, 187b, 190
immunity defects 184
Bacteria 34, 46, 206, 207, 220, 369
Bacterial colonization 268
Bacterial empyema, spontaneous 385
Bacterial infection 208, 239, 240, 241f, 414
nosocomial 240
patterns of 209f
recurrent 197
Bacterial pneumonia 45, 167f, 212f, 216f, 221, 222f, 239, 240, 240t, 263f, 264, 264t, 357
Bacteroides melaninogenicus 56
Barry-Perkins-Young syndrome 268
Bartonella henselae 240
Basidiomycota 72
Bhalla and Brody systems 269
Biopsy, pleural 318
Bird's nest sign 94, 95, 216f
Blastomyces dermatitidis 72, 92, 101
Blastomycosis 41, 104
pulmonary 104f
Boerhaave's syndrome 406
Bone marrow transplant 344
Breast hematoma
large 329f
post-biopsy 329f
Brochoalveolar lavage 37
Bronchi 25
peripheral 421
Bronchial anthracofibrosis 419
Bronchial artery 328f, 440
embolization 324, 327f, 328f
pseudoaneurysm 325f, 332f
Bronchial communication 306
Bronchial wall thickening 54f, 212f, 269
Bronchiectasis 97, 154f, 170, 198, 333, 334, 427f
bilateral 54f
distribution of 271f
postinfectious 426
post-tubercular 139f
severity of 269
Bronchiolitis 25, 65, 256
infectious 165f
non-infectious 428f
obliterans 208f, 237, 264f, 265f
syndrome 235f
Bronchitis 29, 256, 421
Bronchoalveolar lavage 32, 79, 147f, 152f, 225, 326f
Bronchobiliary fistula 110f
Bronchoesophageal fistula 426f
Bronchogenic cyst 273
Broncholithiasis 431f, 432
Bronchopleural fistula 304, 331333, 336, 394f
postinfective 305f
Bronchopneumonia 39, 78, 164, 165f, 178, 179f, 180f, 211, 211t, 212f, 262, 273, 301, 345f, 346, 346f
Bronchostenosis 333, 334
Bronchus intermedius 278f
Brugia malayi 122
Bruton's agammaglobulinemia 188
Bulging fissure sign 52, 52f, 361, 362f, 436
Bulla, infected 171f
Burkholderia cepacia 53, 269, 427
C
Calcific pancreatitis, chronic 178f
Calcified subcarinal lymph nodes 280f
Candida
albicans 26, 92, 99, 175, 385
pneumonia 205f
pseudohyphal forms of 42f
Carbon monoxide 338
Carcinoid tumors 275, 277
Carcinomas, mucoepidermoid 275
Cardiac chamber 413, 437, 442
Cardiogenic pulmonary edema 355
Cartilage hair hypoplasia 199f
Castleman's disease 414
Causative organism 99, 100, 346
Causative virus 64
Cavitary disease 333
Cavitary lesions 25, 39
malignancy in 371, 371t
Cavitary nodule 226f
Cavitary pulmonary
aspergillosis, chronic 81, 82f, 382, 451f
histoplasmosis, chronic 101
Cavitating nodules, multiple 180f, 374f
Cavities, infective 370f
Central airway diseases, classification of 420t
Central bronchiectasis, diffuse 190f
Central necrosis favoring tuberculosis 39f
Central pulmonary arteries, enlarged 250
Central venous access 202
Centrilobular nodules 54f, 55f, 130, 152f, 209f
types of 365f
Centrilobular tree-in-bud nodules 328f
Cepacia syndrome 54
Cerebrospinal fluid 96
Cestodes 111
Chédiak-Higashi syndrome 195
Chest infection 3, 6b, 10b, 12, 291, 312, 318, 324, 364
complication of 291, 310f
nonvascular complications of 292t
Chest radiograph 4, 12, 74, 147f
types of 6
Chest tuberculosis 124
sites of 125
Chest wall 292
abscesses 329
actinomycosis 400f
cold abscess of 401, 402f
infections 385, 398
types 398
tuberculosis 136
spectrum of 137f
Chest X-ray 269f, 347
Chlamydia pneumoniae 58, 170, 240, 347
Chlamydia trachomatis 255
Chlamydophila pneumoniae 58, 160, 164, 255
Chondrodysplasia, metaphyseal 199f
Chronic pulmonary aspergillosis, classification of 80f
Ciliary dyskinesia
primary 267, 267f, 286f
secondary 271
Classical bulging fissure sign 163
Cleft palate 273
Coaxial technique 313
Coccidioides enzyme immunoassay 103
Coccidioides immitis 72, 92, 101, 102, 245
Coccidioides posadasii 102
Coccidioidomycosis 102
pulmonary 104f
Cold abscess 329
Collapse therapy 337
Common cold 26, 27
Community-acquired pneumoniae 61, 159, 160, 161t, 240, 343, 344
treatment of 171
Complement system defects 185
Concomitant sinusitis 95
Congenital bronchopulmonary foregut malformations 278
Congenital malformations 273
Congenital pulmonary airway malformation 273, 276
Congenital tuberculosis 140, 141f
Congestion, stage of 38
Coronal multiplanar reformation 7f
Coronary heart disease 344
Coronavirus 67
Costochondral junction 137
Cough
reflex, loss of 36
chronic 147f, 153f, 154f
C-reactive protein, serum 257
Crescent sign 113
Cryptococcosis 95, 96f
Cryptococcus fungus, round-shaped 42f
Cryptococcus neoformans 92, 245
Cryptogenic organizing pneumonia 351
Cumbo sign 114f
Curtain sign, loss of 16
Cyclical neutropenia 195
Cyst 236, 298, 379, 381f
duplication 273, 281
Cystic bronchiectasis 88f
Cystic fibrosis 53, 170, 268, 269, 269f, 271f, 282, 284
Cystostomy 332
Cytomegalovirus 41, 204, 211, 215, 218, 220, 229, 237, 246, 252
infection 301f
pneumonia 68, 212f, 224f
D
Dark bronchus sign 262f
Dengue 307
Dense adhesions 338
Diabetes mellitus 71, 336
Diffuse alveolar hemorrhage, causative organisms of 307t
DiGeorge syndrome 187, 191
Digital subtraction angiogram 327f, 328f
Diphtheria 28
Dirofilaria immitis 120
Dirofilariasis 107, 120
Disseminated histoplasmosis 102f
Disseminated nocardia infection 194f
Distal air-space nodules 210f
Distal pulmonary nodule 360f
Draining parapneumonic effusions 318
Dry cough 97
Dynamic air bronchogram 16, 22
Dysplasia, metaphyseal 198
Dyspnea 97
severe 67f
E
Early postengraftment infections 206f
Echinococcosis 108, 111
Echinococcus granulosus 111, 112, 380
Echinococcus multilocularis 111
Echinococcus vogeli 111
Edema 347
noncardiogenic 355
pulmonary 182, 206f, 230, 231, 231f, 348, 349
Eloesser flap 336, 337f
Embolism, pulmonary 230
Emphysema 101
Empirical antibiotic therapy 169f
Empyema 25, 301, 301, 319f, 331, 334, 389, 394f
chronic 335f, 394f
management for 332, 335t, 336t
necessitans 138, 402f, 403
stage of 335
stage-wise management of 334
Encephalitis 70
Endemic fungi 72, 224
Endobronchial lesions 277f
Endobronchial mass 275, 358f
Endobronchial ultrasound, guidance of 314
Endocarditis 293
Endotracheal intubation 330
Endotracheal tube 32
Entamoeba histolytica 41, 107, 391
Enterobacteriaceae 299
Enzyme-linked immunosorbent assay 332
Eosinophilia
simple pulmonary 121
tropical pulmonary 122f, 123
Eosinophilic hyaline membrane structures 39f
Eosinophilic pneumonia 349, 351f
Epiglottitis 25, 26, 28
Epithelial cell, enlarged 39
Epithelioid granuloma 39f
Epstein-Barr virus 70, 232, 247
infections 210
Escherichia coli 53, 175, 176, 240, 346, 385
Esophageal perforation 406, 406f
Esophagitis 406
Esophagus 102, 413
malignancies of 406
Eustachian tube dysfunction 273
Extrapulmonary tuberculosis 125, 133
Exudative effusion 386
infectious 396, 397
infectious 396t
malignant 396t
noninfectious causes of 395
Exudative pleural effusion 388t, 389
F
Fast field echo 10
Fast imaging employing steady-state acquisition 10
Febrile neutropenia 203
Feeding vessel sign 359, 360f
Fever 97
Fibrinoid organizing pneumonia, acute 236
Fibrinolytic agents 320
Fibrocavitary disease 439
Fibrocavitary lesion 333f
Fibrocavitary pattern 381, 382f, 383f
causes of 383t
Fibrosing mediastinitis 103f
diffuse 412f
secondary effects of 413t
Fibrosing pulmonary aspergillosis, chronic 82, 83f
Fibrosis 451
mediastinal 11f
Fibrothorax 397, 398f
Fistula 304
node-to-bronchus 425f
Fluconazole 96
Fluid bronchogram 16, 22, 358, 358f, 436
Focal fibrosing mediastinitis 411f
Focal lung lesions 108
Follicular bronchiolitis 252, 428f
Frank extravasation 406f
Fungal hyphae 339f
Fungal infection 71, 92, 197, 205, 208, 244, 245b
pulmonary 73
spectrum of 72t
Fungal osteomyelitis 399
Fungal pneumonia 30, 181f
manifestations of 219
Fungi 92, 101, 207, 220
classification of 72
xygomycetes group of 227
Fusariosis 100
Fusarium solani 92, 100
G
Galactomannan
antigen 84
serum 74, 225
Gangrene, pulmonary 296, 296f
Gastrointestinal tract 26
Giemsa and toluidine blue stain 38
Goblet cell hyperplasia 271
Gömöri methenamine silver stain 33
Graft ischemia 225
Graft-versus-host disease 202, 215, 216f
Gram's stain 33, 38
Gram-negative
bacilli 46, 51, 255
bacteria 160, 221
cocci 46, 51
Gram-positive
bacilli 46, 50
cocci 45, 46
Granulocyte
colony stimulating factor 203
disorders of 193
Granulomatosis 420, 422
polyangiitis 372, 349
Granulomatous
disease, chronic 193, 194f, 195
disorder, chronic 199f
infections 348
lung lesions 40
polyangiitis 424f
Grocott's silver methenamine 38, 41
Ground-glass opacities 62, 64, 66f, 69f, 76f, 154f, 167f, 170f, 180f, 211, 215, 247, 315, 346f, 348, 348f, 362f, 437
bilateral 325f, 447f, 349f
diffuse 246
H
Haemophilus influenzae 26, 38, 54, 164, 170, 171, 175, 207, 208, 221, 240, 255, 346, 347, 429
infection 356
pneumonia 55f
Halo sign 216f, 225, 368f, 436, 453f
reverse 75, 94f, 95, 358, 359f, 368f, 436
Hamman-Rich syndrome 299
Head cheese pattern 154f
Healed nodes, signs of 134
Healed pleural tuberculosis, signs of 135
Healthcare-associated pneumonia 160, 173, 344
Heart transplantation 221
Hematopoietic stem cell transplantation 79t, 200, 201f, 201t, 211, 215, 219, 440, 453f
technique of 202t
Hemoptysis 326f, 330, 334
Hemorrhage 65, 347
post-biopsy 317f
pulmonary 182, 230, 231f, 291, 306, 308f, 348, 349
Henoch-Schönlein purpura 355
Hepatic abscesses, multiple 194f
Hepatic hydrothorax 385
Herpes simplex virus 204, 210, 220, 246, 252, 255
Herpes virus 247, 248
Heterotopic heart transplantation 221
High-resolution computed tomography 89, 99t, 147f
Hilar adenopathy 264
Hilar lymph nodes, calcified left 279
Hilar nodes 310
Histiocytic cell, cytoplasm of 39f
Histoplasma capsulatum 72, 92, 101, 102, 103f, 239, 245
infection 101
Histoplasmosis 101, 414
Hodgkin lymphoma 239, 247, 252
Hospital-acquired
infections 391
pneumonia 61, 159, 160, 173, 174f, 175t, 178f-181f, 343, 344
mimics of 182
Human herpes virus 204, 210, 218
Human immunodeficiency virus 71, 95, 238, 240t, 245b, 246b, 249t
Human metapneumovirus 66
Humoral immunity 184
Humoral immunodeficiency 190b
Hydatid cyst 22f, 329, 331, 332, 332f, 338, 381f
infected 117f
mediastinal 117f
pulmonary 113t, 279
rupture of 116f
uncomplicated 113f
Hydatid membrane 41, 42f, 339f
Hyper-IgE syndrome 195, 196
Hyper-IgM syndrome 189, 190
Hyperintense signal of mucoceles 88f
Hypersensitivity pneumonitis 153, 154f
Hypertrophy, tonsillar 273
Hypodense
mediastinal lymph node, enlarged 243f
sign 75, 76f
Hypoplasia 191
pulmonary 273, 283
Hypoxemia 97
Hypoxia 301f
I
Idiopathic pneumonia syndrome 207f, 213f
Idiopathic pulmonary fibrosis 142
Ill-defined ground glass nodules 366
Ill-defined nodules 365f
Immune reconstitution inflammatory syndrome 142, 142f, 155, 249, 249t,
Immunity, suppression of 218
Immunocompromised host 61, 183, 307, 351
Immunodeficiency
combined 194f
disorder, primary 186, 198t
Infarction 370
pulmonary 348, 351, 351f, 352, 352t, 354f
Infection 203, 206, 357, 371, 405
non-necrotizing 176
pulmonary 218, 220t, 331
spread of 36
tubercular 401
types of 197
Infectious pneumonia, causative organism of 254
Infiltrative lymphocytosis syndrome, diffuse 251
Inflammation, mediastinal 406
Inflammatory cytokine syndrome 248
Inflammatory myofibroblastic tumor 275, 277
Influenza virus 65
Infradiaphragmatic infections 385
Inhalational pneumonia 174
Inhomogeneous opacities 300
Intercostal tube drainage 334, 336, 339f
Interlobular septal thickening 245, 247
Interstitial capillaries 39f
Interstitial lung disease 148, 151, 237
drug induced 232f
Interstitial pneumonia 39f, 345f, 346, 347f, 349
acute 39f, 40, 299, 349f, 355
nonspecific 231
Interventional radiology procedures, types of 312, 313t
Intrabronchial mass, small 277
Intracerebral hemorrhage 170f
Invasive aspergillosis 225
subacute 83, 84f
Invasive fungal infection 370, 377, 377t
Invasive pulmonary aspergillosis 73, 74, 75f, 76f, 79t, 225, 453f
treatment of 78
Itraconazole 105
K
Kaposi sarcoma 239, 246249, 252
Kartagener's syndrome 267
Kidney disease, chronic 160, 344
Klebsiella pneumoniae 51, 52, 52f, 53f, 163, 166, 175, 176, 179f, 181f, 221, 345f, 346, 351, 369
infection 52f, 361f
Klebsiella rhinoscleromatis 419
Koh-Calcofluor white stain 33
L
Lactate dehydrogenase 393
Langerhans cell histiocytosis 233f
Laryngeal cleft 273
Laryngitis 25, 26
Laryngoepiglottitis 25, 26, 28
Late postengraftment
infections 208f
noninfectious diseases 208f
Latent tubercular infection 125
Legionella 175
pneumonia 221, 242, 299, 346
pneumophila 57, 160, 164, 175, 176, 240
pneumonia 57f
Lepidic growth pattern 369
Leptospirosis 307
Leukemia
acute 200, 201
neutropenic acute 196f
Leukocyte adhesion defects 195
Leukocytosis 176
Lipoid pneumonia 285
Liposomal amphotericin B 105
Listeria monocytogenes 255
Liver
acquisition 10
disease, chronic 69f
transplant 220
Living donor liver transplantation 220
Living lobar lung transplantation 221
Living related renal transplant 220
Living unrelated renal transplant 220
Lobar consolidation 163f, 178, 260
etiology of 351
Lobar pneumonia 344, 345f
Lobe bronchiectasis, bilateral lower 195f
Lobe nodules, bilateral upper 453f
Lobe parenchymal involvement
lower 243f
middle 243f
Lobectomy 334
Loculated pyopneumothorax 303t, 306
Loeffler's syndrome 121, 122f, 123, 351f
Low power field 32
Lower lobe
bronchiectasis, left 334f
left 222f
peribronchial thickening 265f
predominant 285f
involvement 286
Lower respiratory
infection, types of 61
tract, infections of 25t
Lung 273
abscess 19, 25, 178, 262, 292, 293t, 295f, 303t, 331, 332, 373, 374
catheter drainage of 323f
drainage of 322
evolution of 294f
allograft dysfunction, chronic 232
alveolar space of 25
cancer, primary 246
carcinoma 239
cavity containing air 19
disease
chronic 344
diffuse 106, 108, 108t
infection 16t
pathology of 36
injury, acute 237, 299, 302t
lesions, infective 316f
nodule 247
low attenuation 194f
multiple 141, 194f
small deep-seated 317f
nonaerated 352t
parenchyma 116f
perfusion, impaired 280
transfer factor of 338
transplant 221
ultrasound 12
ventilation, impaired 282
Lymph node 127, 133, 237, 313, 314, 438, 440, 442, 448
enlargement 273, 413
residual 135
Lymphadenopathy 9f, 68, 97, 198
tubercular 134f, 138
Lymphoblastic leukemia, acute 201
Lymphocytic interstitial pneumonia 239, 251, 251f
Lymphoid hyperplasia complex, pulmonary 239
Lymphoid interstitial pneumonia 239
Lymphoma 247f, 249, 347, 357, 415t, 416f
refractory 201
Lymphoproliferative disorder, post-transplant 232, 233f, 234f, 237
M
Malaria 107, 110, 307
Mammary vessels, internal 329f
Massive hemoptysis 334
Measles
infection 39
virus 69
Meconium aspiration syndrome 260f
Mediastinal adenopathy, tubercular 243f
Mediastinal collection drainage 322, 322f
Mediastinal infections, classification of 405t
Mediastinal lymphadenopathy, causes of 415t
Mediastinal nodal collections, tubercular 407t
Mediastinitis
acute 404, 405
chronic 405, 411
Mediastinum, infections of 404
Meniscus sign 113, 114f
Mesothelioma
infections in 397t
pleural thickening in 397t
Methicillin-resistant staphylococcus aureus 161, 204, 297f
Methotrexate 202
Methylprednisolone 105
Microsporidia 72
Middle lobe predominant disease 286
Middle-eastern respiratory syndrome associated coronavirus 67
Miliary nodules 130, 302f
Miliary tuberculosis 223f, 302f
Mixed connective tissue disorder 149f
Molecular test 32
Monod sign 81f, 377
Moraxella catarrhalis 26, 51, 170, 171, 346, 427
Mucicarmine 38
Mucociliary clearance defects 266
Mucormycosis 41, 92, 216f, 227, 228f, 326f, 358
over aspergillosis 95t
pulmonary 94f
Mucus plug 304, 304f, 428
Multicentric castleman disease 239, 248
Multicystic lesion 281
Multidetector computed tomography 143
Multi-drug resistant tuberculosis 140, 305f, 333
Multilocular thymic cysts 239, 252
Multiorgan disease 332
Multiple cavitary nodules, causes of 373b
Multiple centrilobular tree-in-bud nodules 223f
Multisystem syndrome 251
Muscle flap interposition 334
Mycobacteria 149f, 154f
Mycobacterial infection 30, 239, 333, 369
atypical 244f
Mycobacterium
abscessus 152f, 153f
infection 242
kansasii 146
simiae 146, 147f
szulgai 146
tuberculosis 39, 124, 125, 146, 149, 168f, 220, 221, 229, 237, 242, 369, 419
xenopi 146
Mycobacterium avium
complex 249
intracellulare 153
intracellulare complex 146, 151
infection 147f, 149f
Mycoplasma 299
pneumonia 57, 58f, 160, 164, 166, 240, 255, 266, 347, 362, 429
Mycotic pseudoaneurysm 309f, 310f, 324
Myeloid leukemia, acute 201
Myeloma, multiple 201
N
Necrotic lymph nodes 141
Necrotic nodal collections, tubercular 408f
Necrotizing infections 304
Necrotizing mediastinitis, descending 406, 409f
Necrotizing pneumonia 19, 165, 177f, 178, 228f, 308f, 331, 332, 445f
Neisseria meningitidis 51
Nematodes 118
Neoplasms 357
Nephrotic syndrome 194f
Neutropenia 202
episodes of 195f
Nipah virus 70
Nocardia 41, 221, 242
asteroides 50, 240, 242
infection 221
Nocardiosis 25
pulmonary 222f
Nodular opacities 63, 168f
Nodular wall thickening 421
Nodules 130, 364, 441
large 131, 368f
multiple 217f
non-centrilobular distribution of 367f
perilymphatic 130
small 97, 236
Noncystic fibrosis bronchiectasis 54f
Non-Hodgkin lymphoma 246
Nonsteroidal anti-inflammatory drugs 250
Nontuberculous mycobacteria 146, 148f, 150, 151t, 220, 348
classification of 150t
infections 146, 148, 242, 284
Non-vascular procedures, complications of 324
O
Obliterative bronchiolitis pattern 429f
Obstructive airway disease, chronic 169, 252
Obstructive bronchiolitis, postinfectious 264
Obstructive bronchopulmonary aspergillosis 89
Obstructive pulmonary disease, chronic 72, 101, 148, 148f, 151, 174f, 239, 250, 271, 344, 445f
Onion peel sign 114
Opportunistic fungi 72
Opportunistic infections 33, 34t
Oral flora, normal 56
Orthotopic heart transplantation 221
Orthotopic lung transplantation
bilateral 221
post-bilateral 233f, 235f
single 221
Osseous infections 399
types of 399
Osteitis, tubercular 399
Osteochondroplastica, tracheobronchopathia 420
Osteomyelitis 136, 405
Osteopenia 198
P
Pancreas, fatty replacement of 195f
Pancreatic fatty atrophy 199f
Pancreatic origin, mediastinal collection of 410
Pancreatitis 410f
Paracoccidioides brasiliensis 72, 92
Paragonimiasis 108
Parainfluenza virus 61, 65
Paranasal sinuses, mucoperiosteal thickening of 187f
Parapneumonic effusion
stages of 302, 392t
transudative 318
Parasite 35, 106
life cycle of 107f
Parasitic infections 106, 197
Partial combined immunodeficiency syndromes 193
Patchy atelectasis 264f
Pediatric lower respiratory tract infections 254, 255
Penicillium marneffei 245
Peribronchial nodules 180f
Pericardial diseases 136f
Pericardium 439, 442
Pericystectomy 332
Perihilar opacities, bilateral 226f, 230
Periodic acid-Schiff 38, 41
Peripheral air-way disorders 273
Peripheral bronchi, infections of 426
Phagocytic defects 185, 195b
Phagocytic disorders 193
Phagocytic mechanism, normal 36
Pharyngitis 25, 26, 27
Pigtail catheter 322f
Plasmodium
falciparum 110
ovale 110
vivax 110
Pleura pulmonary fibroelastosis 236
Pleural effusion
bilateral mild 447f
drainage of 318, 321t
transudative 388t, 389
Pleural fluid, quantification of 387
Pleural infection 385, 397
Pleural membranes 385
Pleuritis, tuberculous 385
Pleuropulmonary fibrosis, chronic 89
Pneumatocele 50f, 262, 297, 376, 377f
large 197f
Pneumococcal pneumonia 52, 252
Pneumocystis 99
carinii pneumonia 227
jirovecii 72, 92, 97, 207, 224, 245, 347
pneumonia 68, 93, 97, 98f, 99t, 208f, 211, 213, 215, 220, 227, 229, 229f, 237, 239, 244, 245f, 246f, 252, 301f, 350, 362, 362f
Pneumocytes 65
Pneumonectomy 334
Pneumonia 19f, 20f, 21f, 25, 26, 29, 159, 343, 344, 347, 348
atypical 160
causative organism of 255t
causes
of nonresolving 274t
of recurrent 273t
clinical assessment of 344fc
complication of 309f, 310f
differential diagnosis of 24f
long-term sequelae of 311t
mass-like 314
neonatal 258
non-necrotizing 177f
non-resolving 22f, 272, 313
nosocomial 173
organizing 39, 40, 233f, 349
patterns of 345f, 345fc
pediatric 343
postobstructive 362
primary endpoint 257, 258f
radiological assessment of 344fc
recurrent 272, 273, 284f, 287
pneumococcal 190f
resolving bacterial 362
right upper lobe 304f
round 48f, 164f, 262, 349
severe community-acquired 298
typical 160
ventilator-acquired 173, 175t, 179f
ventilator-associated 12, 159, 344
Pneumonitis 9f
Pneumothorax 302, 302f, 445f
drainage 321
post-biopsy 316f
right-sided 302f
spontaneous 245
Polyangiitis 420, 422
Polychondritis, relapsing 422
Polyclonal hyperplasia, benign 232
Polycystic echinococcosis 118
Polymerase chain reaction 32
Post-heart transplant 226f
Postliver transplant 224f
Postrenal transplant 223f, 228f, 229f, 233f, 234f
Post-viral pneumonia bronchiolitis obliterans 67f
Pre-antiretroviral therapy 238
Pre-engraftment noninfectious disease 206f
Procalcitonin, serum 176
Protozoa 107
Pseudoaneurysms 291
formation of 324
Pseudocavitation sign 371
Pseudomonas 367
aeruginosa 53, 54f, 171, 174176, 204, 205, 221, 240, 298, 346, 369, 399, 427
pneumonia 205f
Puerperal sepsis 168f
Pulmonary artery
hypertension 311
hypertrophy 311
left 265f
superior 326
pseudoaneurysms 307
unilateral interruption of 280, 283
Pulmonary aspergillosis, chronic 73, 78, 86t, 382
Pulmonary histoplasmosis, acute 101
Pulmonary infections
organism-wise classification of 221
treatment of 331
Pulmonary mucormycosis, complications of 94f
Pyogenic bacteria 399
Pyogenic infections 349
Pyogenic osteomyelitis, acute 399
R
Rasmussen aneurysm 307
Recurrent infections 266, 286f
Red hepatisation, stage of 38
Renal function tests 313
Renal transplant 220
Respiratory distress syndrome 259
acute 26, 182, 206f, 211, 215, 237, 298, 298fc, 299f, 302t
adult 104, 111f
Respiratory papillomatosis, recurrent 420, 422
Respiratory syncytial virus 61, 65, 66, 220
Respiratory syndrome, severe acute 299
Respiratory tract infection 25, 25t, 26t, 65
lower 25
upper 25, 26, 27t
Respiratory viruses 210, 255
Restrictive allograft syndrome 234, 235f
Retinoic acid, all-trans 211
Reverse bat's wing 122
Rheumatoid
arthritis 370
nodules 373
Rhinoscleroma 422f
Rhodococcus equi 239, 240
Ribs 136
Rising sun sign 114, 115f
Rubella 255
Ruling out cystic fibrosis 195f
Runyon system 149, 150t
S
Sabouraud dextrose agar 32
Saphylococcus aureus infection 50f
Sarcoidosis 249, 370, 373, 415t, 416f
Scedosporium apiospermum 224
Schistosoma haematobium 120
Schistosoma japonicum 120
Schistosoma mansoni 120
Schistosomiasis 120
Seldinger technique 322, 324
Septate hyphae 34
Septic emboli 49f, 53f, 168f, 180f, 360f, 375, 375f, 376f
Sequelae infection 397
Serratia marcescens 176
Shred sign 16
Shwachman-Diamond syndrome 195, 195f, 199f
Signet ring sign 113
Silhouette sign 360, 360f
Silicosis 147f
Sinus ostia obstruction 273
Sinusitis 25, 26, 28
Sinusoid sign 16, 19f
Small airways, infections of 428
Smooth wall thickening 421
Soft tissue
infections 401
nodules 366
larger 365f
Solid organ transplantation 79t, 218, 219, 220t, 236t, 344, 219, 440
Solitary pulmonary nodule 152
Splenectomy 190f
Splenic abscesses 199f
Splenic focal lesions, multiple 141
Sputum grading system 30
Staphylococcal pneumonia 217f
recurrent 197f
Staphylococcus aureus 26, 38, 41, 49, 49f, 161, 164, 175, 176, 178, 179f, 180f, 205, 221, 240, 255, 346, 356f, 369, 375, 377, 404
infection 50f, 180, 355f
pneumonia 49f
Static air bronchogram 16
Stem cell 200
transplantation 203
Stenosis, subglottic 424f
Stenotrophomonas maltophilia 299
Sternoclavicular joint
infection 400
tuberculosis 401f
Sternoclavicular junction involvement 137
Streptococcus pneumoniae 26, 38, 41, 45, 47f, 48f, 160, 163, 175, 176, 177f, 207, 221, 240, 255, 346, 351, 356, 356f, 391
infection 349
Streptococcus pyogenes 26, 391
Streptokinase 320, 321
Strongyloides stercoralis 120
Strongyloidiasis 107, 120
Sweat chloride test 195f
Swine flu 65
Swiss cheese sign 361, 362f, 436
Swyer-James syndrome 264, 265f, 280
Synpneumonic effusion 389
Systemic lupus erythematosus 181f
T
T cell disorders 187b, 190
Tacrolimus 231
T-cell immunity, chronic impairment of 219
Thoracentesis 334, 336
Thoracocentesis 317
Thoracoplasty 334, 336
Thoracostomy, open window 336
Thromboembolism, pulmonary 109
Thrombolytics 321t
Thrombosis 309
venous 310f
Thymic aplasia 191, 191f, 192f
Thymic hypoplasia 191f, 192f, 199f
Toxoplasma gondii 207, 239
Trachea 25, 304f, 413, 421
infections of 419
postintubation 431f
stenosis 430
Tracheobron-chial airway obstruction 273
Tracheobronchial tree involvement 138
Tracheobronchial wall thickening-adenocarcinoma, diffuse 424f
Tracheobronchitis 25, 225
complications of 425
tubercular 423f
Tracheoesophageal fistula 273
Tracheomalacia 273
Transcriptase-polymerase chain reaction, reverse 32
Transplant lymphoproliferative disorder 230
Tree-in-bud
appearance 209f
nodules 54f, 365f, 428
opacities 130
pattern 211, 212f
Trocar technique 319f
Trypanosoma cruzi 111
Trypanosomiasis 107, 111
Tube thoracostomy 334, 336
Tuberculoma 132
Tuberculosis 9f, 25, 124, 125, 141, 141f, 144, 148, 152f, 154f, 193f, 212f, 223, 244f, 336, 348, 349, 365f, 400f, 414, 415t, 416f, 420, 422
active 132f, 133f
nodules in 131f
postprimary 126, 127t, 128f
primary 127t, 128f, 243f, 263f
pulmonary 125, 128, 132f, 133f, 223f
Tubular low attenuation fluid filled bronchioles 358f
Tumor
cells 347
necrosis factor 393
Turbo spin echo 10t
Typical acute respiratory distress syndrome 300f
U
Ultrasonographic quantification technique 390f
Unilocular cystic echinococcosis 112
life cycle of 112f
Upper lobe
collapse, left 279
left 451
parenchymal lesion, left 295f
Urokinase 321
V
Vacuo-pneumothorax 325
Varicella pneumonia 70f, 362f
Varicella zoster
pneumonia 208, 210f
virus 69
Vascular endothelial damage 65
Vascular rings 273
Vascular thrombosis 291
Veins
pulmonary 282f, 413
right pulmonary 265f
Vena cava
superial 102, 413
thrombosis, superior 310
Vessel sign 352
Video-assisted thoracoscopic surgery 336
Viral infections 64, 210, 246, 246b
common 64t
patterns of 210f
severe 65t, 197
Viral pneumonia 60, 61, 63f, 65, 262f, 263f, 264, 264f, 264t, 265f, 346f, 350, 362
clinical settings of 60, 61t
Viral pulmonary infections 223
Viruses 34, 164, 175, 207, 220
Voriconazole prophylaxis 95
W
Warthin-Finkeldey giant cells 39
Water lily sign 113, 116f, 378f
Wiskott-Aldrich syndrome 184, 187, 193
Wuchereria bancrofti 122
X
X-linked agammaglobulinemia 188, 188f
Y
Young's syndrome 268
Z
Zygomycota 72
×
Chapter Notes

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1General
  1. Imaging Techniques in Evaluation of Chest Infections
  2. Ultrasound in Chest Infections
  3. Microbiology of Pulmonary Infections
  4. Pathology of Lung Infections
2

Imaging Techniques in Evaluation of Chest InfectionsCHAPTER 1

Devasenathipathy Kandasamy
Chest infections are a frequent cause of morbidity and mortality both in the community and hospital-acquired settings. These infections are generally self-limiting or mild; however, they can become severe in immunocompromised individuals. The most common site of infection is lung parenchyma, with extrapulmonary sites including nodes pleura and chest wall. Tracheobronchial tree is not only the most common route of spread of infection but is the most frequently involved site.
 
ROLE OF IMAGING
  • To confirm the diagnosis of pneumonia
  • To detect complications and to look for treatment response
  • Help in diagnosing specific pathogen in case of characteristic imaging finding
  • For identifying underlying lung disease which may predispose to superadded infection.
 
APPROACH TO CHEST INFECTIONS
  • The diagnostic approach to lower respiratory tract infection requires combined evaluation of clinical, laboratory and imaging features.
  • In the clinical evaluation, the background setting is important whether it is community-acquired pneumonia or a hospital-acquired pneumonia; the patient is immunocompetent or immunocompromised; and whether the patient is an adult or a child.
  • Immunocompromised individuals are prone to opportunistic infections. Opportunistic infections are caused by microbes which are otherwise4 innocuous in healthy individuals. They are more frequent and severe in immunocompromised than in immunocompetent individuals. Immunosuppression can be secondary to various causes such as congenital, drugs, malignancy, acquired immunodeficiency syndrome (AIDS), etc.
  • Proper evaluation based on the above factors allow in narrowing down the differential diagnosis and pinpoint a possible pathogen.
  • The final diagnosis depends on isolating the organism. However, it is not always possible to isolate the organism. Hence, clinicoradiological evaluation regarding a possible pathogen allows the initiation of therapy prior to the availability of microbiological reports.
  • Histopathology or cytology is generally employed in extrapulmonary sites and in nonresolving pneumonia.
  • Imaging is best evaluated using a pattern approach, though overlap of patterns is often observed. Some infections present a pathognomonic feature on imaging allowing a confident prediction of a possible pathogen.
  • This book hence, in addition to detailing imaging findings of chest infections resulting from specific organisms, also discusses imaging in various clinical scenarios as well as approach to radiological patterns. While taking the pattern-based approach on imaging chest infections, noninfectious causes of similar appearances should always be borne in mind.
 
IMAGING MODALITIES
 
Chest Radiograph
  • Chest radiograph is the primary imaging modality used in the evaluation of chest infections, particularly in community-acquired pneumonia.1
  • Frontal chest radiograph erect posteroanterior (PA) view being the standard technique, anteroposterior (AP) view is used in those unable to co-operate for a PA view such as in sick patients and small children (Figs 1.1A and B).
  • The practice of addition of a lateral view as a part of standard protocol is variable across the world. Currently, lateral view for chest is grossly underutilized mainly because of the rampant usage of computed tomography (CT) scan. There are occasions where lateral view can provide information over and above what the PA view can provide (Figs 1.2A and B). Assessment of lung volume, evaluation of hila and detection of lesions in hidden areas are better performed with lateral view. However, compared with CT scan there is virtually no situation where lateral view outperforms CT; except being significantly low on radiation, the ease of performing it on bed side and less expensive. Role of ancillary chest radiographic views is enlisted in Table 1.1.
5
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Figs. 1.1A and B: Chest radiograph PA view (A) showing multiple ill-defined opacities in bilateral lungs and bilateral hydropneumothorax (thin arrows). Chest tube is seen in the left side pleural cavity.
  • Supine AP chest radiograph (B) in a child showing right lower lobe collapse (thick arrow).
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Figs. 1.2A and B: Chest radiograph lateral view (A) in a different patient showing ”spine sign” (arrow) which is evidenced by increased opacity over the lower dorsal spine suggestive of lower lobe consolidation. Middle lobe is also well visualised in this view
  • Chest radiograph lordotic view (B) in which clavicles are projected out of the lung fields and apices are clearly visualized. Middle lobe is also well visualized in this view.
 
Computed Tomography
  • CT scan is a revolutionary modality and the workhorse as far the chest imaging is concerned.
  • The spatial resolution of CT scan for lungs is much superior than any other modality. The ability to show it in cross section, removing overlapping structures, fast acquisition enough to freeze motion (recent scanners);6 and ability to show contrast enhancement are some of the major points in its favor.
  • One of the major downside of CT scan is the amount of radiation involved in the process, which necessitates its judicious use. There are various indications for performing a CT scan, some of which are shown in Box 1.1.
  • Noncontrast CT (NCCT) is useful for the evaluation of lung parenchyma, whereas contrast-enhanced CT (CECT) is useful for the evaluation of mediastinal structures, lymph nodes, solid masses and pleural pathologies (Figs. 1.3 and 1.4).2
  • In the immunocompromised setting where the interest is in the lung parenchyma evaluation, NCCT is optimal.
  • In situations such as mediastinal lymphadenopathy, empyema and mass like lesions evaluation with CECT is necessary.
Table 1.1   Radiographic views of chest.
Types of chest radiograph
Current utility
Posteroanterior view
  • Standard technique
  • Most commonly performed
  • Most of the measurements and signs described on radiographs apply to this view
Anteroposterior view
  • Performed when patient cannot be positioned for PA view such as in ICU, bedside and children
Lateral view
  • Standard part of chest imaging in few centers around the world
  • CT has almost replaced this view
Lordotic view
(Apicogram—if only the apices are included)
  • Specialized view to demonstrate the apices of lungs which are usually hidden behind the clavicles on routine views also used for middle lobe pathology
7
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Figs. 1.3A to D: Standard set of images for chest CT interpretation in a patient with left upper lobe pneumonia. CECT mediastinal window (A), lung window (B), lung window in high resolution kernel (C), bone window (D) showing consolidation in the left upper lobe and a prevascular lymphadenopathy.
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Figs. 1.4A and B: Coronal multiplanar reformation (MPR) in lung window (A) and thin minimum intensity projection image (MinIP) (B) of the same patient in Figure 3 showing left upper lobar consolidation. MPR and MinIP images provide information about the craniocaudal distribution of disease and highlighting areas of hyperinflation.
  • The routine postcontrast CT of chest is performed during the venous phase and depending on the indication, CT pulmonary angiographic and/or CT thoracic angiographic phase can be added on to it, for instance in patients presenting with hemoptysis.
8
 
Ultrasonography
Transthoracic ultrasonography has recently emerged as a useful adjunct to chest radiograph in specific clinical scenarios such as in children and sick patients admitted in intensive care units (ICUs).
 
Magnetic Resonance Imaging
  • Magnetic resonance imaging (MRI) is one of the latest additions to chest imaging armamentarium. Traditionally, MRI was considered as an unsuitable modality, mainly because of its susceptibility to artifacts and low proton density in the lungs. However, with recent improvements in hardware and sequences lung MRI is emerging as an alternative modality, especially in children and pregnant women.
  • Most of the lung pathology, especially infections, tends to increase water content in the parenchyma replacing the air leading to increased density of protons. Hence, these areas appear hyperintense on T2-weighted images.
  • MRI can show areas of interstitial infiltration, septal thickening and consolidation.
  • Lymph nodes or soft tissue in the mediastinum and pleural pathologies can also be very well assessed (Figs. 1.5 and 1.6). The major indications are described in Box 1.2.
  • There are a variety of sequences and their modifications described in the literature. The basic sequences are described in Box 1.3.
  • An abbreviated MRI lung study has also been proposed which can be performed in few minutes. This can reduce the MRI scanner time, sedation time and can be used as quick screening tool without radiation penalty. HASTE, TrueFISP, radially acquired T2 WI and volumetric interpolated breath-hold examination (VIBE) are the sequences generally performed as a part of “rapid lung MRI”.3
 
18F FDG-PET-CT
  • 18F fluorodeoxyglucose (FDG)-positron emission tomography-computed tomography (PET-CT) has been in wide usage in oncological diseases and its role in the evaluation of lung infection or inflammation is emerging. Most of the times radiograph or CT scan is sufficient to characterize chest infections. However, in exceptional situations 18F PET-CT can play a supportive role.4
  • It shows increased uptake in any acute or acute on chronic infection; whether it is bacterial, viral or fungal. Also, avid uptake has been described in acute lung injury and acute respiratory distress syndrome (Figs. 1.7 and 1.8).
  • It has been shown to demonstrate response after treatment in pneumonia such as pneumocystis pneumonia. However, the cost and amount of radiation involved generally discourages its utility as a primary modality to evaluate lung infections.
9
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Figs. 1.5A to E: Lymphadenopathy, pneumonitis and pleural effusion on MRI in a patient with TB. T1W MRI (A), STIR (B) and TrueFISP images (C) showing enlarged lymph nodes (thin arrow) in right paratracheal and right hilar locations. TrueFISP image also shows areas of pneumonitis (thick arrow) and pleural effusion (outlined arrow).
  • Images D and E are the postcontrast images showing a heterogeneous node in azygoesophageal location and another necrotic node in aortopulmonary window.
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Figs. 1.6A to C: Mediastinal and pleural collection on MRI. Axial T1W image (A), T2 fat saturated image (B) and postcontrast image (C) showing collections in the anterior mediastinum (thin arrows) and in the left pleural cavity (thick arrows). Postcontrast image showing thick enhancement in the walls of the collections.
10
(FFE: Fast field echo; FIESTA: Fast imaging employing steady-state acquisition; LAVA: Liver acquisition with volume acquisition); THRIVE: T1W high resolution isotropic volume examination; TrueFISP: True fast imaging with steady state precession; TSE: Turbo Spin echo; VIBE: volumetric interpolated breath-hold examination)
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Figs. 1.7A and B: 18F FDG-PET in a patient with carcinoma lung. CECT and PET images (A and B) showing a central mass lesion involving the right main bronchus showing avid tracer uptake (thin arrows) and adjacent collapse-consolidation in the right lung (thick arrows) which is showing distinctly different pattern of tracer uptake. PET-CT can reliably differentiate tumor from the adjacent collapsed/consolidated parenchyma.
 
CONCLUSION
There are number of modalities and techniques available to evaluate chest infections and each of them has their own advantages and disadvantages. Still, radiographs are the primary imaging modality used for screening and preliminary evaluation.11
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Figs. 1.8A and B: Mediastinal fibrosis on 18F FDG-PET. CECT and FDG-PET images showing plaque like ill-defined soft tissue seen in the right paratracheal location. There was minimal uptake of tracer in that area and biopsy from the lesion showed fibrosis.
CT is the modality of choice to evaluate complicated lung infections and where radiographs fail to provide desired information. MRI chest is in the process of evolution and currently it can be used in children and pregnant patients. Like anywhere else, diagnosis should be made based on the clinical, radiological and histopathological findings. On imaging, one should follow a systematic approach based on various imaging patterns.
REFERENCES
  1. Speets AM, van der Graaf Y, Hoes AW, et al. Chest radiography in general practice: indications, diagnostic yield and consequences for patient management. Br J Gen Pract. 2007;56(529):574–8.
  1. Whiting P, Singatullina N, Rosser JH. Computed tomography of the chest: I. Basic Principles. Contin Educ Anaesth Crit Care Pain. 2015;15(6):299–304.
  1. Sodhi KS, Khandelwal N, Saxena AK, et al. Rapid lung MRI in children with pulmonary infections: Time to change our diagnostic algorithms. J Magn Reson Imaging. 2016;43(5):1196–206
  1. Capitanio S, Nordin AJ, Noraini AR, et al. PET/CT in nononcological lung diseases: current applications and future perspectives. Eur Respir Rev. 2016;25(141):247–58.