ACUTE PULMNARY INFECTIONS: UNDERSTANDING THE CHEST RADIOGRAPH. Leonard E. Swischuk, M.D. University of Texas Medical Branch

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1 ACUTE PULMNARY INFECTIONS: UNDERSTANDING THE CHEST RADIOGRAPH Leonard E. Swischuk, M.D. University of Texas Medical Branch

2 AUTHOR HAS NOTHING TO DECLARE

3 LEARNING OBJETIVES Understand the pathophysiology behind images of pulmonary infections. Be able to evaluate chest radiographs with more confidence. Appreciate common pitfalls in radiographic image assessment.

4 PULMONARY INFECTIONS TO BE CONSIDERED Bacterial Viral Mycoplasma

5 PATHOPHYSIOLOGY Airspace (alveolar) disease Airway (bronchial) disease

6 CONFUSING CASES

7 CASE 1

8

9 CASE 2

10 CASE 3

11 CASE 4

12 CASE 5

13 CASE 6

14 CASE 7

15 CASE 8

16 CASE 9

17

18 CASE 10

19 CONFUSING IMAGES YES BUT EACH HAS A DIAGNOSIS SO LET S SEE HOW WE CAN DO THIS

20 CLINICAL PICTURES A. Bacterial pneumonia Toxic, septic Shallow breathing B. Viral bronchitis Respiratory distress Rapid breathing Bad gases (bronchiolitis) Air trapping Usually not toxic C. Mycoplasma Mildly sick

21 FEVER High in bacterial pneumonia 39 o, 40 o C, o F Low or high in viral infection but usually low Usually low with mycoplasma

22 THE CHEST RADIOGRAPH FEATURES AND CONCEPTS BUILDING A TEMPLATE

23 DESCRIPTIVE ADJECTIVES -CLEAN VS DIRTY -VOLUME LOSS VS NO LOSS -PERIPHERAL VS CENTRAL -SYMMETRIC VS ASYMMETRIC

24 CLEAN VS DIRTY

25 CLEAN

26 DIRTY

27 CLEAN BACTERIAL PNEUMONIA DIRTY VIRAL BRONCHITIS

28 VOLUME LOSS VS NO VOLUME LOSS

29 VOLUME LOSS

30 NO VOLUME LOSS

31 VOLUME LOSS ATELECTASIS (VIRAL) NO VOLUME LOSS PNEUMONIA (BACTERIAL)

32 CAN BE A BIT OF A PROBLEM WITH SMALL LOBES RML AND LINGULA

33

34

35 CENTRAL SYMMETRIC VS PERIPHERAL ASYMMETRIC

36 CENTRAL SYMMETRIC

37 PERIPHERAL ASYMMETRIC

38 CENTRAL SYMMETRIC VIRAL BRONCHITIS PERIPHERAL ASYMMETRIC PNEUMONIA CONSOLIDATION

39 BACTERIAL INFECTIONS (Pathophysiology) Inhale organism Organism deep in alveoli Organism trapped Organism multiplies Body reacts (polys) Purulent exudate Replaces air ( no volume loss) Consolidation

40 CONSOLIDATION Smooth homogenous infiltrate Starts from the periphery (pleural based) Occasionally fluffy, nodular Occasionally round or mass-like No volume loss

41

42

43

44

45 NO VOLUME LOSS WHY?

46 BECAUSE Exudate simply replaces air

47

48 CONSOLIDATION Occasionally fluffy, nodular

49

50 CONSOLIDATION Occasionally round or mass like

51

52

53

54 CONSOLIDATION Occasionally Multilobar Double Pneumonia

55 DOUBLE PNEUMONIA

56

57

58

59 BUT USUALY NOT SYMMETRIC AND NOT BOTH LOWER LOBES UNLESS SICKLE CELL ACUTE CHEST SYNDROME

60

61

62 CONSOLIDATIONS ( PLEURAL BASED ) Effusions common Empyemas common

63

64

65

66

67 CONSOLIDATING PNEUMONIA HIDING LLL MOST COMMON LOOK FOR DIFFERENT DENSITY OF THE HEART

68

69

70

71

72 CASE 1

73

74 TEMP 105

75 ACUTE ABDOMEN AND PNEUMONIA THE ACUTE ABD SERIES

76

77

78 VIRAL INFECTIONS (Pathophysiology) Intracellular infections Begin in nasal passages and hypopharynx Descend into trachea and bronchi Tracheo-bronchitis

79 VIRAL TRACHEO-BRONCHITIS Peribronchial thickening Bilateral parahilar (central) infiltrates Radiate outward Symmetric The end result is PHPB infiltrates Parahilar peribronchial Hilar adenopathy Overaeration (bronchospasm)

80 VIRAL TRACHEO-BRONCHITIS PARAHILAR PERIBRONCHIAL INFILTRATES PHPB BILATERAL, CENTRAL,SYMMETRIC AND DIRTY

81 DIRTY

82

83

84

85

86

87 SPECTRUM OF PHPB STILL Bilateral, Central, Symmetric

88

89

90

91 CASE 2

92 VARIATIONS Hilar Adenopathy (bilateral)

93 BILATERAL HILAR ADENOPATHY

94 CLEAR BUT OVERAERATED LUNGS BRONCHIOLITIS

95

96

97

98

99 NOW ATELECTASIS THE BIG PROBLEM - LOBAR - SEGMENTAL - MUCOUS PLUGS

100 LOBAR ATELECTASIS Volume loss Often multiple

101 ATELECTASIS (VOLUME LOSS) LOBAR

102 LOBAR ATELECTASIS VOLUME LOSS AND SHIFT

103 ATELECTASIS OR PNEUMONIA?

104 NEXT DAY

105 PARTIAL LOBAR MULTIPLE

106 CASE 3

107 SEGMENTAL ATELECTASIS Streaky, linear Wedge-like Multiple

108 WEDGELIKE

109 STREAKS, WEDGES, MULTIPLE,DIRTY

110

111

112 SEGMENTAL ATELECTASIS WHISKERS

113 WHISKERS

114 MORE WHISKERS

115 FULL BEARD

116 CASE 4

117 VIRAL INTERSTITIAL INFECTION (Pneumonitis) Reticulo-nodular infiltrates (bilateral) Hazy / opaque lungs (bilateral) Both lungs totally involved Both lower lobes involved

118 RETICULO NODULAR INFILTRATES

119

120

121

122 HAZY / OPAQUE INFILTRATES interstitial inflammatory edema

123 BILATERAL LOWER LOBES

124

125

126 CASE 5

127 BUT CAN LEAD TO PSEUDO CONSOLIDATION (Viral Interstitial Inflammatory Edema)

128 CASE 6

129 ALSO CAN BE TOTAL LUNG INVOLVEMENT BUT AGAIN BILATERAL

130

131 CASE 7

132 ENTIRE SPECTRUM Clear lungs to pseudoconsolidation Single patient

133

134

135

136

137 CASE 8

138 CASE 9

139

140 VIRAL INFECTION WITH SUPERIMPOSED BACTERIAL CONSOLIDATION TAKES ABOUT A WEEK

141 CLINICAL PICTURE CHANGES FROM VIRAL TO BACTERIAL

142

143

144

145

146 ANOTHER CASE PNEUMONIA LLL?

147 SORT OF WEDGELIKE

148 NEED CLINICAL CORRELATION?

149 LOW FEVER AND VIRAL PICTURE

150 AND SO ATELECTASIS WITH PHPB

151 MYCOPLASMA INFECTION (Pathophysiology) Basicaly the same as viral

152 MYCOPLASMA INFECTION (PHPB) BUT USUALLY NOT BILATERAL

153 BILATERAL NOT VERY COMMON

154 MOST OFTEN Lobar (often one lobe) Pseudoconsolidation (uncommon) Retriculonodular (very common) Hazy (very common)

155

156

157

158

159 PLUS ATELECTASIS

160

161 PLUS PSEUDO CONSOLIDATION

162

163 CASE 10

164 MYCOPLASMA INFECTIONS UPPER LOBES Mimic TBC Ipsilateral hilar adenopathy

165 MYCOPLASMA INFECTIONS CAN MIMICK TBC

166

167

168

169 CONCLUSION PATHOPHYSIOLOGY IMAGING CLINICAL CORRELATION

170 THIS PRESENTATION WILL BE AVAILABLE ON OUR WEB SITE FOR THIRTY DAYS radiology.utmb.edu (go to main page, go to pediatric radiology)

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