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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