Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Lobar Pneumonia
- Necrotizing Pneumonina
- PCP Pneumonia with Pneumatocele
- Pneumothorax
- Pleural Effusion
- Parapneumonic Effusion
- Aortic Transection
- Lung Mass
- ARDS
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: October Cases
1. Adult Chest X-Rays Of The Month
Travis Barlock MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
October 2020
2. Disclosures
This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
The goal is to promote widespread mastery of CXR interpretation.
There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.
3. Process
Many are providing cases and these slides are shared with all contributors.
Contributors from many CMC/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
Cases submitted this month will be distributed next month.
When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.
28. Management of necrotizing pneumonia and pulmonary gangrene: A case series
and review of the literature
BACKGROUND:
Necrotizing pneumonia is an uncommon/severe complication of bacterial pneumonia, associated with high morbidity and mortality. The
availability of current data regarding the management of necrotizing pneumonia is limited to case reports and small retrospective
observational cohort studies. Consequently, appropriate management for these patients remains unclear.
OBJECTIVE:
To describe five cases and review the available literature to help guide management of necrotizing pneumonia.
METHODS:
Cases involving five adults with respiratory failure due to necrotizing pneumonia admitted to a tertiary care centre and infected with
Streptococcus pneumoniae (n=3), Klebsiella pneumoniae (n=1) and methicillin-resistant Staphylococcus aureus (n=1) were reviewed. All
available literature was reviewed and encompassed case reports and retrospective reviews dating from 1975 to the present.
RESULTS:
All five patients received aggressive medical management and consultation by thoracic surgery. Three patients underwent surgical
procedures to debride necrotic lung parenchyma. Two of the five patients died in hospital.
CONCLUSIONS:
Necrotizing pneumonia often leads to pulmonary gangrene. Computed tomography of the thorax with contrast is recommended to
evaluate the pulmonary vascular supply. Further study is necessary to determine whether surgical intervention, in the absence of
pulmonary gangrene, results in better outcomes.
Chatha N, Fortin D, Bosma KJ. Management of necrotizing pneumonia and pulmonary gangrene: a case series and review of the literature. Can Respir J. 2014
Jul-Aug;21(4):239-45. doi: 10.1155/2014/864159. Epub 2014 May 2. PMID: 24791253; PMCID: PMC4173892.
29. Management of necrotizing pneumonia and pulmonary gangrene: A case series
and review of the literature
Key Points:
“Necrotizing lung infections constitute a spectrum of disease severity ranging from simple lung abscess to
necrotizing pneumonia to pulmonary gangrene…”
“patients with necrotizing pneumonia or pulmonary gangrene may present to hospital severely ill with
sepsis and experience a rapid clinical deterioration, requiring ventilator support and/or exhibiting signs of
septic shock within 72 h of presentation…”
“As exemplified in these cases, necrotizing pneumonia is most commonly caused by S pneumoniae and S
aureus, which may be methicillin sensitive or methicillin resistant, and less commonly by Klebsiella and
Haemophilus species, and Pseudomonas aeruginosa. Of special concern is the emergence of a community-
acquired MRSA strain containing the gene for Panton-Valentine leukocidin, a toxin known to cause
necrotizing pneumonia with rapid progression to respiratory failure and shock and associated with a high
mortality rate.”
“Up to 40% of patients with CAP admitted to the ICU will experience clinical deterioration after initial
stabilization. Therefore, early identification of the pathogen and its antibiotic sensitivities is important to
ensuring appropriate antibiotic coverage (18,19).”
Chatha N, Fortin D, Bosma KJ. Management of necrotizing pneumonia and pulmonary gangrene: a case series and review of the literature. Can Respir J. 2014
Jul-Aug;21(4):239-45. doi: 10.1155/2014/864159. Epub 2014 May 2. PMID: 24791253; PMCID: PMC4173892.
30. Necrotizing pneumonia (aetiology, clinical features and management)
Key Points:
• Several pathogens are implicated in necrotizing pneumonia, Staphylococcus
aureus is the most common in adults and Pneumococcus in children, both
are most likely to occur following a viral respiratory infection.
• Diagnosis is with CT imaging of the chest, which can identify the small
cavities characteristic of necrotizing pneumonias, as well as areas of
devitalized lung in pulmonary gangrene
• Adjunctive therapies like intravenous immunoglobulins and pulmonary
resection may be required if antibiotic therapy alone is ineffective
Krutikov, Mariaa; Rahman, Anannab; Tiberi, Simona,c Necrotizing pneumonia (aetiology, clinical features and
management), Current Opinion in Pulmonary Medicine: May 2019 - Volume 25 - Issue 3 - p 225-232 doi:
10.1097/MCP.0000000000000571
![Disclosures
This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
The goal is to promote widespread mastery of CXR interpretation.
There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)