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Unresolved pulmonary infections..radiological highlights

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The lecture discovers how to radiologically approach cases of unresolved chest infections.

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Unresolved pulmonary infections..radiological highlights

  1. 1. Unresolved pulmonary infections...radiological highlights Dr/Ahmed Bahnassy Consultant Radiologist MBCHB-MSc-FRCR
  2. 2. • Success is to be measured not so much by the position that one has reached in life... as by the obstacles which he has overcome while trying to succeed. • - Booker T. Washington
  3. 3. Unresolved pneumonia failure of pneumonia to resolve can be due to: 1.virulent ,or undiagnosed organism. 2.underlying disease process or pathology. 3.Occurence of complications. 4.Other diagnosis than infection.
  4. 4. roles of Radiology • Diagnose infection… • Detection of Etiology… • Follow up for response to treatment. • Monitoring of complications.
  5. 5. I-Evaluation of offending organism
  6. 6. Radiological Patterns • Pathologically pulmonary infections can be divided into infections involving :central air ways ,small air ways and pulmonary parenchyma. • Pneumonia is subdivided into :lobar ,broncho and interstitial pneumonia . • Lung abscess is an additional pattern seen with lobar or bronchopneumonia where the infection?
  7. 7. I- Bronchiolitis • Inflammation of small air ways (membranous and respiratory bronchioles). • Caused by viruses (RSV is most common). • Acute bronchiolitis ,causd by adenovirus ,may cause constrictive bronchiolitis ,chronic bronchiolitis, bronchiectasis. .forming a syndrome called Mc leod syndrome.
  8. 8. Obstructive viral pneumonia –RSV (note air trapping )
  9. 9. Swyer-James Syndrome
  10. 10. Laryngeotracheobronchitis..Croup (church steeple sign)
  11. 11. II-Lobar pneumonia. • Caused by streptococcal or Klebsiella pneumoniae . • Begins by a peripheral opacity that evolves into a confluent ,consolidation. • Expansion of the lobe can cause bulging fissure ( associated with Klebsiella pneumoniae )
  12. 12. Bacterial lobar pneumonia
  13. 13. Bulging fissure sign
  14. 14. III-Bronchopneumonia • Begins with infection of air way mucosa ,then extends into adjacent alveoli . • Present as ill defined air space nodules or patchy areas of consolidation. • Caused by virulent organism …( Staph aureus ,or G –ve organisms ) • Can develop abscess. • Result in scarring .
  15. 15. Broncho -pneumonia
  16. 16. Bronchopneumonia - HRCT
  17. 17. IV-Lung Abscess • Localized infection that undergoes tissue destruction and necrosis. • Cavitations and air fluid level can occur due to communication with tracheobronchial tree . • Caused by mixed anaerobic infections , S.aureus ,and Pseudomonas aeruginosa. • Multiple abscesses may result from septic emboli .
  18. 18. Lung abscess
  19. 19. what is the organism?
  20. 20. I -Nocardia Asteroids • Organisms live in soil. • In immunodeficient state. • Cavitation may occur . • Pleural effusion in 50% .
  21. 21. II- Pneumococcal Pneumonia • Most common G +ve. • Air space consolidation with air bronchogram. • Multifocal consistent with bronchopneumonia. • Pleural effusion in < 50%.
  22. 22. III- Staph Pneumonia • Common cause of nosocomial infection. • Usually bronchopneumonia with patchy lower lobe consolidation. • Cavitation frequent. • Pnematoceles may be seen. • Septic emboli. • Pleural effusion in 50%,Empyema may result .
  23. 23. IV-Infective endocarditis with septic emboli
  24. 24. V-Tuberculosis :Primary T.B. • Ghon focus-Ranke Complex-air space consolidation-LNs common in children-P. effusion may be seen without lung disease .
  25. 25. Necrotic LN-TB infection
  26. 26. TB variable examples
  27. 27. Cavitating pneumonia TB
  28. 28. Post Primary TB- cavitating lesion • Cavitations in 40%. • Pleural effusion and LNs are uncommon.
  29. 29. Miliary TB • Miliary spread refers to numerous ,well defined nodules,1-2 mm in size, diffusely distributed throughout the lung.
  30. 30. VI-Mycobacterium Avium Complex • I-Resembles TB, occurs in old men with COPD or mild immunodepression. • II-Bronchiectasis and nodules in lingula or middle lobe. • III-GG opacity and small nodules with hypersensitivity pneumonitis . Lady Windermere syndrome
  31. 31. Mycobacterium Avium Complex-CT • Bronchiectasis and centrilobular nodules .
  32. 32. VII- Histoplasmosis • Patchy pneumonia- Histoplasmoma with Bull’s eye calcification. fibrosing mediastinitis- miliary spread)
  33. 33. VIII- Coccidioidomycosis • May present as consolidation +/- LN; nodules +/- cavitate ;or miliary pattern often with LN
  34. 34. Coccidioidomycosis -Disseminated • Miliary pattern
  35. 35. IX- Blastomycosis
  36. 36. X- Cryptococcosis (in AIDS )
  37. 37. XI- Aspegillosis :Invasive Aspergillosis -Halo Sign • Neutropenia present. • Patchy consolidations with halo sign in Angio-invasive form • Centrilobular nodules ,tree in bud in airway invasive form.
  38. 38. Invasive Aspergillosis • Air way invasive. • Ill defined nodules.
  39. 39. Angio -invasive Aspergillosis with air crescent sign of Lung Ball.
  40. 40. Semi-Invasive Aspegillosis • Mild immunocompromise (TB, diabetes,mild corticosteroid use ) • Consolidation, • cavitation , • Pleural thickening , • +/-mass within the cavity )
  41. 41. Aspergilloma • Saprophytic infection with underlying structural lung disease. • Normal immunity. • Haemoptysis may be life threatening.
  42. 42. XII- Pneumocystis jiroveci (carinii)
  43. 43. Pneumocystis • Associated with AIDS ,LowCD4 cell count. • Perihilar GG opacity,consolidation,pn eumatoceles, • pneumothorax,
  44. 44. XIII- Mycoplasma Pneumonia • Community acquired pneumonia. • Patchy consolidations or GG opacities. • Effusion in 20%. • LN uncommon
  45. 45. XIV -Amebic Pneumonia • Extension from amebic liver abscess .
  46. 46. II-Evaluating routes of infection • Air borne. • Septic embolization. • Extension from neck. • Extension from liver.
  47. 47. Blood borne ..septic emboli common causes?
  48. 48. by extension mediastinitis
  49. 49. Danger Space • Danger Space – Anterior border is alar layer of deep fascia – Posterior border is prevertebral layer – Extends from skull base to diaphragm and is so named because it contains loose areolar tissue and offers little resistance to the spread of infection.
  50. 50. • Necrotizing Mediastinitis A- MDCT of the neck shows two large fluid collections containing gas in both the submandibular spaces (arrows).(B) At the level of the hyoid bone, a large fluid collection is seen in the visceral space (C) Large fluid collection in the visceral space (D) The fluid collection spreads to the anterior mediastinum (E) Sagittal multiplanar reformatted CT image shows spread of descending necrotizing mediastinitis
  51. 51. contiguous infection • Thoraco-hepatic amebiasis
  52. 52. Take home message..Do ultrasound nature of effusion
  53. 53. presence of pneumonia
  54. 54. liver evaluation
  55. 55. III-Evaluation of Complications • Empyema. • Pulmonary abscess. • Bronchopleural fistula. • Septic embolization.
  56. 56. Empyema after staph pneumonia
  57. 57. Empyema necessitans
  58. 58. Bronchopleral fistula after staph pneumonia
  59. 59. Retropharyngeal cellulitis/abscess
  60. 60. Pulmonary abscess
  61. 61. IV-Evauating recurrent/chronic pulmonary problems in pediatrics Mechanism Causes 1. Aspiration CNS malformation-cerebral tumors-Tracheo- esophageal fistula-Reflux 2.Anomaly Congenital lobar emphysema-Sequestration- Tracheobronchial tree anomalies(tracheal bronchus-stenosis-atresia)-bronchogenic cyst. 3.Allergy. Astham- Loeffler pneumonia-allergic alveolitis 4.Systemic disease. Cystic fibrosis 5.Immunodeficiency. Prematurity-AIDS-Neutropenia 6.Physical agents. Foreign body-Drugs-radiation-Bronchopulmonary dysplasia 7.Neoplasm. Leukemia-Lymphoma-Histiocytosis 8.CVS Left to right shunt -PA stenosis-vascular ring 9.specific Infections. TB-Mycoplasma-Bronchiectasis 10.Miscellaneous Interstitial Pneumonia-Collagen vascular disease- Alveolar proteinosis-sarcoidosis. special problem
  62. 62. Role of Radiology • The role of radiology is 3 folds : • 1 .Evaluate the present X-ray. • The presence and distribution of opacities, • Pleural involvement ,Lymph nodal swellings ,pulmonary vascularity ,soft tissue involvement , bony structures . • 2.Review of previous films. • Are the lesion stable in the same location (Sequestration ?) • Are they present always in upper lobe (aspiration ? ) • Are they changing in location (Immunodeficiency ?) • 3.Perform esophagogram. • Reflux of gastric contents. • Abnormal peristalsis. • Compression of esophagus by a mass ,vascular ring. • Tracheo-esophageal fistula. • Hiatal Hernia
  63. 63. Recurrent right basal consolidation • Posteroanterior (top, A) and lateral (bottom, B) chest • radiographs demonstrate an area of ill-defined consolidation • involving the medial segment of the right lower lobe.
  64. 64. Lung sequestration Figure 2. Axial CT images through the area of apparent consolidation during the administration of IV contrast show a mass with inhomogenous enhancement involving the medial aspect of the right lower lobe. There are focal areas of low density in keeping with necrotic regions within the mass. There are no air bronchograms or cavitations within the mass. A vessel is clearly seen to arise from the anterior aspect of the aorta (curved arrow; top, A), running laterally to the right, to enter the mass
  65. 65. Bronchopulmonary sequestration
  66. 66. Di-George syndrome absent thymus hypocalcaemia chronic /recurrent chest infection
  67. 67. Cystic fibrosis
  68. 68. Immunodeficieny syndromes
  69. 69. Bronchiectasis
  70. 70. HRCT
  71. 71. V-Pulmonary opacities.. That are NOT infection
  72. 72. Causes of consolidations
  73. 73. Pulmonary lymphoma
  74. 74. Lung adenocarcinoma
  75. 75. Lung adenocarcinoma with aerogenic spread
  76. 76. Wegener granulomatosis
  77. 77. Wegener cavitating nodules
  78. 78. Cavitating consolidations
  79. 79. Sarcoidosis
  80. 80. Eosinophilic pneumonia acute
  81. 81. chronic
  82. 82. Summary • Evaluate offending organism. • Think of other routes of infection. • Look for underlying disease or pathology. • Evaluate occurence of complications. • Turn to other diagnosis.
  83. 83. • Don't judge each day by the harvest you reap, but by the seeds you plant. • - Robert Louis Stevenson

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