Pneumonia is a general term in widespread use, defined as infection within the lung.
It is due to material,
usually purulent, filling the alveoli.
Terminology
Pneumonia is in contrast to pneumonitis, which is inflammation of the pulmonary interstitium. Of note, some
of the interstitial lung diseases are termed pneumonia rather than pneumonitis.
Classification
Pneumonias can be classified by:
aetiology
o infection
bacterial (pyogenic) pneumonia
cavitating bacterial pneumonia
fungal pneumonia
pneumocystis pneumonia (PCP)
mycobacterial pneumonia
viral pneumonia
varicella pneumonia
o aspiration pneumonia
o lipid: lipoid pneumonia
o location
community-acquired pnemonia
hospital-acquired pneumonia
method of spread (a pathological description)
o bronchopneumonia
o lobar pneumonia
multilobar pneumonia
radiographic appearance
o atypical pneumonia
o round pneumonia
o cavitating pneumonia
o haemorrhagic pneumonia
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Pulmonary cavities are gas-filled areas of the lung in the center of a nodule, mass or area of
consolidation. They are usually evident on plain radiography and CT. They are typically thick walled and
their walls must be greater than 2-5 mm. They may be filled with air as well as fluid and may also
demonstrate air-fluid levels.
Terminology
According to the Fleischner society pulmonary cavities are defined "gas-filled space, seen as a lucency or
low-attenuation area, within pulmonary consolidation, a mass, or a nodule" 7.
Pathology
The cause of pulmonary cavities is broad. They may develop as a chronic complication of a pulmonary
cyst, or secondary to cystic degeneration of a pulmonary mass. They may enlarge or involute over time.
Aetiology
Pulmonary cavities may be the result of malignancy, infection, inflammation or be congenital:
cavitating malignancy
o primary bronchogenic carcinoma (especially squamous cell carcinoma)
o cavitating pulmonary metastases
squamous cell carcinoma
adenocarcinoma, e.g. gastrointestinal tract, breast
sarcoma
infection
o pulmonary tuberculosis 3
o pulmonary bacterial abscess/cavitating pneumonia
o post-pneumonic pneumatocoele: a thin walled pneumatocoele is not really a cavity but
when infected can be thick walled
o septic pulmonary emboli
o other rare infections
pulmonary coccidioidomycosis
pulmonary actinomycosis / thoracic actinomycosis
pulmonary nocardiosis
melioidosis
pulmonary cryptococcosis 8
non-infective granuloma
o granulomatosis with polyangitis
o rheumatoid nodules
vascular
o pulmonary infarct
trauma
o pneumatocoeles (a thin walled pneumatocoele is not really a cavity)
congenital (not true "cavity")
o congenital cystic adenomatoid malformation (CCAM)
o pulmonary sequestration
o bronchogenic cyst
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Mycoplasma pneumonia is a type of community-acquired pneumonia caused by the
organism Mycoplasma pneumoniae.
Epidemiology
It is relatively common in the paediatric population where it is considered the most common community-
acquired pneumonia in 5 to 20-year-olds (may account for 40% of such cases 7). It may account for 10-15%
of community-acquired pneumonia in adults. In adults, mycoplasma can rarely result in
a bronchiolitis without giving a pneumonia.
Pathology
Mycoplasma pneumonia is the smallest organism which could be cultured and lacks cell wall hence it is
resistance to the penicillin. It spreads via inhalation of the droplets contain the microorganisms. It initially
involves the peribronchovascular interstitium and then extends to the adjacent alveoli.
Extrapulmonary manifestations:
headache
arthropathy
immune haemolytic anaemia
pericarditis and myocarditis
meningoencephalitis
transverse myelitis
Guillain-Barre syndrome
Stevens-Johnson syndrome
Radiographic features
Plain radiograph
There can be variable chest radiographic features, although four different patterns have been
described 1. No pattern is, however, pathognomonic:
peribronchial and perivascular interstitial infiltrates - reticular densities most common ~ 49% (can
be patchy with a segmental or non-segmental distribution)
airspace consolidation ~ 38%
reticulonodular opacification ~ 8%
nodular or mass-like opacification ~ 5%.
Bilateral peribronchial perivascular interstitial infiltrations in central and middle lung zones have also been
described. Lower lobes are more commonly involved.
Other reported plain film findings include bilateral lesions, pleural effusion (uncommon - in approximately
25% of cases) and hilar lymphadenopathy.
CT
Areas of ground-glass attenuation and air-space consolidation have reported being frequent on HRCT
(about 80% of cases 2)
In about 60% of cases, areas of consolidation may have a lobular distribution evident on CT.
Intrapulmonary nodules can also be seen (approximately 90% of cases) and these tend to have a
predominantly centrilobular distribution 3.
Other findings include thickening of the bronchovascular bundles
Treatment and prognosis
Most patients recover well although a small proportion of patients may develop bronchiectasis in the
affected region or Swyer James syndrome.
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Atypical pneumonia
Dr Jeremy Jones◉ and Dr Michael Paks et al.
Atypical pneumonia refers to the radiological pattern associated with patchy
inflammatory changes, often confined to the pulmonary interstitium, most
commonly associated with atypical bacterial aetiologies such as Mycoplasma
pneumoniae, Chlamydophila pneumoniae and Legionella pneumophilia. Viral
and fungal pathogens may also create the radiological and clinical picture of
atypical pneumonia.
Epidemiology
Atypical pneumonia makes up a significant proportion of community-acquired
pneumonia.
Mycoplasma pneumoniae (see mycoplasma pneumonia) is the causative
organism in up to 20% of community acquired pneumonia and is often seen in
paediatric populations and young adults . It is especially associated with
3
patients living in close community settings.
Chlamydophila pneumoniae (Chlamydia pneumonia) is the causative
organism in up to 10% of community-acquired pneumonia, and similarly
to Mycoplasma pneumoniae it often affects paediatric populations and young
adults.
Specific causative organisms have other associated epidemiological
associations; for example, Legionella pneumophila (see Legionella
pneumonia) infection is associated with immunocompromised patients and
exposure to contaminated aerosolised water (for example, from air
conditioning systems). Coxiella burnetii infection (Q fever pneumonia) is
associated with exposure to livestock . 4
Clinical presentation
The presentation of atypical pneumonia is often similar to the presentation of
more typical bacterial pneumonia. However, there are some clinical features
that are more characteristic of atypical pneumonia : 2
more pronounced constitutional symptoms such as a headache and
myalgia
a low-grade fever
persistent dry cough
more insidious onset and protracted clinical course
lack of consolidation
a mixture of upper and lower respiratory tract symptoms and signs
Despite these characteristic features, there is often considerable overlap
between the clinical features of typical bacterial pneumonia and atypical
pneumonia . 2
Pathology
Atypical pneumonia may be caused by a variety of pathogens. The most
common cause of atypical pneumonia is Mycoplasma pneumoniae.
Other aetiological agents include :
1
Chlamydophila pneumoniae
Legionella pneumophilia : Legionella pneumonia
viruses including influenza, respiratory syncytial virus, rhinoviruses,
varicella viruses and adenovirus
Coxiella burnetii (the causative organism of Q fever pneumonia)
Infection prompts an immune response, necrosis and inflammation. In atypical
pneumonia, the inflammation is often confined to the pulmonary
interstitium and the interlobular septa; this causes the characteristic
radiological features of atypical pneumonia. As there is often no exudate in the
alveolar air spaces, consolidation is less common sign in atypical pneumonia
than in bacterial pneumonia of more typical causative organisms.
Radiographic features
Plain radiograph
Because the inflammation is often limited to the pulmonary interstitium and the
interlobular septa, atypical pneumonia has the radiographic features of patchy
reticular or reticulonodular opacities. These opacities are especially seen in
the perihilar lung . Subsegmental and sometimes segmental atelectasis from
5
small airway obstruction may occur. The radiographic features are often more
extensive than what is suggested clinically.
CT
Atypical pneumonia has a pattern of focal ground-glass opacity in a lobular
distribution. Involvement is often diffuse and bilateral . There may also be
9
evidence of pleural effusion. Bronchial wall thickening is another common CT
finding .
6
Diffuse ground glass nodules in a centrilobular pattern are often present,
although they progress to a soft tissue density as the infection and
inflammation progress . 9
In Mycoplasma pneumoniae infection, airspace consolidation is common.
HRCT is sensitive for nodules, which are seen in ~90% of patients .
7
In Legionella pneumophila infection, residual scarring may persist after
resolution of the infection . 8
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