illustration of imaging of cases of unresolved pneumonia ...and how to diagnose its cause .

1. Pediatric chest infections..that never
resolve….imaging considerations .
Dr/Ahmed Bahnassy
Consultant radiologist
PSMMC

2. Case 1…

3. Case 2

4. Case 3

5. Case 4

6. Lines of thinking of unresolved
pneumonia
o Virulent or atypical organism.
o Low immunity (congenital conditions:Di gerorge
syndrome,Nezelof
syndrome,hypogammaglobulinaemia,Chronic
granulomatous disease of childhood.
o Recurrent aspirations (severe GERD,mild
malrotation.)
o Structural lung abnormality (ELS,CPAM).
o Not infection.

7. Role of imaging
• CT chest (conventional ,with special protocols)
• HRCT chest for lung parenchyma evaluation.
• Upper GI.
• Ultrasound.

8. What to request ?.
• Prioritize the information you need .
• Discuss with radiologist or enter FULL clinical
data in the request form .
• Begin with ultrasound-if possible.
• Correlate radiological findings with laboratory
results.

9. Case 1

10. Bronchiectasis

11. Another finding

12. Tree-in bud

13. thymus

14. Lymph nodes

15. Which organ is missing ?!
pan
SV

16. Diagnosis ?
• Chronic process.
• Main feature is bronchiectasis.
• The latter involving central and upper lobes.
• Severe fatty infiltration of pancreas.

18. Historical perspective
• The term CF of the pancreas was first used in 1938 by
Dr. Dorothy Anderson, [whose work on
clinicopathologic correlation in infants and children led
her to the first comprehensive description of the
destruction of the pancreas and frequent infection and
damage to lung airways. The name was coined because
of the macroscopic appearance of the pancreas.
• By the 1940s, physicians understood that the ductal
systems and other passages in the organs affected by
CF were clogged with thick tenacious secretions.
• By 1946, the autosomal recessive character of the
inheritance of a single gene mutation was appreciated.

19. Radiographic changes
• Hyperinflation and peribronchial cuffing may be confused
with asthma or bronchiolitis.
• Linear streaking and scattered nodules, which are seen in
moderate CF, may be present in granulomatous or fungal
disease or sarcoid.
• CT scan, done with high-resolution technique because it
achieves better spatial resolution than is obtainable by
conventional imaging, may be useful in the evaluation of
minimally affected individuals.
• The earliest radiographic sign of CF in infants and children is
hyperinflation due to mucus plugging .
• Atelectasis, especially of the right upper lobe, is common in
infancy.

20. • Obstruction of small airways may result in a nodular or reticulonodular
appearance on radiographs and centrilobular nodules on HRCT scan
• On HRCT scan, the centilobular nodule is characterized by a cluster of ill-
defined nodules .
• As the disease progresses the classic findings of CF, representing
progressive bronchiectasis involving the large airways, become more
apparent…Thick parallel bronchial walls are seen as linear shadows or
tram-line tracts.
• Ring shadows represent dilated thick-walled bronchi seen on-end and
multiple nodular densities represent mucus plugging .
• Bronchiectasis is defined as bronchial dilatation relative to the adjacent
pulmonary artery. The normal ratio is 1:1.
• Bronchi adjacent to a pulmonary artery branch demonstrate a signet ring
appearance.

21. • Mucoid impaction of the bronchi with the thick
tenacious mucus of CF appears as areas of increased
density that follow the course of dilated bronchi .
• Large cystic airspaces may be identified.
• Lung abscesses may develop late in the course of the
disease.
• Spontaneous pneumothorax is believed to be due to a
rupture of subpleural blebs. It is observed in 5% to 20%
of patients and it is associated with a worse
prognosis, generally being seen in more severe disease.

22. Scoring systems
• The most commonly used is the Birmingham system .
• 5 elements are assessed by the Brasfield method including (1) air-
trapping; (2) linear markings; (3) nodular, cystic lesions; (4) general
severity; and (5) large lesions, such as atelectasis or consolidation.
• The first four elements are scored from zero to four.the last 0,3 or 5.
• The points are added together and then subtracted from 25. A
normal chest radiograph scores 25. The minimum score is three.
• Newer scoring systems, including those utilizing HRCT scan have
been developed to assess less severe disease and in an attempt to
correlate better with minimal progression of disease. The most
popular scoring system utilizing HRCT scan is the Bhalla system.
• The presence, extent, and severity of bronchiectasis, peribronchial
thickening, mucus plugging, atelectasis or consolidation, and
emphysema are recorded.

23. Case 2

27. Diagnosis
• It is severe infection (empyema
necessitantes).
• Large pneumatoceles which can…
• Narrow differential diagnosis .
– AFB
– Staph aureus.
– Strept.
– HI
– G-ve organism (Klebsiella-pneumonia)
– PCP .

29. • Necrotising pneumonia has increasingly been
identified as a complication of paediatric
• pneumonia. Streptococcus pneumoniae
remains the predominant organism, but since
2002, different bacteria have been isolated
and the age range of cases has broadened.

30. • Necrotising pneumonia (NP) is a severe
complication of community-acquired
pneumonia characterised by liquefaction and
cavitation of lung tissue.

31. Radiological diagnosis
• Radiological diagnosis for NP include the loss of normal
pulmonary parenchymal architecture and the presence of
areas of decreased attenuation and
enhancement,representing liquefaction, that are
progressively replaced by multiple small air or fluid filled
cavities .
• The pathophysiology of NP is thought to be one of massive
pulmonary gangrene, tissue liquefaction and necrosis .
• Prior reports have focused on NP caused by Streptococcus
pneumoniae although other bacterial organisms, including
• Staphylococcus aureus and Mycoplasma pneumoniae,
• have reportedly led to NP .

32. Case 3

35. Case 3 CT

39. Diagnosis
• It is congenital .
• Mass like (not consolidation)
• Has aortic (systemic) blood supply .
• Venous drainage not clear .

41. • Pulmonary sequestration is an embryonic
mass of lung tissue that has no identifiable
bronchial communication and that receives its
blood supply from 1 or more anomalous
systemic arteries. Multiple feeding vessels
may be present. This congenital anomaly can
be classified as extralobar sequestration (ELS)
or intralobar sequestration (ILS).

42. • ELSs are masses composed of nonfunctioning primitive
pulmonary parenchymal tissue that have no connection to the
tracheobronchial tree.
• This sequestration is called extralobar because the mass lies
outside of the normal investment of visceral pleura; it also
may lie outside of the thorax in a subdiaphragmatic position
in 10% of patients.
• The arterial supply is predominantly via systemic arteries
(95%) rather than pulmonary arteries (5%); the systemic
arteries are commonly branches of the thoracic aorta or the
abdominal aorta (80%).
• Venous drainage also occurs most commonly via the systemic
veins (75%), for example, the inferior vena cava (IVC) or
azygos or portal veins rather than pulmonary veins (25%).

43. Role of imaging
• CT scans have a 90% accuracy in the diagnosis of
pulmonary sequestration.
• Arteriography (conventional or CT angiography [CTA]) is
helpful in differentiating the lesion from other
abnormalities of the lung, such as pulmonary
arteriovenous fistulae.
• MRI and magnetic resonance angiography (MRA) can
provide information similar to that on CT scans.
• Ultrasonography is noninvasive and safe, making its use
ideal in prenatal and postnatal settings.
• Color flow and duplex Doppler ultrasound can
elegantly depict the ectopic blood supply

44. Differential diagnosis
• Solid mass in the differential diagnosis for ILS
Metastatic lung neoplasms
Lung abscess
Bochdalek hernia
Neurogenic tumor
Meningocele
Pleural tumor
Extramedullary hematopoiesis

45. Cystic masses DD for ILS
Congenital lobar emphysema
Cystic adenomatoid malformation
Intrapulmonary bronchogenic cyst
Arteriovenous malformation
Lung abscess
Necrotizing pneumonia
Cavitating infarct
Fungal , orTB pneumonia
Bronchogenic foregut cyst
Pericardial cyst
Empyema

46. DD for ELS
Neuroblastoma
Teratoma
Foregut duplication
Mesoblastic nephroma
Adrenal hemorrhage

47. Case 4

51. Diagnosis
• Bilateral symmetrical involvement.
• Mainly intersitial.
• Alveoli not aerated.
• Cystic changes.
• Bronchiolectasis.

55. Preferred Diagnosis for last case
• Pulmonary interstitial glycogenosis.
• Lymphocytic interstitial pneumonia.
• Early pulmonary LCH.
• Recommendation:
• Lung biopsy.