The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumonia and is brought to you by Elissabeth Hagler, MD and Tom Shuman, MD. Guest Editor is Michael Leonard, MD, Infectious Disease specialist.

1. Pneumonia Case Studies
Tom Shuman, MD & Elissabeth Hagler, MD
Departments of Internal Medicine & Emergency Medicine
Carolinas Medical Center
Atrium Health
Michael Gibbs, MD
Emergency Medicine
Lead Editor
Michael Leonard, MD
Infectious Disease
Guest Editor

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 clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: PNEUMONIA.

8. Typical vs. Atypial
Community Acquired Pneumonia
Typical
• Often lobar infiltrate
• Classically presents with
abrupt onset fever,
pleuritic chest pain,
productive cough
• Common pathogens:
Streptococcus pneumoniae
(#1 cause), Haemophilus
influenzae, Moraxella
catarrhalis
Atypical
• Often patchy, diffuse
interstitial infiltrates
• Often more gradual
presentation with non-
productive cough, along with
extra-pulmonary symptoms
• Common pathogens:
Mycoplasma pneumonia,
Chlamydophila pneumonia,
Legionella, and respiratory
viruses

9. Before We Review
Lobar Pneumonias,
Let’s Review
Lung Anatomy
wikiradiography.netanatomynote.com

10. Before We Review
Lobar Pneumonias,
Let’s Review
Lung Anatomy
wikiradiography.net
anatomynote.com

11. 43-Year-Old
Presents To An
Outpatient Clinic
After A Syncopal
Episode
He Has Normal
Labs, A Normal
ECG And This
Chest X-Ray
He Is Sent Home

12. Subtle pneumonias can be easy to
miss (especially with overlapping
structures nearby). Make sure you
are comparing each lung field with
the other side.
43-Year-Old
Seen Four Days
Ago In The
Outpatient Clinic
Let’s Take
Another Look At
The First CXR…

13. Right Upper Lobe Pneumonia
43 Year Old Seen
In The
Outpatient Clinic
Four Days Later
He Now
Presents To The
ED With Cough,
Fever & Rigors

14. 68-Year-Old
Diabetic With
Cough And Fever

15. 68-Year-Old
Diabetic With
Cough And Fever
Right-Sided Infiltrates – Primarily RUL

16. Right-Sided Infiltrates – Primarily RUL
Right Upper Lobe
Pneumonias appear
above the horizontal
fissure.
68 -Year-Old
Diabetic With
Cough And Fever

17. Prior CXR
Now
54-Year-Old With COPD & Diabetes Fever, Hypoxia, Altered Mental Status
RUL Pneumonia

18. RUL Infiltrate

19. RML Pneumonia:
 Blurred right heart border
 Lateral diaphragm clear
 Often seen best on the lateral

20. 73-Year-Old With
Fever, Cough And
Confusion
Right Middle Lobe Pneumonia

21. RML Infiltrate

22. 69-Year-Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary
Symptoms

23. RLL Pneumonia
69-Year-Old Fever And Right Upper Quadrant Abdominal Pain & No Pulmonary
Symptoms

24. Healthy 27-YearOld Male With Severe Right Pleuritic Chest Pain And Cough
Chest X-Ray Read As “Negative” By The Radiologist.
But It Is Not Normal To See Lung Markings Abutting The Diaphragm.

25. Right Lower Lobe Pneumonia
Healthy 27 Year Old Male With Severe Right Pleuritic Chest Pain And Cough

26. RLL Pneumonia – The Lateral Views Helps Differentiate From RML Involvement

27. RLL Infiltrate

28. RLL Infiltrate – Superior Segment

29. 51-Year-Old
With Cough,
Rigors, Chills

30. 51 Year Old
With Cough,
Rigors, Chills
Lingular
Pneumonia

31. 51-Year-Old
With Cough,
Rigors, Chills

32. 51 Year Old
With Cough,
Rigors, Chills
Lingular Pneumonia
 Wedge Shaped
 Seen Best On Lateral

33. Lingular Pneumonia

34. LLL Infiltrate

35. LLL Infiltrate

36. 55-Year-Old
With Fever
And Dyspnea
Single AP View
Portable CXR
Obtained At
The Bedside
Sent For A Chest CT After This
CXR Was Taken

37. 55-Year-Old
With Fever
And Dyspnea
Retrocardiac LLL Pneumonia

38. 55-Year-Old
With Fever
And Dyspnea
Let’s Take
Another Look
At The CXR!
The Left
Hemidiaphragm Is
Indistinct

39. 40-Year-Old
With Fever
And Dyspnea
Single AP View
Portable CXR
Obtained At
The Bedside
Sent For A Chest CT After This
CXR Was Taken

40. 40-Year-Old
With Fever
And Dyspnea
Retrocardiac LLL Pneumonia

41. 40-Year-Old
With Fever
And Dyspnea
Let’s Take
Another Look
At The CXR!
The Left
Hemidiaphragm Is
Indistinct

42.  In patients who are sick [i.e.: challenging for them to travel to Radiology] – we
may start with a single-view AP chest X-ray.
 In the last two cases the “next step” was a CT scan of the chest.
 Another option would have been to obtain a higher quality two-view study that
would have provided the benefit of the lateral projection.

43. CMC/LCH Technical Charges – March 2020
1 view chest X-ray $296
2 view chest X-ray $369
CT chest with contrast $2,628
CT chest with contrast - angiogram $3,398

44. 51-Year-Old-With
Cough & Fever.

45. 51-Year-Old With
Cough & Fever.
The Lateral View can be useful in identifying
retrosternal and retrocardiac disease.
Retrocardiac LLL Pneumonia On The Lateral View

46. 5-Year-Old With
Fever, Cough And
Tachypnea

47. 5-Year-Old With
Fever, Cough And
Tachypnea
RUL Collapse + RLL Necrotizing Pneumonia

48. 5-Year-Old With Fever, Cough And Tachypnea
RUL Collapse + RLL Necrotizing Pneumonia

49. Healthy 5-Year-Old
Treated With
Tamiflu For Flu
Symptoms,
Admitted With
Pneumonia

50. HD #1: LLL Pneumonia
Healthy 5-Year-Old
Treated With
Tamiflu For Flu
Symptoms,
Admitted With
Pneumonia

51. HD #4: LLL Pneumonia + Effusion
Chest
Tube
Healthy 5-Year-Old
Admitted With
Pneumonia

52. HD #14: After Video Assisted Thoracoscopic Surgery [VATS]
One Liter Of Pus Removed
Pneumohydrothorax
With Mediastinal Shift
Pneumohydrothorax– concurrent
pneumothorax and pleural effusion
Healthy 5-Year-Old
Admitted With
Pneumonia

53. Air-Fluid Level: If It’s Flat There’s Air In There!

54. Healthy 5 Year Old Admitted With Pneumonia
HD #14: Pneumohydrothorax And Severe Pulmonary Necrosis/Trapped Lung (*)
Discharged The Following Day On IV Antibiotics With Planned Follow-Up
*

55. 68-Year-Old
Diabetic With
Cough And Fever

56. 68-Year-Old
Diabetic With
Cough And Fever
Right-Sided Infiltrates – Primarily RUL

57. 68-Year-Old
Diabetic With
Cough And Fever
Right-Sided Infiltrates – Primarily RUL

58. Patient With A
History of ESRD
Presents With
Fever And Cough

59. Patient With A
History of ESRD
Presents With
Fever And Cough
Patchy Multifocal Pneumonia

60. Healthy 20-Year-
Old Male Seen At
His PCP’s Office
Where This Chest
X-Ray Was
Obtained.

61. Healthy 20-Year-
Old Male Seen At
His PCP’s Office
Where This Chest
X-Ray Was
Obtained:
Diagnosed With
RLL Pneumonia.
Rx: Ceftriaxone + A Prescription For Amoxicillin/Clavulanate

62. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.

63. The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.
Worsening Pneumonia Despite Therapy.

65. ED Rx: Azithromycin + Ceftriaxone & Admitted.
The Patient Presents To The ED 24 Hours Later With Cough + Persistent Tachycardia & Hypoxia.

66. Serology [+] For Mycoplasma.

67. The Patient Was Initially Treated
With Ceftriaxone In The Office And
Prescribed Amoxicillin-Clavulanate.
Is This An Appropriate Strategy For
The Outpatient Management of
Community Acquired Pneumonia?

68. The Patient Was Initially Treated
With Ceftriaxone In The Office And
Prescribed Amoxicillin-Clavulanate.
Is This An Appropriate Strategy For
The Outpatient Management of
Community Acquired Pneumonia?
According To The Most Recent IDSA/ATS
Guidelines: The Answer is Yes.

70. This Represents A Change From The 2007 IDSA/ATS Guidelines.

72. “In a departure from the prior CAP guidelines, the panel did not give a strong
recommendation for routine use of a macrolide antibiotic as monotherapy for
outpatient community acquired pneumonia. This was based on studies of macrolide
failures in patients with macrolide-resistant S. pneumonia1,2, in combination with a
macrolide resistance rate of >30% among S. pneumonia isolates in the United States, of
which is high-level resistance3.”
1Lonks JR. Clin Infect Dis 2002;35:556-564.
2Daneman N. Clin Infect Dis 2006; 43:432-438.
3CDC. Active Bacteria Core Surveillance (ABCs) Report - 2015. Report Accessed 2019.
PUNCH LINE?
 Pneumococcal resistance makes macrolide monotherapy risky.
 Know your local resistance patterns.
 Choose double therapy if atypical pneumonia is a possibility.

73. Diffuse Airspace Opacities.
45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
The Patient Has
Recently Been
Diagnosed With
HIV.

74. 45-Year-Old
Presents With
One Week Of
Dyspnea and
Night Sweats.
The Patient Has
Recently Been
Diagnosed With
HIV.
Pneumocystis Jiroveci Pneumonia.

75. 25-Year-Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Diffuse Infiltrates Consistent With PCP Pneumonia
But What
Is This?

76. 25-Year-Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Diffuse Infiltrates Consistent With PCP Pneumonia
Large
Pneumatocele

77. 25-Year-Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Large Pneumatocele
Next Day:
Pneumatocele
Rupture And
Pneumothorax

78. 25-Year-Old With
Recently
Diagnosed HIV and
PCP Pneumonia
Large Pneumatocele
Percutaneous
Chest Tube

82. Treatment Of Pneumocystis Pneumonia
Trimethoprim-sulfamethoxazole First Choice
Primaquine + clindamycin Alternative
Atovaquone suspension Alternative
Pentamidine1 Alternative
Patients with suspected or documented PCP and moderate to severe
disease, defined by a room air PO2 <70 mmHg should receive
adjunctive corticosteroids as soon as possible and certainly within
72 hours after starting specific PCP therapy.
1IV route only; aerosolized pentamidine should not be used.

83. Clinical, Diagnostic, and Treatment Disparities
between HIV-Infected and Non-HIV-Infected
Immunocompromised Patientswith Pneumocystis
jirovecii Pneumonia
Helmut J.F. Salzera, b
Guido Schäferc, d
Martin Hoenigle, f
Gunar Günthera, g Christian Hoffmannh,i Barbara Kalsdorfa, b
Alexandre Alanioj–l Christoph Langea, b, m,n
aDivision of Clinical InfectiousDiseases,Research Center Borstel,LeibnizLung Center,Borstel, Germany;
bGerman Center for Infection Research,Clinical TuberculosisCenter,Borstel,Germany; cInfectiousDiseasesClinic,
University Medical Center Hamburg-Eppendorf,Hamburg,Germany; dSection of Rheumatology,3rd Department
of Internal Medicine,University Medical Center Hamburg-Eppendorf,Hamburg,Germany; eDivision of Infectious
Diseases,University of Californiaat San Diego,San Diego,CA,USA; fSection of InfectiousDiseasesand Tropical
Medicine and Division of Pulmonology,Medical University of Graz,Graz,Austria; gDepartment of Internal Medicine,
School of Medicine,University of Namibia,Windhoek,Namibia; hInfektionsmedizinischesCentrum Hamburg
(ICH) Study Center,Hamburg,Germany; iDepartment of Medicine II,University Hospital of Schleswig-Holstein,
CampusKiel,Kiel,Germany; jParasitology-Mycology Laboratory, Lariboisière Saint-LouisFernand Widal Hospitals,
Assistance Publique-Hôpitaux de Paris,Paris,France; kParis-Diderot,Sorbonne ParisCité University,Paris,France;
lInstitut Pasteur,Molecular Mycology Unit,CNRSCMR2000,Paris,France; mInternational Health/InfectiousDiseases,
University of Lübeck,Lübeck,Germany; nDepartment of Medicine,KarolinskaInstitutet,Stockholm,Sweden
Accepted:February 13,2018
Published online:April 10,2018
DOI:10.1159/000487713
Clinical, Diagnostic, and Treatment Disparitie
between HIV-Infected and Non-HIV-Infected
Immunocompromised Patientswith Pneumo
jirovecii Pneumonia
Helmut J.F.Salzera,b Guido Schäferc,d Martin Hoenigle,f
Gunar Günthera,g Christian Hoffmannh,i Barbara Kalsdorfa,b
Alexandre Alanioj–l Christoph Langea,b,m,n
a
Division of Clinical InfectiousDiseases,Research Center Borstel,LeibnizLung Center,Borstel,Germany
b
German Center for Infection Research,Clinical TuberculosisCenter,Borstel,Germany; c
InfectiousDisea
University Medical Center Hamburg-Eppendorf,Hamburg,Germany; d
Section of Rheumatology,3rd De
of Internal Medicine,University Medical Center Hamburg-Eppendorf,Hamburg,Germany; e
Division of I
Diseases,University of Californiaat San Diego,San Diego,CA,USA; f
Section of InfectiousDiseasesand T
Medicineand Division of Pulmonology,Medical University of Graz,Graz,Austria; g
Department of Intern
School of Medicine,University of Namibia,Windhoek,Namibia; h
InfektionsmedizinischesCentrum Ham
i
Respiration
Clinical, Diagnostic, and Treatment Disparities
between HIV-Infected and Non-HIV-Infected
Immunocompromised Patientswith Pneumocystis
jirovecii Pneumonia
Helmut J.F. Salzera,b
Guido Schäferc,d
Martin Hoenigle,f
Gunar Günthera,g Christian Hoffmannh,i Barbara Kalsdorfa,b
Alexandre Alanioj–l
Christoph Langea, b,m,n
a
Division of Clinical InfectiousDiseases,Research Center Borstel,LeibnizLung Center,Borstel,Germany;
b
German Center for Infection Research,Clinical TuberculosisCenter,Borstel,Germany; c
InfectiousDiseasesClinic,
University Medical Center Hamburg-Eppendorf,Hamburg,Germany; d
Section of Rheumatology,3rd Department
of Internal Medicine,University Medical Center Hamburg-Eppendorf,Hamburg,Germany; e
Division of Infectious
Received:February 13,2018
Accepted:February 13,2018
Published online:April 10,2018
DOI:10.1159/000487713
Review
Respiration Received:February 13,2018
Accepted:February 13,2018
Published online:April 10,2018
DOI:10.1159/000487713

87. 2003; 126:859-861.
• Thin walled parenchymal cysts
• More common in children than in adults
Causes:
• Blunt chest trauma
• COPD and other bullous/cystic lung diseases
• Severe pneumonia [aspiration, anaerobic, TB, Pneumocystis…]
• Mechanical ventilator barotrauma
Complications:
• Infection
• Rupture and pneumothorax
• Rapid expansion and tension pneumatocele

88. Cavitary TB
Patient may present
with chronic
productive cough,
anorexia, weight loss,
fever, night sweats,
and hemoptysis.
Miliary TB

92. 65-Year-Old
Diabetic With
Fever, Cough,
Pleuritic
Chest Pain.

94. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of
Cough.
What do you notice?

95. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of
Cough.
Multifocal Infiltrates

96. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of
Cough.
Multifocal Infiltrates: What
opportunistic infection should
you consider?

97. 57-Year-Old Renal Transplant Patient Presents With Two Weeks Of
Cough.
Diagnosis: Cryptococcal Pneumonia

99. Cryptococcosis
• Cryptococcosis is a major opportunistic pathogen worldwide.
• In developed countries the widespread use of HAART for patients
with HIV has lowered the incidence of cryptococcosis dramatically.
• In developing countries with persistently uncontrolled HIV and limited
access to HAART therapy, the incidence of cryptococcosis, and its
associated mortality remain extremely high.

100. Cryptococcosis
In developed countries cryptococcosis in largely seen in patients:
• With newly diagnosed HIV
• Receiving immunosuppressants following organ transplantation
• Taking high-dose corticosteroids
• On certain monoclonal antibody therapies, e.g.:
• Infliximab (Remicade®) for rheumatologic conditions
• Alemtuzumab (Lemtrada®) for chronic lymphocytic leukemia

101. Cryptococcosis
Punch Line For The Acute Care Clinician?

102. Cryptococcosis
Punch Line For The Acute Care Clinician?
THINK ABOUT IT In The At-Risk Patient!

103. Treatment for
Cryptococcosis

109. RLL Pulmonary Infarct
Not All Infiltrates Are Pneumonia!

110. 60-Year-Old With Right Sided Pleuritic Chest
Pain
Chest CT [+] For PE: RLL Pulmonary Infarct

111. A Complete Summary Of The 2019
IDSA/ATS Guidelines
For The Management of
Community Acquired Pneumonia
Are Discussed Next In The Appendix.

112. APPENDIX

118. Question #1:
In adults with CAP, should gram stain and cultures of lower respiratory secretions be
obtained at the time of diagnosis?
 Recommend not obtaining sputum Gram stain and cultures routinely in adults with
CAP managed in the outpatient setting.
 Recommend obtaining Gram stain and cultures in adults with CAP who: (1) have
severe CAP* [especially if intubated], or (2) are being treated empirically for MRSA or
P. aeruginosa.
*See next slide for IDSA/ATS definition of “severe community-acquired pneumonia.”

119. Question #2:
In adults with CAP, should blood cultures be obtained at the time of diagnosis?
 Recommend not obtaining blood cultures in adults with CAP managed in the
outpatient setting.
 Recommend obtaining blood cultures in adults with CAP managed in the hospital who:
(1) are classified as severe CAP, (2) are being treated empirically for MRSA or P.
aeruginosa, (3) were previously infected with MRSA or P. aeruginosa, (4) were
hospitalized and received parenteral antibiotics in the last 90 days.

120. Question #3:
In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be
performed at the time of diagnosis?
Recommend not routinely testing adults with CAP, except in: (1) patients with severe CAP,
and/or (2) in cases where this is indicated by epidemiological factors such as exposure to
a Legionella outbreak, or recent travel.

121. Questions #4, #5, #6:
In adults with CAP:
 Should a respiratory sample be tested for Influenza virus at the time of diagnosis?
 Should influenza treatment be initiated for adults with a [+] test?
 Should influenza [+] adults being treated with an antiviral also be treated with an
antibacterial regimen?
 When influenza is circulating in the community, a rapid influenza molecular assay is
recommended.
 For [+] tests, treatment with oseltamivir is recommended.
 For [+] tests, standard antibacterial treatment is recommended.

122. Question #7:
In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical
judgment alone be used to withhold initiation of antibiotic treatment?
Recommend that empiric antibiotic therapy should be initiated in adults with clinically
suspected and radiographically confirmed CAP regardless of initial serum procalcitonin
level.

123. Question #8, 9:
Should a clinical prediction rule for prognosis plus clinical judgment versus clinical
judgment alone be used to determine: (1) inpatient versus outpatient treatment location
for adults with CAP, and (2) the best site of treatment [floor vs. Step-Down vs. ICU]?
 In addition to clinical judgement clinicians should use a validated clinical prediction
rule for prognosis, preferentially the Pneumonia Severity Index (PSI).
 When compared with CURB-65, PSI identifies larger proportions of patients as low
risk, and has a higher discriminative power in predicting mortality.
 Compared with PSI, there is less evidence that CURB-65 is effective as a decision aid in
guiding the initial site of treatment.

124. Question #10:
In the outpatient setting, which antibiotics are recommended for empiric treatment of
CAP in adults?
For healthy outpatient adults: (1) amoxicillin 1 g TID, or (2) doxycycline 100 mg BID, or (3)
azithromycin 500 mg on first day then 250 mg daily, or (4) clarithromycin 500 BID.
For outpatient adults with comorbidities (heart failure, liver or renal disease, diabetes,
alcoholism, malignancy or asplenia):
 Amoxicillin/clavulanate 500mg/125 mg TID, or a cephalosporin, AND a macrolide
(azithromycin, clarithromycin, or
 Monotherapy with a respiratory fluoroquinolone: levofloxacin 750 mg QD, or
moxifloxacin 400 mg QD, or gemifloxacin 320 mg QD.

125. Question #11:
In the inpatient setting, which antibiotics are recommended for empiric treatment of CAP
in adults without risk factors for MRSA and P. aeruginosa?
In inpatients with non-severe CAP:
 A 𝛽-lactam + a macrolide, or
 Monotherapy with a respiratory fluoroquinolone, or
 A 𝛽-lactam + doxycycline [if macrolides & fluoroquinolones are not tolerated]
In patients with severe CAP:
 A 𝛽-lactam + a macrolide, or
 A 𝛽-lactam + a respiratory fluoroquinolone

126. Question #12:
In the inpatient setting, should patients with suspected aspiration pneumonia receive
additional anaerobic coverage beyond standard empiric treatment?
Recommend not routinely adding anaerobic coverage for suspected aspiration
pneumonia unless lung abscess or empyema is suspected.

127. Question #13:
In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa
be treated with extended-spectrum antibiotic therapy instead of standard CAP regimens?
Recommend that clinicians only cover empirically for MRSA or P. aeruginosa in adults
with CAP if locally validated risk factors for either pathogen are present.
MRSA Vancomycin (15 mg/kg), or linezolid (600 mg BID)
P. aeruginosa Piperacillin-tazobactam (4.5 grams Qº6), or cefepime (2 grams Qº8), or
aztreonam (2 grams Qº8), or imipenem 500 mg Qº6)

128. Question #14:
In outpatient and inpatient adults with CAP who are improving, what is the appropriate
duration of antibiotic therapy?
Recommend that the duration of antibiotic therapy should be guided by a validated
measure of clinical stability (resolution of vital sign abnormalities, ability to eat, and
normal mentation), and antibiotic therapy should be continued until the patient achieves
stability for no less than 5 days.

129. Question #15:
In the inpatient setting, should adults with CAP be treated with corticosteroids?
 Recommend not routinely using corticosteroids in adults with non-severe CAP.
 Recommend not routinely using corticosteroids in adults with severe CAP.
 Recommend not routinely using corticosteroids in adults with severe influenza CAP.
 Endorse the Surviving Sepsis Campaign recommendations on the use of corticosteroids
in patients with CAP and refractory septic shock.