Typical Bacterial Pneumonia Imaging 

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Pneumonia is the eighth leading cause of death, and the number 1 cause of death from infectious disease, in the United States. About 1 million adults in the US are hospitalized with pneumonia every year, and about 50,000 die from this disease. Globally, pneumonia is the leading cause of death in children under 5 years old. There are 120 million cases of pneumonia reported each year, and over 10% (14 million) progress to severe episodes. An estimated 935,000 deaths from pneumonia occured in children under the age of 5 years in 2013. ^[1]

Chest radiography with posteroanterior and lateral views is the preferred imaging examination for the evaluation of typical bacterial pneumonia.  Ultrasonography has the potential to more accurately and efficiently diagnose pneumonia, as well as pleural effusions, pneumothorax, pulmonary embolism, and pulmonary contusions. Because lung ultrasonography can be performed at the bedside in an average of 13 minutes and lacks ionizing radiation, it is a good diagnostic option in primary care and emergency department settings. Chest computed tomography (CT) scanning should be considered when concern for alternative or concurrent diagnoses remains high (eg, interstitial lung disease, cavitary lesions, sarcoidosis, malignancy). ^[2]

The image below depicts typical bacterial pneumonia.

The classification of pneumonias as either typical or atypical arose from the observation that the presentation and natural history of some patients with pneumonia differed from those with pneumococcal infection.

Pathogens such as Haemophilus influenzae, Staphylococcus aureus, and gram-negative enteric bacteria cause clinical syndromes similar to that caused by Streptococcus pneumoniae. Other bacteria that cause pneumonia, including Mycoplasma pneumoniae, Chlamydia pneumoniae, C psittaci, and Legionella pneumophila, are referred to as “atypical” because pneumonia caused by these organisms have slightly different symptoms and appearance on a chest radiograph and respond to different antibiotics than do the typical bacteria that cause pneumonia. ^[3]

When patients present with fever, chills, or cough, pneumonia is suggested on the basis of focal or diffuse opacities.

Controversy exists with regard to the time required for an opacity to appear on chest radiographs. The vast majority of opacities appear within 12 hours. When patients are referred from the community to the radiologist, adequate time has usually elapsed for its detection. However, when nosocomial pneumonia is suspected, these patients may undergo chest radiography within a few hours, when opacities may not yet be visible on radiographs. ^{[4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]}

In immunosuppressed patients, especially those with coexistent neutropenia, diabetes, alcoholism, or uremia, the appearance of infiltrates may also be delayed.

Other findings that suggest the presence of pneumonia include air bronchograms; the silhouette sign; parapneumonic effusions; and complications of pneumonia, such as lung abscesses, and atelectasis.

Findings that have been associated with an increased mortality include bilateral pleural effusion and multilobar pneumonia.

The change in infiltrates on chest radiographs is not necessarily correlated with the activity of clinical disease. In some patients, chest infiltrates may worsen with the start or treatment, despite clinical improvement.

Pneumonia that is slow to resolve after appropriate antibiotic therapy can be a problem. Nonresolving pneumonia has been variously defined by Amberon in 1943, Henden in 1975, and Fein and colleagues in 1987 and 1993. In general, this entity is thought to be present when a patient does not improve clinically or when a radiographic infiltrate resolves slowly despite adequate and appropriate antibiotic therapy. About 10% of diagnostic bronchoscopy procedures and 15% of pulmonary consultations are performed to evaluate a nonresolving infiltrate.

The most common cause of unnecessary invasive evaluation is a failure to appreciate the length of time that infections need to clear radiologically. Studies have shown that impaired host defenses are more important determinants of delayed resolution than the infecting pathogen.

Host factors responsible for delayed resolution of pneumonia include age older than 50 years, smoking; and chronic illnesses, such as diabetes mellitus, renal failure, chronic obstructive pulmonary disease (COPD), and alcoholism.

Bacterial pneumonias usually tend to be unilobar and have cavitary lesions and effusions. Atypical pathogens can cause multilobar involvement with nodular or reticular infiltrates, lobar or segmental collapse, or perihilar adenopathy.

S pneumoniae causes 10-50% of all cases of community-acquired pneumonia (CAP). Radiographic consolidation of the alveoli begins in the peripheral airspaces, as in the image below. The disease usually causes a lobar or segmental pattern, and a patchy bronchopneumonic pattern involving the lower lobes is seen in the elderly. A striking characteristic of S pneumoniae infection is its tendency to involve the pleura. Parapneumonic effusions are common in pneumococcal pneumonia. ^[16]

In a study of bacteremic pneumococcal patients, 50% had clear radiographs at 9 weeks, compared with 5 weeks in nonbacteremic pneumococcal pneumonia.

In patients older than 50 years with both alcoholism and COPD, 60% have an abnormal chest radiograph at 14 weeks. In patients younger than 50 years with bacteremia and no underlying illness, 40% have an abnormal chest image at 2 weeks. For the group as a whole, 37% have residual consolidation at 4 weeks, with complete resolution by 18 weeks in almost all patients.

Despite therapy during the initial phase of illness, 52% of bacteremic patients, compared with 26% of nonbacteremic patients, had radiographs showing deterioration. Jay and colleagues recommended that an appropriate interval for serial radiographic examination is 6 weeks, unless otherwise indicated by a patient’s worsening clinical status. ^[16]

H influenzae pneumonia, shown in the image below, is commonly seen in COPD patients who are smokers; in the elderly; and in those with alcoholism diabetes, sickle cell anemia, or immunocompromise. This organism can be present in up to 38% of outpatients and 10% of hospitalized patients with CAP.

In most patients, radiographs demonstrate a patchy bronchopneumonic pattern, but segmental and lobar consolidation may be seen. Therefore, H influenzae pneumonia is indistinguishable from pneumococcal pneumonia. Pleural effusion is a common finding. Radiographs usually show a multilobar infiltrate and pleural effusions in 50% of cases. Resolution is usually slow.

The radiographic patterns seen in Klebsiella pneumonia include patchy bronchopneumonia and dense lobar consolidations. The alveoli are filled with large amounts of fluid and mucoid suppurative exudates that may cause the volume of the affected lung to increase with bulging of the interlobar fissures. Although these findings are thought to be characteristic of Klebsiella pneumonia, they may be seen in other causes of pneumonia.

There is a strong tendency for abscess formation as well as pleural involvement. Cavities may develop rapidly after the onset of illness, and these may be associated with massive lung gangrene.

P aeruginosa pneumonia has a characteristic predilection for the lower lobes. Patchy bronchopneumonia or extensive consolidation may be present. Involvement may be unilateral or bilateral and extensive. Extensive necrosis may be seen, with the formation of parenchymal abscesses. Massive bilateral consolidation is usually associated with a poor prognosis. Nodular infarcts may occur in the lung parenchyma.

This type of pneumonia may be seen as a complication of influenza, particularly during an epidemic. S aureus pneumonia usually begins in the peripheral airways rather than in the acini proper. In adults, patchy bronchopneumonia is more common and often bilateral, though lobar consolidation may be seen. Late development of abscesses is relatively common. When staphylococcal pneumonia occurs as a complication of influenza, it is usually rapidly progressive with extensive bilateral pneumonia that resembles pulmonary edema.

In children, it is usually a lobar or multilobar consolidation, rapidly progressing with the development of pneumatoceles and/or empyema. The presence of pneumatoceles in children is virtually diagnostic of staphylococcal pneumonia. Rapid progression is seen with lobar or multilobar consolidation. Pneumatoceles may rapidly develop, and empyema is frequent. ^[17]

Q fever is caused by the bacterium Coxiella burnetii found in feces, urine, and milk of infected animals. Unilateral, single segmental opacities is the most common finding, but patchy and lobar infiltrates are also found in some patients. In the majority of patients, the lower lobes are affected. The left lung is more commonly affected than the right lung, but involvement of both lungs is possible. ^[18]

In patients with underlying structural lung disease, the appearance of the various signs of pneumonia may not be straightforward.

Narrowing the differential diagnosis of pneumonia into typical and atypical forms on the basis of radiographic appearance alone is not reliable, as shown in a prospective study by Fang et al. ^[19]

Computed tomography (CT) scanning is increasingly used in clinical practice, but various groups have questioned its usefulness in evaluating pneumonia. Their reports have suggested that its usefulness in the diagnosis of pneumonia is limited to the following settings:

Evaluation of an indistinct, abnormal opacity depicted on a chest radiograph

Assessment of patchy, ground-glass, or linear/reticular opacities on chest radiographs

Confirmation of pleural effusion

Examination of neutropenic patients with fever of unknown origin (with the use of ultra–thin-section CT scanning)

In clinical practice, coinfection with multiple organisms is not rare, and underlying abnormalities of the lung parenchyma usually predispose patients to pneumonia. Hence, the overall clinical and radiologic picture must be considered. ^[20]

CT scans of typical bacterial pneumonia are provided below.

The literature indicates that ultrasonography can aid in the differentiation of consolidation and effusion. Consolidated lung tissue may appear as hypoechoic areas with blurred margins. The texture varies with the amount of aeration, being more heterogeneous with aeration and homogeneous with dense consolidation. ^[21] Ultrasonography may also help in diagnosing empyema and abscesses. ^{[15, 22]}

The role of ultrasonography in clinical practice is limited to the identification and quantification of parapneumonic effusions. This area can then be marked for subsequent diagnostic or therapeutic thoracentesis.

American Thoracic Society (ATS). Top 20 Pneumonia Facts 2015. Thoracic.org. Available at https://www.thoracic.org/patients/patient-resources/resources/top-pneumonia-facts.pdf. November 2015; Accessed: March 28, 2018.

Kaysin A, Viera AJ. Community-Acquired Pneumonia in Adults: Diagnosis and Management. Am Fam Physician. 2016 Nov 1. 94 (9):698-706. [Medline]. [Full Text].

Centers for Disease Control and Prevention. Pneumonia. CDC.gov. Available at https://www.cdc.gov/pneumonia/atypical/index.html. December 14, 2017; Accessed: March 28, 2018.

Hagaman JT, Rouan GW, Shipley RT, Panos RJ. Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia. Am J Med Sci. 2009 Apr. 337(4):236-40. [Medline].

Brolin I, Wernstedt L. Radiographic appearance of mycoplasmal pneumonai. Scand J Respir Dis. 1978 Aug. 59(4):179-89. [Medline].

Coletta FS, Fein AM. Radiological manifestations of Legionella/Legionella-like organisms. Semin Respir Infect. 1998 Jun. 13(2):109-15. [Medline].

Dietrich PA, Johnson RD, Fairbank JT, Walke JS. The chest radiograph in legionnaires” disease. Radiology. 1978 Jun. 127(3):577-82. [Medline].

Foy HM, Loop J, Clarke ER, et al. Radiographic study of mycoplasma pneumoniae pneumonia. Am Rev Respir Dis. 1973 Sep. 108(3):469-74. [Medline].

Goodman LR, Goren RA, Teplick SK. The radiographic evaluation of pulmonary infection. Med Clin North Am. 1980 May. 64(3):553-74. [Medline].

Hasley PB, Albaum MN, Li YH, et al. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?. Arch Intern Med. 1996 Oct 28. 156(19):2206-12. [Medline].

Lynch DA, Armstrong JD. A pattern-oriented approach to chest radiographs in atypical pneumonia syndromes. Clin Chest Med. 1991 Jun. 12(2):203-22. [Medline].

Macfarlane JT, Miller AC, Roderick Smith WH, et al. Comparative radiographic features of community acquired Legionnaires” disease, pneumococcal pneumonia, mycoplasma pneumonia, and psittacosis. Thorax. 1984 Jan. 39(1):28-33. [Medline].

Tew J, Calenoff L, Berlin BS. Bacterial or nonbacterial pneumonia: accuracy of radiographic diagnosis. Radiology. 1977 Sep. 124(3):607-12. [Medline].

Zornoza J, Goldman AM, Wallace S, et al. Radiologic features of gram-negative pneumonias in the neutropenic patient. Am J Roentgenol. 1976 Dec. 127(6):989-96. [Medline].

Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS One. 2015. 10 (6):e0130066. [Medline].

Jay SJ, Johanson WG, Pierce AK. The radiographic resolution of Streptococcus pneumoniae pneumonia. N Engl J Med. 1975 Oct 16. 293(16):798-801. [Medline].

Don M, Canciani M, Korppi M. COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN: WHAT’S OLD? WHAT’S NEW?. Acta Paediatr. 2010 Jun 22. [Medline].

Biecker A, Bitzer M, Biecker E. Q Fever Pneumonia in Southwest Germany: Radiographic and Clinical Findings. Rofo. 2017 Feb. 189 (2):146-151. [Medline]. [Full Text].

Fang GD, Fine M, Orloff J, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore). 1990 Sep. 69(5):307-16. [Medline].

Shiley KT, Van Deerlin VM, Miller WT Jr. Chest CT features of community-acquired respiratory viral infections in adult inpatients with lower respiratory tract infections. J Thorac Imaging. 2010 Feb. 25(1):68-75. [Medline].

Beckh S, Bolcskei PL, Lessnau KD. Real-time chest ultrasonography: a comprehensive review for the pulmonologist. Chest. 2002 Nov. 122(5):1759-73. [Medline]. [Full Text].

Urbankowska E, Krenke K, Drobczyński Ł, Korczyński P, Urbankowski T, Krawiec M, et al. Lung ultrasound in the diagnosis and monitoring of community acquired pneumonia in children. Respir Med. 2015 Sep. 109 (9):1207-12. [Medline].

Shakeel Amanullah, MD Consulting Physician, Pulmonary, Critical Care, and Sleep Medicine, Lancaster General Hospital

Shakeel Amanullah, MD is a member of the following medical societies: American College of Chest Physicians

Disclosure: Nothing to disclose.

David H Posner, MD Assistant Professor of Medicine, New York University School of Medicine; Assistant Chief of Pulmonary Diseases, Instructor, Intensive Care Unit, Education Coordinator for Pulmonary Fellowship, Lenox Hill Hospital

Disclosure: Nothing to disclose.

Mina Farhad, MD, PhD Clinical Instructor of Radiology, New York University School of Medicine; Head of Thoracic Imaging, Department of Radiology, Lenox Hill Hospital

Mina Farhad, MD, PhD is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Satinder P Singh, MD, FCCP Professor of Radiology and Medicine, Chief of Cardiopulmonary Radiology, Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine

Disclosure: Nothing to disclose.

Typical Bacterial Pneumonia Imaging 

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