Presentacion caso Rx - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/respiratory/Karsulovic.pdf · Necrotizing Pneumonia • Small pneumonic foci in the RUL • New

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Necrotizing Pneumonia

Claudio Karsulovic, Universidad de Chile Year VII

Gillian Lieberman, MD

October 2010Claudio Karsulovic, VIIGillian Lieberman, MD

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Our Patient: History (part I)

• 59 year‐old male, smoker, no significant past medical history, with recent diagnosis of non‐ small cell lung cancer.

• He underwent Chemoradiation therapy due to locally advanced disease in mediastinoscopy

Claudio Karsulovic, VIIGillian Lieberman, MD

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Our Patient: First Chest CT

• Spiculated left hilar

mass encasing the

distal main

left pulmonary

artery.


3AXIAL, C+, CHEST CTPACS, BIDMC

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Our Patient: PET‐SCAN

CORONAL, FDG, PET‐SCANPACS, BIDMC

Large, 4 cm FDG avid left hilar mass, with invasion into mediastinal structures

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Our Patient: History (part II)


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• During 2nd chemoradiation cycle, patient presents to the ED with fever, cough, chills,

night sweats and left sided pleuritic pain

• Physical exam is significant for left‐sided rales and left chest tenderness to palpation

• Immunocompetent (undergoing chemotherapy)

• A Chest CT was ordered

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Chest CT Findings

Let’s see the Chest CT findings in our patient…

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Our patient: Summary Index


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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for

Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main

bronchus

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Our Patient: Chest CT Severe Paraseptal Emphysema

Severe paraseptal emphysema


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AXIAL, C+, CHEST CTPACS, BIDMC


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bronchus

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Our Patient: Chest CT Cavitating Consolidation

Consolidation in superior segment of LLL with septated space, containing air and air

broncogram



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bronchus

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Our Patient: Chest CT Ground‐Glass Infiltrates

Peribronchial ground‐glass opacification in the RUL.


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bronchus

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Our Patient: Chest CT Subsegmental Atelectasis

Subsegmental atelectasis in the lateral basal segment, local bronchial inflammation and

bronchial wall thickening.


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bronchus

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Our Patient: Chest CT Residual Tumor

Residual peribronchial tumor infiltration in the mediastinum along the left main

bronchus


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bronchus

Let’s check out some important Topics…

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Our patient: Topic Review


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bronchus

Let’s talk a little about different types of Emphysema…

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Types of Emphysema: Paraseptal

Features:

•Distal airway

•Along the septae and pleura

•Airflow preserved

•Associated with spontaneous pneumothorax (SP)


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History spotlights of SP:

•Young

•Tall

•Thin

•Acute chest pain

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Types of Emphysema: Panacinar


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AXIAL, C‐, CHEST CTPACS, BIDMC

AAT Deficiency:

•AAT protects Elastin from destruction by

Neutrophils´ Elastase

•Without AAT, tissue lose compliance and are

more fragile

•Severe form: < 10% of fuctional enzyme

•Suspect in: Young patient with Cirrhosis +

Emphysema

Features:

•Destruction of entire alveolus

•Predominates in lower half of the lungs

•Associated with AAT (alpha 1 antitripsin) deficiency (homozygous)

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Types of Emphysema: Centriacinar


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AXIAL, C‐, CHEST CTPACS, BIDMC

Tobacco:•Cause airway inflammation increasing neutrophil chemotaxis

•Diminish in Elastin/Elastase ratio

•Accelerated destruction of parenchyma

Features:

•Starts in bronchioles and spreads peripherally

•Predominates in upper half of the lungs

•Associated with long-standing cigarette smoking

Let’s continue with our patient findings…

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Our patient: Findings Summary


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Necrotizing Pneumonia • Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main

bronchus

Let’s talk a little about a Cavitating Infective Consolidation…

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Cavitating Infective Consolidation: Main Points

Associated most commonly with aspiration

and/or

Impaired local or systemic immune response.

•Misra, Rakesh. A‐Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press; 2007:22‐25.


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Cavitating Infective Consolidation: Radiological features

•Misra, Rakesh. A‐Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press; 2007:22‐25.


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• Most commonly: Apicoposterior aspect

of the UL or the apical segment of the

LL.

• Spherical area of consolidation >2 cm in

diameter.

• Usually an air‐fluid level present.

• Thick and Irregular wall.

• Abscesses abutting the pleura form

acute angles.

• The cavitation does not cross fissures

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Cavitating Infective Consolidation: DDX

Necrotizing Infections

Anaerobic bacteria

Other Bacteria Staphylococcus aureus, Enterobacteriaceae,

Pseudomona aeruginosa, Legionella, HiB, Nocardia,

Actinomyces

Mycobacteria M. tuberculosis, M. avium, M. Kansasii

Fungi Aspergillus, Coccidiodes, Histoplasma, Blastomyces,

Cryptococcus, Mucor, Pneumocystis carinii

Non‐Infectious Causes

Bland embolism with infarction

Vasculitis

Neoplasm

Pulmonary sequestration

Bullae o Cysts with air fluid level

Bronchiectasis

Empyema with air fluid level

Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009


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Our patient: Findings Summary


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Necrotizing Pneumonia • Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main

bronchus

What is the most likely cause in our patient?...

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Anaerobic bac

Other Bac Staphylococcus aureus, Enterobacteriaceae,


Actinomyces




Non‐Infectious


Vasculitis

Neoplasm



Bronchiectasis


Our patient: DDX

Ruled Out

We know that our patient has NSCLC under treatment and has presented with fever, chills and productive cough



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Let’s continue with the follow‐up…

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Our Patient: 2 weeks follow‐up…


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Our Patient: 2 weeks follow‐up note

• Not responsive to antibiotics: Vancomycin + Piperacillin‐Tazobactam

• Positive Galactomannan

• A follow‐up Chest CT was ordered


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Let’s see the findings on follow‐up images…

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Our patient: 2 weeks follow‐up Chest CT Findings Index


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• Severe Paraseptal Emphysema

• Cavitating consolidation

• Ground‐glass infiltrates in the RUL

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Our Patient: 2 weeks Follow‐up Chest CT Paraseptal Emphysema

Severe paraseptal emphysema


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SCOUT, C+, CHEST CTPACS, BIDMC

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Our Patient: 2 weeks Follow‐up Chest CT Cavitating Consolidation

Large cavitary lesion with thick wall in the superior segment of

LLL with a dense

consolidation that extends to the left hilum



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SAGITTAL RECONSTRUCTION, C+, CHEST CTPACS, BIDMC

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Our Patient: 2 weeks Follow‐up Chest CT Ground‐Glass Infiltrates

Patchy ground‐glass infiltrate in the RUL


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Our patient: 2 weeks follow‐up Chest CT Findings


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Let’s review some important points about Necrotizing Pneumonia…

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Necrotizing Pneumonia: Summary Index

Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70‐75.


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• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia

• Infectious Causes

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Necrotizing Pneumonia: Pathophysiology

Thrombotic occlusion of alveolar capillaries associated with

adjacent inflammation, resulting in ischemia and eventually

necrosis of the lung parenchyma.

Tumor inside the vessel

Extrinsic compression

Intraluminal thrombus

Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.


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• Predisposing risk factor, e.g. aspiration or inmunocrompromised patient

• Cough with purulent sputum.

• Fever.• Failed response to antibiotics.• Indolent course of existing pneumonia.

• Pulmonary neoplastic disease or TB infection.

Necrotizing pneumonia: Clinical Features

•Misra, Rakesh. A-Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press; 2007:22-25.


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Necrotizing pneumonia: Radiological Features

•Loss of normal pulmonary parenchyma architecture

•Dominant area of consolidation

•Thickened‐wall cavitary lesion

•Low contrast enhancing wall of the cavitary lesion



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Necrotizing Pneumonia: v/s Lung Abscess

Very controversial topic because for many authors

is considered as one entity



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Necrotizing Pneumonia Lung AbscessSevere complication causing necrosis

of lung parenchymaSupurative process with a well‐

defined fibrous wall

Low contrast enhancing wall in Chest

CTContrast enhancing wall in Chest CT

Thick wall > 2 cm with or without air‐

fluid levelThick wall > 2cm, with air‐fluid level

Loss of normal lung parenchyma Normal pulmonary parenchyma

architecture

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Necrotizing Pneumonia: Infectious causes

Anaerobes

Most common cause

Associated with aspiration

Aerobes

•MRSA

Associated with Panton Valentine Leukocidine (PVL)

Present as a community‐acquire pathogen in the US

•E.Coli

•S.Pneumoniae

•Pseudomona aeruginosa

Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009Bartlett JG. Anaerobic Bacterial Infections in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009


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Let’s continue with our patient’s history…

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Our Patient: 3 weeks follow‐up…


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• Change of antibiotic theraphy to: Ceftriaxone 2 gr Q24 + Metronidazol 500 mg Q8

• Antifungical coverage with: Voriconazol 300 mg twice daily

• Stable clinical condition• A follow‐up Chest X Ray was ordered


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Let’s see the findings on the follow‐up X ray…

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Our patient: 3 weeks follow‐up Chest X Ray Findings


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• Large medial lucencies (Severe Emphysema)


• Focal opacity in the RUL

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Our patient: 3 weeks follow‐up Chest X Ray Large medial lucencies (Severe Emphysema)

• Large thin‐walled areas

of lucency in the

anterior chest

corresponding to large

areas of bullous disease.


51PA VIEW, C‐, CHEST X RAYPACS, BIDMC

LATERAL VIEW, C‐, CHEST X RAYPACS, BIDMC

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Our patient: 3 weeks follow‐up Chest X Ray Cavitating consolidation

• Large lucent lesion

demonstrating a thick

rim of increased

opacity, situated in the

superior segment of the

LLL


53PA VIEW, C‐, CHEST X RAYPACS, BIDMC


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Our patient: 3 weeks follow‐up Chest X Ray Focal opacity in the RUL

• Focal opacity in the left

lower lung and the right

mid lung.


55Do you remember the “Spine Sign”?


PA VIEW, C‐, CHEST X RAYPACS, BIDMC

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Our patient:“Spine Sign”


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ZOOM IN IMAGEPACS, BIDMC

But, what finally happened with our patient?


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Anaerobic bac

Other Bac Staphylococcus aureus, Enterobacteriaceae,


Actinomyces




Non‐Infectious


Vasculitis

Neoplasm



Bronchiectasis


Our patient: Final DDX

Ruled Out

We know that our patient has NSCLC under treatment and he has infectious symptoms



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UnlikelyNegative cultures and Non‐responsive to ATBs,

but still is the most common cause

Possible: Positive Galactomannan and indolent evolution

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• Stable clinical condition

• Slow improvement with new theraphy

• Follow‐up with Pulmonary and Infectious Disease teams for monitoring and serial

imaging


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Acknowledgements

• Carole Ridge, MD

• Gillian Lieberman, MD

• Ada Gropper, HMS IV

• Scott Zimmer, MD

• Emily Hanson, Educational Coordinator

• Our webmaster: Larry Barbaras


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References•Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1):

70‐75.

•Misra, Rakesh. A‐Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press;

2007:22‐25.

•Sawicki GS, Lu FL, Valim C. Necrotising pneumonia is an increasingly detected complication of

pneumonia in children. Eur Respir J 2008; 31: 1285–1291

•Mahfouz, M. Necrotizing Pneumonia: Sequential Findings on Chest Radiography.

EJB 2009: 3: 86‐89

•Kim EA, Lee KS, Shim YM. Radiographic and CT findings in complications following pulmonary

resection. Radiographics.

2002 Jan‐Feb;22(1):67‐86

•Labandeira‐Rey M, et al. Staphylococcus aureus Panton‐Valentine Leukocidin Causes Necrotizing

Pneumonia. Science. 2007 Feb 23;315(5815):1130‐3

•Kim DH, Lee JH, Kim BH. Chronic necrotizing bronchopulmonary aspergillosis with elements of

bronchocentric granulomatosis.

Korean J Intern Med. 2002 Jun;17(2):138‐42.


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References•Gillet Y, Issartel B, Vanhems P. Association between Staphylococcus aureus

strains carrying gene for

Panton‐Valentine leukocidin

and highly lethal necrotising

pneumonia in young immunocompetent

patients. Lancet. 2002 Mar 2;359(9308):753‐9.

•Roberts JC, Gulino

SP, Peak KK. Fatal necrotizing pneumonia due to a Panton‐Valentine leukocidin

positive community‐associated methicillin‐sensitive Staphylococcus aureus

and Influenza co‐

infection: a case report. Ann Clin Microbiol Antimicrob. 2008 Feb 19;7:5.

•Vayalumkal

JV, Whittingham H, Vanderkooi

O. Necrotizing pneumonia and septic shock: suspecting

CA‐MRSA in patients presenting to Canadian emergency departments. CJEM. 2007 Jul;9(4):300‐3.

•Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009

•Bartlett JG. Anaerobic Bacterial Infections in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA,

2009

•Macedo M, Meyer KF, Oliveira TC. Necrotizing pneumonia in children submitted to thoracoscopy

due

to pleural empyema: incidence, treatment and clinical evolution. J Bras Pneumol. 2010 Jun;36(3):301‐

5.


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Documents

Presentacion caso Rx - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/respiratory/Karsulovic.pdf · Necrotizing Pneumonia • Small pneumonic foci in the RUL • New